Attitudes of older adults' on being told the diagnosis of Alzheimer's disease.

OBJECTIVE: Controversy exists as to whether Alzheimer's disease (AD) patients should be told their diagnosis, yet no research has been done examining older patients' attitudes on this topic. This study examines patient's attitudes toward this topic. DESIGN: A prospective, community-based study. Participants read vignettes of two patients, one with AD and one with terminal cancer, and then answered questions regarding their attitudes toward these illnesses. SETTING: A community-based retirement community in Charlottesville, Virginia. PARTICIPANTS: One hundred fifty-six community-dwelling older persons (mean age 79.7 +/- 6.9 years). MEASUREMENTS: A structured questionnaire disclosed demographic data (age, sex, race, religion, marital status), personal experience with cancer and AD, and opinions about being told the diagnosis of these diseases. RESULTS: Most participants (n = 124, 79.5%) responded that they would prefer to know if they had AD, but the number was significantly fewer (Fischer exact test, P < .001) than those who would want to know if they had terminal cancer (n = 143, 91.7%) Interestingly, significantly fewer married subjects would want their spouse to know if the spouse had either illness. Only 65.7% (n = 69) of subjects would want their spouse to know if the spouse had AD (Fisher exact test, P = .008), whereas for cancer, 80.2% (n = 77) would want their spouse to know if the spouse had cancer (Fisher exact test P < .001). No demographic variables distinguished subjects who did from those who did not want to know the diagnosis for themselves or their spouses for either AD or cancer. Among the reasons some subjects gave for wanting to know of the diagnosis of AD was being able to consider suicide. CONCLUSION: Although these results may support disclosure of diagnosis for most patients with AD, clinical and ethical issues remain in individual cases.

Cognitive screening of nursing home residents: factor structures of the Mini-Mental State Examination.

OBJECTIVE: To examine factor structures of the Mini-Mental State Examination, attempting first to replicate any of previously proposed 2-factor solutions; and to explore, secondly, the presence of clinically more differentiated and statistically stable factor structures representing common neurocognitive dimensions. DESIGN: Factor analytic investigation of descriptive dataset collected on nursing home residents. Two factor analyses were performed, one in which the number of factors was fixed at 2 in an effort to replicate previous studies, and one in which the number of factors to retain was determined by the scree test. Both factor analyses used established methods for judging the adequacy of the correlation matrix and the significance of factor loadings, and both applied principal components analysis for initial factor extraction and the equamax criterion for orthogonal rotation. SETTING: Seven nursing homes with a total of 894 beds. PARTICIPANTS: 922 assessments on nursing home residents were performed, of which 892 were complete and entered into the factor analyses. The observation-to-variable ratio exceeded 81:1, assuring the statistical stability of factor solutions derived. MEASUREMENT: The Mini-Mental State Examination, with standardization of words to be recalled and the inverted spelling of "world" as the mental reversal task. MAIN RESULTS: Two factor structures were derived. A 2-factor solution, explaining 36.5% of the variance and statistically and conceptually different from those obtained in previous studies, distinguished between Perceptual-Organizational and Psychomotor skills. A 4-factor solution, which explained 56.1% of the variance, included a factor named Executing Psychomotor Commands, while also further differentiating the perceptual-organizational processes into the factors of Memory, Concentration, and Language. CONCLUSION: The 2-factor solution shows that, notwithstanding previous claims to the contrary, the MMSE can make stable and independent distinctions between psychomotor and perceptual-organizational processes. However, this solution is statistically and conceptually limited and, therefore, of limited clinical and scientific relevance. The 4-factor solution of the MMSE maps well onto commonly recognized dimensions of neurocognitive ability. It offers a stable, intuitively sound, and statistically supported framework for clinical differentiation of cognitive screening data into independent clinical dimensions of neurocognitive functioning. Thus, it offers clinicians and researchers a 4-dimensional framework for interpreting data obtained by means of the MMSE. Studies with other populations of cognitively impaired and intact elderly are recommended to validate and extend the present findings.

Multidisciplinary assessment of patients with Alzheimer's disease.

The complexity of AD necessitates that multiple disciplines interface effectively in the assessment of patient, caregiver, and family. This multidisciplinary effort should not be focused on the mere exchange of data. As this article emphasized, just from the perspective of nursing, it is critical that the various disciplines involved know about the purpose, focus, and process of assessment approaches used by each in the convergent effort to comprehensively evaluate the disease and its possible changes, as well as its impact on function, cognition, behavior, and emotion. From this article, it should be apparent that effective multidisciplinary assessment is not exchange of data but rather purposive interchange of clinical information to achieve the clinical goals of assessment, diagnosis, explanation, intervention, prognosis, and evaluation.

Psychogeriatric outreach to rural families: the Iowa and Virginia models.

Elderly residents of rural areas are at significant risk for mental health problems, yet have less access to mental health services. Thus, most mental health problems among rural elderly remain either undiagnosed or untreated. We describe two models of mental health outreach programs to rural elderly in Iowa and Virginia, serving demographically, culturally, and epidemiologically different populations in geographically and economically dissimilar regions. Programs are compared on the basis of initiation, community partnerships, target population, target region, clinical disciplines involved, coordinating discipline, referral sources, operational model, initial home assessment, care planning, sustainability, cost, patient demographics, and primary and secondary diagnosed. Outreach programs are argued to be effective models of delivering services to geographically and/or socially isolated elderly populations. The experiences of our programs, though limited to rural populations, may be of relevance to any outreach program attempting to serve elderly presenting with or at risk for mental health problems.

Beyond the Role of ExtenderIndependent and Interdependent Contributions of Nursing to Geriatric Rehabilitation.

Too often, the role of nursing in geriatric neurorehabilitation is defined in terms of extending the care of other disciplines and assuring continuity of selected aspects of care over 24 hours. This article argues that nursing has made significant clinical and scientific progress in contributing, independently and interdependently, to quality rehabilitation care for older adults; and that the role of nursing clearly exceeds the realm of mere extension and continuity of care. Reviewed are nursing's innovations in the areas of promoting comprehensive assessment; fostering functional independence, self-care, and self-care agency; enhancing communication; encouraging family involvement; improving cognitive status; and assuring quality physical care. We conclude with a discussion of the relationship of nursing to other disciplines, and how nursing's contributions can be optimized within the broader context of multidisciplinary geriatric rehabilitation.

A psychogeriatric nursing assessment protocol for use in multidisciplinary practice.

The assessment of geriatric patients with psychiatric or neurobehavioral problems demands a multidisciplinary approach linking nursing, psychiatry, neurology, geriatrics, and internal medicine. While the medical disciplines have relatively well-established approaches to assessing psychogeriatric patients, nursing lacks a comprehensive assessment strategy that supports both nursing and multidisciplinary practice. This article describes the Psychogeriatric Nursing Assessment Protocol (Abraham, 1989) developed for use in a multidisciplinary geriatric neuropsychiatric outpatient clinic. The relationship of the protocol to psychiatric, neurological, geriatric, and medical assessments is discussed in an attempt to clarify the linkages of knowledge and care required for successful service delivery to geriatric patients with psychiatric or neurobehavioral problems, as well as to their families and formal and informal caregivers.

Angioimmunoblastic lymphadenopathy with associated selective myeloid hypoplasia.

Angioimmunoblastic lymphadenopathy is a disease characterized systemic symptoms, lymphadenopathy, hepatosplenomegaly and polyclonal hypergammaglobulinemia. Hematologic abnormalities are common, especially anemia, which is often Coombs positive, and lymphocytopenia. This report cites a case of angioimmunoblastic lymphadenopathy associated with selective hypoplasia of the myeloid line and normal maturation of all other marrow-derived cell lines. Possible relationships of this finding to the immunologic abnormalities associated with angioimmunoblastic lymphadenopathy are discussed.