Clinical presentations in monozygotic twins with dementia with Lewy bodies.

BACKGROUND: Dementia with Lewy bodies (DLB) is widely recognized as the second most common neurodegenerative cause of dementia in patients over the age of 65. The clinical distinction between DLB and Alzheimers's disease (AD) can be difficult due to the significant clinical overlap between the two disorders. Although the specificity of current consensus criteria is high, the sensitivity of case detection is lower and more variable. In some cases, the diagnosis is only made at postmortem examination. CASE REPORT: Monozygotic twins with the neuropathological diagnosis of Lewy body disease are presented in this report. Despite a very similar presentation and a comparable course of illness, the twins received different clinical diagnoses during life, one DLB and the other AD. This highlights the difficulty of making a clinical diagnosis of DLB, which very much depends on recognizing the features of fluctuation in level of awareness, hallucinations, delusions and the occurrence of falls, and the interpretation of the importance of these signs and symptoms. Pathological examination was virtually identical for the two cases showing the classic neuropathological features of Lewy Body disease.

Radiographic assessment of osteoarthritis.

Osteoarthritis is one of the most prevalent and disabling chronic conditions affecting older adults and a significant public health problem among adults of working age. As the bulk of the U.S. population ages, the prevalence of osteoarthritis is expected to rise. Although the incidence of osteoarthritis increases with age, the condition is not a normal part of the aging process. More severe symptoms tend to occur in the radiographically more advanced stage of the disease; however, considerable discrepancy may exist between symptoms and the radiographic stage. Roentgenograms of involved joints may be useful in confirming the diagnosis of osteoarthritis, assessing the severity of the disease, reassuring the patient and excluding other pathologic conditions. The diagnosis of osteoarthritis is based primarily on the history and physical examination, but radiographic findings, including asymmetric joint space narrowing, subchondral sclerosis, osteophyte formation, subluxation and distribution patterns of osteoarthritic changes, can be helpful when the diagnosis is in question.

Early diagnosis of dementia.

Until recently, the most significant issue facing a family physician regarding the diagnosis and treatment of dementia was ruling out delirium and potentially treatable etiologies. However, as more treatment options become available, it will become increasingly important to diagnose dementia early. Dementia may be suspected if memory deficits are exhibited during the medical history and physical examination. Information from the patient's family members, friends and caregivers may also point to signs of dementia. Distinguishing among age-related cognitive decline, mild cognitive impairment and Alzheimer's disease may be difficult and requires evaluation of cognitive and functional status. Careful medical evaluation to exclude treatable causes of cognitive impairment is important. Patients with early dementia may benefit from formal neuropsychologic testing to aid in medical and social decision-making. Follow-up by the patient's family physician is appropriate in most patients. However, a subspecialist may be helpful in the diagnosis and management of patients with dementia with an unusual presentation or following an atypical course.

A case-oriented web-based curriculum in geriatrics for third-year medical students.

OBJECTIVES: This paper describes the development, implementation, and evaluation of a case-oriented, web-based curriculum in geriatric medicine for third-year medical students. DESIGN: Single cohort, pre/post trial. SETTING: University of Kansas School of Medicine, Kansas City, Kansas. PARTICIPANTS: Third-year medical students (n = 130). INTERVENTION: A web-based curriculum, offered during a clinical geriatrics clerkship, is composed of 13 case-oriented, web-based modules spanning key topics in geriatric medicine. Each module topic is also reviewed in a post-module, faculty-led discussion session. MEASUREMENTS: A pre-and post-rotation test of knowledge was completed. Student feedback about the curriculum was collected through web-based and written evaluation. MAIN RESULTS: Pre-and post-rotation comparison of examination scores demonstrated an average increase of 13 correct items on a 40-item exam. Seventy-five percent of students rated each module favorably at the time of completion (range 53-89%). Most modules (10/13) were rated as excellent or good after all modules had been completed. CONCLUSIONS: A case-oriented web-based curriculum in geriatrics was rated favorably by third-year medical students. Students' knowledge increased in key geriatric topics. Student feedback allows for continuous improvement of the curriculum. This model of curricular innovation may be useful for other institutions seeking to develop or enhance geriatric medicine content in the medical school curriculum.

Preliminary report from the Kansas Hartford Geriatrics Project: a model of community university collaboration in geriatric medicine faculty development.

OBJECTIVES: This paper describes the development, implementation, and participant satisfaction of a faculty development program for community-based clinician educators with competencies in geriatric medicine. DESIGN: One group, ongoing trial. SETTING: University of Kansas School of Medicine, Kansas City, Kansas. PARTICIPANTS: Family physicians and general internists from throughout the state of Kansas (n = 30). INTERVENTION: This is an integrated faculty development curriculum of clinical geriatrics and educational process offered in nine sessions over 3 years. MEASUREMENTS: Project retention, session attendance, and participant satisfaction are the measures of program success. MAIN RESULTS: Project retention at 18 months, the midpoint of this project, has been 87%, with 91% of the retained participants attending all of the sessions to date. More than 95% of the participants have rated each of the first five sessions as highly satisfactory or excellent in meeting their needs as a clinician educator. Satisfaction for on-site and interactive televideo participation has been equally high. CONCLUSIONS: Our preliminary results indicate the Kansas Hartford Geriatrics Project model of community-university collaboration in geriatric faculty development is successful in recruitment and satisfaction of participants. The curriculum is highly attractive and rewarding to faculty. Interactive televideo provides a successful innovation in aging-oriented faculty development.

The physician's role in directing long-term care. Understanding the rules is important for protecting your patients and your practice.

Meeting the healthcare needs of patients who require long-term care presents many challenges, not the least of which are local and federal regulations, a formidable bureaucracy, and confusing paperwork. Despite these obstacles, long-term care patients often are among those with the greatest need for well-trained physicians and high-quality medical services. This article reviews elements of long-term care, with an emphasis on how primary care physicians should order and provide services.

Elder mistreatment.

Elder mistreatment is a widespread problem in our society that is often under-recognized by physicians. As a result of growing public outcry over the past 20 years, all states now have abuse laws that are specific to older adults; most states have mandated reporting by all health care professionals. The term "mistreatment" includes physical abuse and neglect, psychologic abuse, financial exploitation and violation of rights. Poor health, physical or cognitive impairment, alcohol abuse and a history of domestic violence are some of the risk factors for elder mistreatment. Diagnosis of elder mistreatment depends on acquiring a detailed history from the patient and the caregiver. It also involves performing a comprehensive physical examination. Only through awareness, a healthy suspicion and the performing of certain procedures are physicians able to detect elder mistreatment. Once it is suspected, elder mistreatment should be reported to adult protective services.

The impact of age-related visual impairment on functional independence in the elderly.

Low vision is an extremely common problem in the elderly, which may have devastating consequences for functional independence and health status. It ranks only behind arthritis and heart disease as the etiology for impaired function in those over the age of 70. Macular degeneration is a leading cause of blindness and poor vision in the elderly. The central vision loss of this disorder can sometimes be postponed through laser therapy. Otherwise, the low visual state is best addressed with vision-enhancing devices, non-optical adaptive equipment, and patient education available through most occupational therapists. Referral to a low-vision rehabilitation program is sometimes needed for more comprehensive evaluation and intervention. Individual adaptation and supportive services often result in a significant improvement in function and quality of life for those elders with low vision.

Geriatric grand rounds: hearing impairment and functional independence.

Hearing loss is a commonly encountered impairment in the elderly. It can profoundly affect physical, psychosocial and cognitive function. In addition to the actual hearing loss, other factors contribute to the hearing handicap experienced by older persons. These include difficulty in understanding speech in noisy situations, difficulty in supplementing hearing with visual information, and the slowing of cognitive and psychologic processes. Many forms of amplification are available and can be very useful in reversing much of the functional impairment associated with hearing loss. A comprehensive audiological assessment should be recommended before selecting the type of hearing aid or assistive listening device. Such a referral also affords an opportunity for more extensive aural rehabilitation.

Malnutrition in the elderly.

Several factors place older patients at risk for malnutrition, including physiologic effects of aging, chronic medical disease, psychiatric disease, various psychosocial problems, and effects of medication. Many of these factors are reversible but require early recognition and assessment. Cholesterol and albumin measurements may help confirm a diagnosis of malnutrition, but the most important indicator is weight loss. The primary interventions for nutritional compromise are increasing caloric, protein, and fluid intakes. Nutritional supplements may need to be prescribed for repletion and maintenance. Other nutrition-promoting interventions include exercise, avoiding constipation, and dental care.

Cervical spondylotic myelopathy: a cause of gait disturbance and falls in the elderly.

Cervical spondylosis is a very common disorder in the elderly that leads to osteophyte formation and degenerative disc disease. Compression of the cervical cord and nerve roots can occur in a small number of patients, often dependent upon a congenitally narrow canal. Cord compression produces progressive spastic paraparesis, frequently asymmetric, and often accompanied by paresthesias and sensory loss in the feet and hands. The course is quite variable. Often, symptoms are mild and do not progress. Such cases are best treated conservatively with a cervical collar and physical therapy. Elderly patients often experience progression of symptoms and more serious neurologic impairment. Surgery should be recommended to arrest progression of myelopathic symptoms in patients whose general condition is satisfactory.