Executive impairment among the functionally dependent: comparisons between schizophrenic and elderly subjects.

OBJECTIVE: Executive deficits have traditionally been associated with frontal lobe brain damage. They are relevant to a variety of disabling mental conditions, including schizophrenia and Alzheimer's disease. To measure these deficits, the authors developed the Executive Interview, a 25-item, 15-minute interview. It has been validated among elderly subjects across a wide range of functional impairment. METHODS: Forty young, chronically ill schizophrenic residents of a state mental health facility and 104 elderly residents, representing three levels of care, of a comprehensive retirement community were tested with the Executive Interview and the Mini-Mental State. RESULTS: When age, gender, education, and number of prescribed medications were controlled, cognitive impairment on the Executive Interview and Mini-Mental State rose with level of care. The Executive Interview alone discriminated between subjects at each level of care, and it was more sensitive to cognitive impairment than the Mini-Mental State. Executive Interview scores correlated the strongest with level of care. Mini-Mental State scores, number of prescribed medications, and age also correlated significantly. Schizophrenic patients showed as much executive impairment on the Executive Interview as elderly subjects at the same level of care despite significant differences in age, sex, and neuroleptic use. Executive Interview and Mini-Mental State scores were highly correlated among the elderly but less so among the schizophrenic patients. Cross-group differences were also found in the pattern of failure on selected Executive Interview items despite similar total Executive Interview scores. CONCLUSIONS: Increasing executive dyscontrol is associated with the need for increasing levels of care and supervision. This finding is neither age nor disease specific. Cross-group differences on selected Executive Interview items suggest the existence of disease-specific patterns of failure. Their recognition could prove useful in the identification of anatomically or pathophysiologically distinct subgroups among patients with executive dyscontrol.

Psychiatric length of stay determinants in a military medical center.

In this 2-year prospective study, 1040 consecutive admissions to an adult inpatient psychiatric unit of the United States Air Force's largest tertiary care medical center were assessed for length of stay (LOS) determinants. Twenty-one demographic, clinical, and diagnostic variables were examined for their effect on LOS. The median LOS at our medical center was 9 days and was similar to the national median LOS of 10 days for psychiatric units in general hospitals. We found several clinical, nonclinical, and diagnostic variables to be independent predictors of LOS, accounting for 31% of the variance, but that much of the variance remained unaccounted for. Primary DSM-III-R discharge diagnoses were helpful in distinguishing a nonoverlapping, short-stay group from a long-stay group. HCFA Diagnostic Related Group (DRG) estimates for LOS were assessed for their ability to predict LOS in our institution. With the exception of substance abuse/dependence disorders, DRGs consistently underestimated LOS. Previous studies using the coefficient of variation (COV) have demonstrated the inability of DRGs to distinguish homogeneous diagnostic groups. However, in this study, COV was helpful in differentiating a majority of DRGs by LOS despite the general underestimation of LOS by DRG. These results continue to support the inadequacy of the DRGs in determining equitable reimbursement and the difficulties in predicting psychiatric LOS despite the inclusion of clinical and nonclinical variables.