Instrumental Activities of Daily Living, Neuropsychiatric Symptoms, and Neuropsychological Impairment in Mild Cognitive Impairment.

BACKGROUND: Neuropsychological deficits, neuropsychiatric symptoms, and problems with instrumental activities of daily living are common in participants with mild cognitive impairment (MCI). OBJECTIVES: To assess how subtle to mildly impaired instrumental activities of daily living (IADLs) might be related to neuropsychological abilities (including executive control and episodic memory) and neuropsychiatric symptoms (including apathy and depression) among participants with a diagnosis of MCI. METHODS: Participants were evaluated for MCI and possible dementia at an outpatient memory clinic on the basis of a comprehensive neuropsychological evaluation, a geriatric psychiatry evaluation, a magnetic resonance image of the brain, and serum studies to evaluate for a possible reversible cause of cognitive decline. A series of stepwise regression analyses were conducted whereby IADL ability was the dependent variable and neuropsychological abilities, such as executive control and episodic memory, or neuropsychiatric symptoms, including apathy and depression, were the independent or predictor variables. The presence and severity of neuropsychiatric symptoms was assessed using a modified version of the Neuropsychiatric Inventory (mNPI). Participants were grouped by MCI diagnosis status (amnestic MCI, combined dysexecutive/mixed MCI, and no MCI). RESULTS: Twenty-six participants were in the amnestic MCI group, 19 in the combined dysexecutive/mixed MCI group, and 36 participants did not meet criteria for MCI (non-MCI group). Groups did not differ in age, education, Mini-Mental State Examination performance, IADL abilities, estimated premorbid general intellectual abilities, or mNPI ratings for apathy and depression. Stepwise regression analyses found a robust relationship between mild IADL impairment and greater apathy (R=0.497, r21,69=0.247, P<.001; ß=-0.497, P<.001). Depression did not enter the final model. A weaker-but statistically significant-relationship was found between mild IADL impairment and worse executive control test performance (R=0.271, r21,68=0.073, P<.023; ß=0.271, P<.23). Episodic memory did not enter the final model. When both apathy and executive control were assessed as related to IADL impairment, only apathy entered the final model (R=0.497, R21,69=0.247, P<.001; ß=-0.497, P<.001). CONCLUSION: Mildly impaired IADL functioning can negatively affect quality of life. Moreover, apathy may be amenable to treatment. In a primary geriatric care setting, neuropsychiatric symptoms and neuropsychological abilities should be routinely assessed.

Effective Patient-Physician Communication Based on Osteopathic Philosophy in Caring for Elderly Patients.

The objective of this article is to discuss effective communication strategies between elderly patients and their physicians from the perspective of osteopathic heritage. The patient-physician communication styles of Andrew Taylor Still, MD, DO, and early osteopathic physicians (ie, DOs) may have influenced how DOs today communicate with their patients. Historical literature describes how Still would discuss with his patients the causes of their health problems using analogies and language they would understand, and how, when caring for a patient at the end of life, he empathically provided emotional support for both patients and their families. Early DOs advocated setting clear expectations for patients regarding clinical outcomes and carefully listening to patients to build trust. The Osteopathic Oath, which calls for the DO to view the patient as a friend, may also affect patient-physician communication. Early osteopathic philosophy and culture, as modeled by Dr Still in his approach to elderly patients, should inspire today's DOs in their communication with their elderly patients.

Axioms, osteopathic culture, and a perspective from geriatric medicine.

Osteopathic medicine is a rapidly growing discipline in health care that has much to offer the wider biomedical community. A distinction of the osteopathic medical profession is the importance of an overall guiding philosophy. Despite the osteopathic medical profession's success, there remains concern about the profession's ability to maintain its unique identity. Among many factors that have contributed to the profession's success, certain axioms from its earliest days are pertinent to the profession's identity. Maintaining a knowledge and appreciation of osteopathic axioms can play an important role in safeguarding the profession's identity. These axioms encapsulate osteopathic philosophy and, moreover, are universally useful for patient care. As osteopathic geriatricians, the authors explore the value and meaning of these axioms for anyone who treats patients, but especially for the care of the elderly. The authors also propose a new axiom, derived from the experience of 2 of the authors: "First try to blame it on the medications."

Promoting successful aging through effective prevention and management of osteoporosis.

Successful aging has been described as having 3 components: a low probability of disease and disease-related disability, a capacity for high cognitive and physical function, and active engagement with social and productive activities. Osteopathic physicians play a critical role in the promotion of successful aging through the prevention, early detection, and management of osteoporosis. Not many years ago, osteoporosis was viewed as an age-related disorder for which there was a lack of effective approaches for early intervention and management. Now, that view has changed.

Practice patterns of osteopathic physicians providing end-of-life care: a survey-based study.

CONTEXT: In 1996, the American Medical Association drafted and organized the Education for Physicians on End-of-Life Care (EPEC) curriculum. Leadership in the osteopathic medical profession has similarly recognized the goals of EPEC-resulting in the development of Osteopathic-EPEC, which incorporates the core tenets of osteopathic medicine. OBJECTIVE: To assess the impact of EPEC training and the integration of osteopathic principles and practice in end-of-life care provided by osteopathic physicians (DOs). METHODS: Osteopathic physicians who participated in the 2002 and 2003 AOA (American Osteopathic Association) End-of-Life Care-National Osteopathic Workshops were surveyed (N=100) on the use of advance directives and on their application of the tenets of osteopathic medicine, including the use of osteopathic manipulative techniques, for terminally ill patients. RESULTS: More than 90% of responding DOs (n=66) ranked each of the four core tenets of osteopathic medicine as important. Among completed responses, 58 DOs (89%) said they believed the tenets and philosophy of osteopathic medicine better prepared them to provide end-of-life care. Forty-eight DOs (79%) agreed that the use of osteopathic diagnostic and treatment skills augmented their ability to provide quality care for terminally ill patients. CONCLUSION: Osteopathic physicians indicated that the tenets of osteopathic medicine improve their effectiveness in providing quality end-of-life care to patients. However, fewer than half of surveyed DOs who used osteopathic manipulative techniques to relieve pain and manage the physical symptoms associated with the dying process reported that the techniques are often or always effective.

Inhibition of p53 by pifithrin-alpha reduces myocyte apoptosis and leukocyte transmigration in aged rat hearts following 24 hours of reperfusion.

Ischemic heart disease is a common age-related disease. Apoptotic cell death and inflammation are the major contributors to I/R injury. The mechanisms that trigger myocyte apoptosis and inflammation during myocardial I/R (MI/R) remain to be elucidated. Published data from our laboratory demonstrated that pretreatment of MI/R rats with pifithrin-alpha (PFT), a specific p53 inhibitor, reduced myocyte apoptosis and improved cardiac function compared with MI/R rats pretreated with saline at 4 h of reperfusion. In the present study, we investigated the effects of PFT on the occurrence of myocyte apoptosis and leukocyte transmigration in the later period of reperfusion. Aged (20-month-old) male F344 rats were subjected to 30 min of myocardial ischemia via ligature of the LCA, followed by 24 h of reperfusion. Pifithrin-alpha (2.2 mg/kg, intraperitoneally) or saline was administered to rats before ischemia. The results indicate that pretreatment of MI/R rats with PFT significantly decreased the percentage of infarct area to ischemic area (33 +/- 8 vs. 54 +/- 9, P < 0.05) and improved cardiac output (79 +/- 11 vs. 38 +/- 9 mL/min per 100 g body weight, P < 0.05) when compared with rats pretreated with saline at 24 h of reperfusion. The protective effects of PFT may involve the p53/Bax-mediated apoptosis because treatment of MI/R rats with PFT attenuated the ratio of Bax to Bcl2 (0.97 +/- 0.1 vs. 2.1 +/- 0.2, P < 0.05) and reduced myocyte apoptosis. Interestingly, inhibition of p53 transcriptional function by PFT alleviated leukocyte infiltration into the ischemic area of the heart (339 +/- 37 vs. 498 +/- 75 cells/10 high-power fields, P < 0.05). These data suggest that inhibition of p53 transcriptional function by PFT attenuates myocyte apoptosis and alleviates leukocyte transmigration at 24 h of reperfusion. The mechanisms by which p53 modulates leukocyte transmigration require further investigation.

Research funding at colleges of osteopathic medicine: 15 years of growth.

CONTEXT: Colleges of osteopathic medicine (COMs) trying to stimulate research and develop research infrastructures must overcome the challenge of obtaining adequate funding to support growing research interests. The authors examine changes in research funding at COMs during the past 15 years. OBJECTIVES: To track 1999-2004 data on COM research funding, COM faculty size, educational backgrounds of principal investigators receiving funding, and funding institutions. To compare these data with published results from 1989 to 1999. METHODS: Data on number of grants, funding amounts by extramural source, percent of total dollars by extramural source, percent of total dollars by COM, and total amount of extramural funding were obtained from the American Association of Colleges of Osteopathic Medicine databases. Data on the Osteopathic Research Center (ORC) were obtained from the ORC's databases. RESULTS: Research, both in terms of number of grants and funding amounts within the osteopathic medical profession, increased substantially from 1999 to 2004. The largest single source of funding remained the National Institutes of Health. The number of COMs whose research funding exceeded $1 million annually more than doubled, increasing from 5 in 1999 to 12 in 2004. The osteopathic medical profession's decision to direct research dollars into a national research center devoted to research specific to osteopathic manipulative medicine resulted in an almost eightfold return on initial investment in 4 years. CONCLUSIONS: The amount of research productivity at a COM may be aligned with the size of the COM's full-time faculty, suggesting that once "critical mass" for teaching, service, and administration are achieved, a productive research program can be realized. Expanding the evidence base for those aspects of medicine unique to the osteopathic medical profession is dependent on the future growth of research.

Pifithrin-alpha attenuates p53-mediated apoptosis and improves cardiac function in response to myocardial ischemia/reperfusion in aged rats.

Ischemic cardiovascular disease is a common age-related disease. The p53-dependent cardiac myocyte apoptosis induced by myocardial ischemia/reperfusion (MI/R) is an important feature in the progression of ischemic heart disease. In the present studies, we hypothesized that inhibition of p53-dependent myocyte apoptosis may improve cardiac dysfunction in aged rats after MI/R. A dose (2.2 mg/kg, i.p.) of pifithrin-alpha (PFT), a p53 inhibitor, or saline was administered to 20-month-old male F344 rats, which were subjected to 30 min of myocardial ischemia by ligating the left main coronary artery, followed by release of the ligature and 4 h of reperfusion. Results of our experiments indicate that MI/R induced a significant decrease in cardiac output index (CI) and mean arterial blood pressure (MABP). Administration of PFT to aged rats 40 min before ischemia significantly improved CI and MABP during 3 to 4 h of reperfusion. The improvement of cardiac function was associated with a marked reduction in DNA fragmentation in the area at risk of the heart when compared with aged MI/R rats pretreated with saline. Interestingly, treatment with PFT 10 min after ischemia or 10 min after reperfusion had a similar protective effect on CI and MABP, but this effect did not reach statistical significance when compared with aged MI/R rats pretreated with saline. Treatment with PFT, however, did not influence plasma creatine kinase activity and the number of circulating leukocytes and infiltrated leukocytes in the area at risk of the heart. Moreover, results of Western blot show that pretreatment with PFT significantly attenuated the ratio of Bax to Bcl-2 in the area-at-risk tissue of the heart compared with that of rats pretreated with saline. Our results suggest that pretreatment with PFT significantly improved cardiac function. The mechanism of protective effect of PFT may involve the inhibition of p53 transcriptional function, thereby attenuating the p53/Bax-mediated myocyte apoptosis during the reperfusion period.

Management of pain in older adults.

The elderly are often untreated or undertreated for pain. Barriers to effective management include challenges to proper assessment of pain; underreporting on the part of patients; atypical manifestations of pain in the elderly; a need for increased appreciation of the pharmacokinetic and pharmacodynamic changes of aging; and misconceptions about tolerance and addiction to opioids. Physicians can effectively manage pain in the elderly by understanding different types of pain (nociceptive and neuropathic), and appropriate use of nonopioid, opioid, and adjuvant medications. Opioids have become more widely accepted for treating older adults who have persistent pain, but their use requires physicians have an understanding of prevention and management of side effects, opioid titration and withdrawal, and careful monitoring. Placebo use is unwarranted and unethical. Nonpharmacologic approaches to pain management are essential and include osteopathic manipulative treatment, cognitive behavioral therapy, exercise, and spiritual interventions. The holistic and interdisciplinary approach of osteopathic medicine offers an approach that can optimize effective pain management in older adults.

Attenuation of antioxidative capacity enhances reperfusion injury in aged rat myocardium after MI/R.

Mortality due to ischemic cardiovascular diseases is significantly higher in elderly than in young adults. Myocardial ischemia-reperfusion (MI/R) can induce oxidative stress and an inflammatory response. We hypothesized that increased vulnerability of aged myocardium to reperfusion injury could be caused by decreased antioxidative capacity, rather than increased oxidant production, after MI/R. Aged (20-mo-old) and young (4-mo-old) male F344BN rats were subjected to 30 min of myocardial ischemia by ligation of the left main coronary artery followed by release of the ligature and 4 h of reperfusion. Four experimental groups were studied: young sham-operated rats, aged sham-operated rats, young rats subjected to MI/R, and aged rats subjected to MI/R. MI/R significantly increased infiltrated leukocyte number and myeloperoxidase (MPO) activity in perinecrotic areas of hearts of young rats compared with aged MI/R rats. These changes in infiltrated leukocyte number and MPO activity were associated with an increase in superoxide generation in perinecrotic areas from hearts of young rats compared with aged rats. Plasma levels of TNF-alpha and IL-1beta were significantly higher in young than in aged MI/R rats. However, plasma 8-hydroxy-2'-deoxyguanosine levels and creatine kinase activity were increased in aged compared with young MI/R rats. Increased reperfusion damage in aged rats was associated with a significant decrease in plasma ratio of GSH to GSSG. Our results suggest that enhanced ischemia-reperfusion injury in aged rat hearts may be related to reduced antioxidative capacity, rather than increased reactive oxygen species production. These findings contribute to a better understanding of effects of aging on oxidative stress and inflammatory responses of the heart after MI/R.

Physicians' practices related to the use of terminal sedation: moral and ethical concerns.

OBJECTIVE: Although terminal sedation (TS) has generally been seen as legal and ethically acceptable, ethical and moral issues remain. Little is known about the use of TS in general clinical practice and about how TS is viewed by physicians, given moral and ethical concerns. The objectives of this study are (1) to describe attitudes of physicians regarding terminal sedation; (2) to explore demographic characteristics, such as age, gender, subspecialty, and number of years in practice, that might be related to the use of TS; and (3) to compare physicians who have and have not used TS on the degree to which they view TS as moral and consistent with their professional and personal ethics. METHODS: An anonymous survey of New Jersey physicians was conducted at the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine. A 39-item questionnaire assessing general opinions about, experiences with, and religious, moral, ethical attitudes toward TS and other end-of-life treatments was utilized. RESULTS: A majority of physicians (73%) had used TS for a patient. Most (93%) said there were circumstances under which they would use TS. With regard to questions about whether TS would be "immoral," "would violate my religious beliefs," "would violate my professional ethics" and "is inconsistent with the physician's role of preserving life," approximately 55% of those who have used TS disagreed; for those who have not used TS, approximately 35% disagreed. SIGNIFICANCE OF RESULTS: Professional education and opportunities for discussion appear necessary to help reconcile the conflicts raised in the use of this end-of-life treatment strategy.

Predictive validity of osteopathic medical licensing examinations for osteopathic medical knowledge measured by graduate written examinations.

The purpose of this study was to evaluate the predictive validity of osteopathic medical licensing examinations for osteopathic medical knowledge measured by graduate written medical examinations. Performances on the three osteopathic initial licensing examinations, the three osteopathic internal medicine in-service examinations, and the osteopathic internal medicine board certification examinations were analyzed for a cohort of the most recent osteopathic internal medicine board certification examination candidates (N = 82). Multiple regressions were performed for the predictive value of licensing examination scores for the late examination scores. Logistic regressions were used for the prediction of pass/fail status on the licensing examinations for that on the board certification. A longitudinal performance profile was constructed to assess the rank changes in decile on the examinations at different times. All correlation coefficients between the licensing examinations and other examinations were significant and higher than .70. The licensing examinations together predicted at least 60% of the variance of any of the other examination scores. The pass/fail status on the licensing examinations predicted 89% of the pass/fail status on the certification examination. Decile ranks since the first licensing examination were consistent and stable over at least 5 years. The osteopathic licensing examinations had high predictive validity for the late written osteopathic internal medicine examinations. Generalization of the findings to other disciplines needs a caution, as a specialty bias may exist for these types of studies.

Age-related difference in myocardial function and inflammation in a rat model of myocardial ischemia-reperfusion.

OBJECTIVE: Aging is associated with a reduced tolerance to myocardial ischemia reperfusion injury when compared to the young adult. However, there is very little information in the literature regarding age-related changes in myocardial function and inflammation during myocardial ischemia-reperfusion (MI/R) in vivo. METHODS: We examined age-related differences in myocyte apoptosis and the inflammatory response in a rat model of myocardial ischemia-reperfusion (MI/R). The aged (19 months) and young (4 months) male F344 BN rats were subjected to 30 min of myocardial ischemia by ligating the left main coronary artery, followed by release of the ligature and 4 h of reperfusion. Four experimental groups, e.g. young sham control, aged sham control, young rats subjected to MI/R, and aged rats subjected to MI/R, were studied. RESULTS: MI/R induced a 78% increase in circulating leukocytes and a 30% increase in superoxide generation in the ischemic region of the heart of young rats, when compared to aged rats. Moreover, the arrhythmia scores were higher in young rats than in aged rats (P=0.058) following MI/R. There was no difference in hemodynamics between young sham and aged sham rats. However, the cardiac index was decreased by 34% at 3 h of reperfusion and by 33% at 4 h of reperfusion in aged rats, when compared to young rats following MI/R. Furthermore, stroke volume index was decreased by 54, 56, and 65% at 2, 3, and 4 h of reperfusion in aged rats, respectively, when compared that of young rats subjected to MI/R. There was an enhanced myocyte apoptosis, as indicated by ELISA and TUNEL staining in the myocardium of aged rats compared to young rats following MI/R. Interestingly, RT-PCR analysis indicated that MI/R significantly increased the ratio of Bax mRNA to Bcl-2 mRNA in aged rats compared to that of young rats (3.51 vs. 0.74). CONCLUSION: MI/R is associated with an increase in circulating leukocytes and generation of superoxide in the peri-ischemic areas of the heart of young rats, compared to aged rats. However, MI/R induces a significant decrease in cardiac index and stroke volume index in aged rats, when compared to young rats following MI/R. Furthermore, aged rats exhibit an increase in the ratio of Bax mRNA to Bcl-2 mRNA and cardiomyocyte apoptosis following MI/R, which may explain, at least in part, the enhanced myocardial dysfunction.

Pain management in the elderly.

Pain in the elderly is often unrecognized and undertreated. Ineffective pain management can have a significant impact on the quality of life of older adults, leading to depression, social isolation, and a loss of function. Proper assessment of older adults requires the physician to regularly ask about the presence of pain and be skillful in assessment strategies to evaluate the frequency and intensity of pain. Assessment of pain in older adults with dementia and communication disorders is especially challenging. Effective pain management in elderly patients should include both pharmacologic and nonpharmacologic strategies. Pharmacologic strategies call for administration of nonopioid analgesics, opioid analgesics, and adjuvant medication. Polypharmacy, drug-drug and drug-disease interactions, age-associated changes in drug metabolism, and the high frequency of adverse drug reactions need to be carefully considered in using medications in this population. Nonpharmacologic approaches such as cognitive-behavioral therapy, education, osteopathic manipulative treatment, and exercise should be applied in addition to pharmacologic therapy. Using a team approach and incorporating principles of pain management can effectively provide good analgesia for older adults.

How physicians approach advance care planning in patients with mild to moderate Alzheimer's disease.

Decision-making ability regarding end-of-life issues is often compromised by dementia in patients with Alzheimer's disease. This study assessed physicians' discussions of advance care planning with patients with mild to moderate Alzheimer's disease. Data were collected by a survey of full-time faculty in the departments of Medicine and Family Medicine and the Center for Aging at the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine, as well as physicians in private practice affiliated with the Kennedy Health System. Data consisted of questions that assessed whether advance care planning was provided, what specific topics were discussed, and what actions were taken if advance care planning was not offered. Of the 271 physicians to whom the survey was sent, 63 responded, for a return rate of 23%. Of those responding, 81% indicated that they counseled their patients regarding advance care planning issues, while 19% did not. Of those who provided advance care planning for their patients (N = 51), 88% discussed living wills; 53%, the durable power of attorney for healthcare; 47%, end-of-life care; and 35%, financial planning issues. Thirty-seven percent recommended an elder law attorney, and 31% made a referral to the Alzheimer's Association. Of those who provided advance care planning for their patients' caregivers (N = 51), 86% discussed living wills; 78%, nursing home care; 69%, driving issues; and 47%, end-of-life care. Twenty-five percent referred their patients to an elder law attorney. Results indicate that physicians need to be more knowledgeable and proactive in their approaches to advance care planning for patients with mild to moderate Alzheimer's disease.

Osteoporosis prevention project: a model multidisciplinary educational intervention.

Osteoporosis is a systemic metabolic disease resulting in low bone mass, which increases the risk for fracture. Evidence suggests that lifestyle changes to prevent or delay development of osteoporosis should be implemented throughout the life span. The purpose of this study was to evaluate the effectiveness of a multidisciplinary primary osteoporosis prevention program for community-dwelling women aged 25 to 75 years to determine if osteoporosis prevention program participants (treatment group) increased their knowledge of osteoporosis, calcium intake, and exercise compared with a control group. Other outcomes included participants' willingness to adopt lifestyle changes and ability to view themselves as able to make behavioral changes. Subjects in the treatment group versus control subjects increased their knowledge of osteoporosis over time. At posttest, subjects in the treatment group were more likely to be planning to change calcium intake, and at follow-up, they were more likely to be changing their calcium intake. No other group differences were found between the two groups. These findings suggest that a multidisciplinary education program may have an impact on knowledge and behaviors that may help to delay the development of osteoporosis.

Attitudes of osteopathic physicians toward physician-assisted suicide.

The use of physician-assisted suicide (PAS) in the care of terminally ill patients is controversial. While there are published surveys assessing the attitudes and views of physicians in certain specialties, both nationally and in targeted geographic areas, no such data are available specifically pertaining to osteopathic physicians, who deliver 9% of the primary care in the United States. This article describes a study whose purpose was to identify the views and perspectives of osteopathic physicians on PAS through a national survey. Questionnaires were forwarded to all board-certified internists who are members of the American College of Osteopathic Internists and all surgeons and a random sample of family physicians who are members of the American Osteopathic Association. Physicians were surveyed with initial and follow-up mailings. The 49-item questionnaire was a modified version of the Physician Survey, Center for Ethics in Health Care: Oregon Health Sciences University. Of the 2910 questionnaires that were mailed, 1028 were returned in a usable form, for a 35% response rate. Respondents were predominantly (81%) male and from all parts of the country. Most (58%) would not be willing to prescribe a medication for a competent, terminally ill patient to use with the primary intention of ending his or her own life, and most (55%) would oppose the legalization of PAS. Thirty-three percent of osteopathic physicians admit to receiving requests by terminally ill patients for PAS. Most (53%) osteopathic physicians indicate that the osteopathic principle of holistic care has influenced their decision-making on this issue, and a significant minority (44%) responded that the osteopathic oath influenced their view on PAS. Religion and the degree of prayer frequency were important predictors of the decisions to support or oppose PAS. When compared to other physician surveys, this survey of osteopathic physicians demonstrates some similarities in response but also significant differences. These data suggest that osteopathic education and training may result in a perspective on PAS that reflects the distinctiveness of the osteopathic profession.