Substance abuse treatment initiation among older adults in the GET SMART program: effects of depression and cognitive status.

This study examines how individual patient characteristics predict substance abuse treatment initiation among older adults, in an investigation based on the behavioral health service use model. Analyses tested the impact of demographic factors, substance abuse symptoms, depression and cognitive status on subsequent treatment initiation. The sample included 250 older male veterans screened for substance abuse problems during inpatient medical treatment, who also participated in a clinical evaluation for substance abuse treatment. Measures included demographics and CAGE alcohol screening score. A subset of patients also completed the Michigan Alcohol Screening Test-Geriatric Version (MAST-G), Hamilton Depression Scale (HAM-D), and Folstein Mini Mental State Exam (MMSE). Patients who initiated treatment following evaluation had more years of education, better cognitive status, and more symptoms of substance abuse and depression, compared with patients who did not initiate treatment. In logistic regression analysis, CAGE and MMSE scores independently predicted treatment initiation. Findings contribute to the understanding of how clinical characteristics of older adults affect substance abuse treatment initiation.

Social isolation predicts re-hospitalization in a group of older American veterans enrolled in the UPBEAT Program. Unified Psychogeriatric Biopsychosocial Evaluation and Treatment.

OBJECTIVES: Does social isolation predict re-hospitalization in a group of older men enrolled in Unified Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT), a mental health care-coordination project at nine Veterans Affairs Healthcare Centers nationwide? METHODS: The current study examined 123 UPBEAT patients located at West Los Angeles, whose ratings were available on the Lubben Social Network Scale (LSNS), the SF-36 scale, the Cumulative Illness Rating Scale (CIRS) and the Mental Health Index (MHI-38) Depression and Anxiety subscales. Within one year of enrollment, 55% of patients were re-hospitalized. Odds of re-hospitalization were calculated using two logistic regression models. Social isolation risk (LSNS) and demographic covariates were included. In addition, Model 1 contained depression and anxiety measures (MHI-38) and physician-rated medical burden (CIRS), while in Model 2, patient-perceived physical (PCS) and mental health (MCS) subscales from the SF-36 were included. RESULTS: The group of patients who were socially isolated or at high or moderate risk for isolation, were 4-5 times more likely to be re-hospitalized within the year, than low isolation risk patients. In both Models 1 (chi-square = 19.86; p = 0.031) and 2 (chi-square = 26.42; p = 0.002) demographic characteristics were not significant predictors of re-hospitalization, but social isolation risk was a significant predictor (Model 1: odds ratio (OR) = 5.31; 95% confidence intervals (CI) = 1.81-15.53; and Model 2: OR = 3.86; 95% CI = 1.39-10.73). In addition, MHI-Anxiety was a significant predictor (OR = 1.22; 95% CI = 1.05-1.43) in Model 1 and in Model 2, patient-perceived physical health significantly predicted re-hospitalization (OR = 0.91; 95% CI = 0.86-0.96). CONCLUSION: When controlling for other covariates, social isolation, physical health and mental health were significant risk factors for re-hospitalization. These findings underline the importance of assessing and addressing lack of social support, along with other factors, in the health care of older male veterans.

UPBEAT: the impact of a psychogeriatric intervention in VA medical centers. Unified Psychogeriatric Biopsychosocial Evaluation and Treatment.

BACKGROUND: The Unified Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT) program provides individualized interdisciplinary mental health treatment and care coordination to elderly veterans whose comorbid depression, anxiety, or alcohol abuse may result in overuse of inpatient services and underuse of outpatient services. OBJECTIVES: To determine whether proactive screening of hospitalized patients can identify unrecognized comorbid psychiatric conditions and whether comprehensive assessment and psychogeriatric intervention can improve care while reducing inpatient use. DESIGN: Randomized trial. SUBJECTS: Veterans aged 60 and older hospitalized for nonpsychiatric medical or surgical treatment in 9 VA sites (UPBEAT, 814; usual care, 873). MEASURES: The Mental Health Inventory (MHI) anxiety and depression subscales, the Alcohol Use Disorder Identification Test (AUDIT) scores, RAND 36-Item Health Survey Short Form (SF-36), inpatient days and costs, ambulatory care clinic stops and costs, and mortality and readmission rates. RESULTS: Mental health and general health status scores improved equally from baseline to 12-month follow-up in both groups. UPBEAT increased outpatient costs by $1,171 (P <0.001) per patient, but lowered inpatient costs by $3,027 (P = 0.017), for an overall savings of $1,856 (P = 0.156). Inpatient savings were attributable to fewer bed days of care (3.30 days; P = 0.016) rather than fewer admissions. Patients with 1 or more pre-enrollment and postenrollment hospitalizations had the greatest overall savings ($6,015; P = 0.069). CONCLUSIONS: UPBEAT appears to accelerate the transition from inpatient to outpatient care for acute nonpsychiatric admissions. Care coordination and increased access to ambulatory psychiatric services produces similar improvement in mental health and general health status as usual care.

Screening for drug and alcohol abuse among older adults using a modified version of the CAGE.

This study examined the sensitivity, specificity, and receiver operating characteristics (ROC) curves of a modified version of the CAGE, a screening measure used in the detection of older alcohol- and drug-abusing individuals. In a retrospective review of clinical records of 976 patients screened by a geriatric substance abuse program, the authors examined patients' responses on a modified version of the CAGE that included queries regarding drug use. The CAGE was administered to individuals age 50 or over draw from three diagnostic groups: alcohol abuse/dependence, drug abuse/dependence, and normal controls. Analysis of variance and discriminant function analyses revealed that the modified CAGE was able to discriminate both alcohol and drug abusers from controls. Analyses examining test sensitivity, specificity, and ROC curves revealed the CAGE to demonstrate excellent sensitivity but poor specificity. Omitting the "cut down'' item from the CAGE significantly improved specificity with only a modest drop in sensitivity. Given the ease of administration and sensitivity to both alcohol and drug abuse, these data suggest that the modified CAGE is well suited as a screening instrument for geriatric drug and alcohol abuse.

Cognitive-behavioral treatment of older veterans with substance abuse problems.

The authors describe the initial cohort of participants in the GET SMART program, an age-specific, outpatient program for older veterans with substance abuse problems. Chief among the program's services is a relapse-prevention intervention consisting of 16 weekly group sessions using cognitive-behavioral (CB) and self-management approaches. Group sessions begin with analysis of substance use behavior to determine high-risk situations for alcohol or drug use, followed by a series of modules to teach coping skills for coping with social pressure, being at home and alone, feelings of depression and loneliness, anxiety and tension, anger and frustration, cues for substance use, urges (self-statements), and slips or relapses. Of the first 110 admissions, more than one-third were homeless, which is indicative of the severity of psychosocial distress of the patients, and more than one-third used illicit drugs. A total of 49 patients completed CB treatment groups and 61 dropped out of treatment. At 6-month follow-up, program completers demonstrated much higher rates of abstinence compared to noncompleters. The results suggest that CB approaches work well with older veterans with significant medical, social, and drug use problems.

Portraits of change: case studies from an elder-specific addiction program.

The authors describe two case histories of patients served by the GET SMART program that provide a glimpse of typical client substance abuse histories and their remarkable journeys of change. An age-specific outpatient program for older veterans with illicit drug and alcohol dependence, the GET SMART program uses individualized and group treatment interventions in an environment of collaboration, respect, and hope. The program employs the stages of change framework and a clinical framework that includes cognitive-behavioral and motivational interviewing approaches.

Pharmacological and psychological treatments for depressed older patients: a meta-analysis and overview of recent findings.

A meta-analysis was carried out to evaluate data published between January 1974 and February 1998 comparing rates of treatment response and tolerability of pharmacological and psychological treatments for depression in persons over age 55. Drugs (tricyclic antidepressants, selective serotonin-reuptake inhibitors, and a mixed group of other drugs) were significantly better than placebo, with an average reduction in symptom severity of 48.0% versus 31.3% (analysis weighted by sample size; 50.6% vs. 21.4% unweighted). No single drug or group of drugs was superior in terms of efficacy, and no statistically significant differences in tolerability emerged between tricyclic antidepressants and selective serotonin-reuptake inhibitors, whether measured by total dropouts or by dropouts due to side effects. Compared to the data on pharmacological treatments, those for outcomes of psychological treatments are very limited. Existing data indicate that cognitive-behavioral, behavioral, and psychodynamic therapies are significantly better than placebo. In the current meta-analysis, response rates to these nondrug therapies did not differ significantly from those observed with tricyclic antidepressants or selective serotonin-reuptake inhibitors, but direct comparison data are insufficient for firm conclusions to be drawn about comparative efficacy. It is possible, even likely, that not only different subtypes of depression but also different patients vary in their treatment responses. However, lack of adequate data prevented the current meta-analysis from addressing these issues. Rigorously designed prospective studies on treatment outcome, taking into account the above differences, are urgently needed to provide robust data on which to base clinical recommendations for the treatment of depression in older patients.

Evidence for association of HLA-A2 allele with onset age of Alzheimer's disease.

Our earlier studies had suggested a possible association between the HLA-A2 allele and Alzheimer's disease (AD). In the present study we tested the hypothesis that A2 is associated with earlier AD onset. We performed two independent studies: a collaborative study with 111 patients and a confirmatory study with 96 patients. We found similar patterns of reduced age at onset as a function of A2 in both data sets. Overall, A2 was associated with a significant 3-year shift to earlier onset. The effects of A2 and epsilon 4 on age at onset appeared additive. Our results suggest A2, or a closely linked gene, modulates onset age of AD. Association with A2 would suggest an immune/inflammatory response mechanism for AD.

D2 dopamine receptor A1 allele in Alzheimer disease and aging.

BACKGROUND: The apolipoprotein E4 (APOE*4) allele is a major risk factor for the common forms of late-onset Alzheimer disease (AD), but does not account for all the genetic variation in late-onset AD; hence, other genetic markers must be examined. The D2 dopamine receptor (DRD2) A1 allele is associated with abnormal brain function and decreased DRD2s. These receptors are decreased in hippocampus and amygdala in AD, and allele frequencies may vary with age. OBJECTIVE: To study APOE and DRD2 genotypes in patients with AD and cognitively intact controls of varying ages. DESIGN: The DRD2 and APOE genotypes were examined in 832 unrelated white subjects, including 554 patients with AD (486 sporadic; 68 familial) and 278 controls. Logistic regressions tested A1 allele effects on disease status and age, and DRD2 linkage with AD was investigated in 60 families with late-onset AD. SETTING: University medical centers. SUBJECTS: Patients (mean +/- SD age, 74.6 +/- 8.1 years; range, 52-98 years) had probable AD, according to standard consensus diagnostic criteria; controls (mean +/- SD age, 69.2 +/- 8.6 years; range, 50-93 years) were cognitively intact. MAIN OUTCOME MEASURES: Disease status, age, and DRD2 linkage with AD. RESULTS: No association between the DRD2 and APOE alleles was found, and the presence of the A1 allele did not increase the risk for AD. There was also no evidence of linkage between DRD2 and AD. Age analyses, including both patients and controls, indicated a decrease in A1 allele frequency with age. CONCLUSIONS: The A1 allele does not contribute to AD risk, alone or in combination with the APOE*4 allele. The DRD2 A1 allele frequencies decrease with age in both patients and controls. Thus, studies of DRD2 disease association need to control for age.

Tetraethylammonium-induced calcium concentration changes in skin fibroblasts from patients with Alzheimer disease.

Potassium (K+) channel dysfunction in fibroblasts was recently proposed as a potential diagnostic marker for Alzheimer disease (AD). We utilized a microspectrofluorometric method with Fura-2AM to measure intracellular free calcium ([Ca2+]i) following depolarization with the K+ channel blocker tetraethylammonium (TEA) in seven AD and seven control fibroblast cultures. Contrary to our expectation, 43% of the AD and 36% of the control fibroblast plated coverglasses responded with an increase in [Ca2+]i on addition of 100 mM TEA. The data suggest that the TEA-elicited [Ca2+]i response is not a useful AD screening test.

Cognitive changes in young-old adults: effect of family history of dementia.

Cognitive performance of 40 first-degree relatives of patients with probable Alzheimer disease was compared to that of 24 matched controls without a family history of dementia. Across a test-retest interval ranging from 1 to 6 years, relatives more often showed evidence of cognitive decline, and in multivariate analyses of memory and intelligence measures, relatives of patients with early-onset dementia (< 67 years) showed greater decline than controls or relatives of patients with late-onset dementia. All changes observed to date are in the subclinical range, and further follow-up will be needed to determine the reliability of change trajectories. However, the findings suggest that family history of dementia may be worthy of monitoring in research on normal cognitive aging.

Self-reports of memory problems in relatives of patients with probable Alzheimer's disease.

This study examined the relationship between subjective memory complaints and performance on tests of memory by relatives of patients with probable Alzheimer's disease (AD) and by older adults without a family history of dementia. Relatives of AD patients did not differ significantly from controls either in level of complaint or in performance on neuropsychological tests. However, among relatives of patients with early-onset AD, significant correlations were found between performance on memory tests and self-rated changes in everyday memory. These findings raise the possibility that relatives who have entered the age range in which their parents or siblings developed dementia symptoms are monitoring their memory performance more diligently than relatives of patients whose illness began at much later ages or persons who have no close relatives with AD.

Clinical, neuroimaging, and environmental risk differences in monozygotic female twins appearing discordant for dementia of the Alzheimer type.

OBJECTIVE: The study of monozygotic twins can elucidate possible environmental causes for a disease in genetically identical subjects. To this end, we studied a pair of monozygotic female twins appearing discordant for dementia of the Alzheimer type (DAT). DESIGN: Clinical and neuroimaging findings were compared in terms of potential environmental risk factors. SETTING: University referral center. PARTICIPANTS: An 81-year-old female monozygotic twin pair. OUTCOME MEASURES: Clinical assessments, standardized rating scales, and brain imaging studies, including magnetic resonance imaging, positron emission tomography, and electroencephalography, were performed. Neuropsychological tests were performed initially and after 1 year. RESULTS: Although DAT was confirmed clinically in only one twin, neuropsychological and brain imaging studies suggested that the unaffected twin may be developing the prodrome of DAT. The twins' varied life histories suggest that environmental risk factors may contribute to apparent discordance for DAT and possible delay in disease onset for the currently nondemented twin. CONCLUSIONS: These results suggest that both genetic and nongenetic factors influence disease onset and expression. Moreover, review of previous reports of monozygotic twin pairs concordant or discordant for Alzheimer's disease, with adequate family history data, suggest a pattern indicating interactions among age at dementia onset, sex, and familiarity. Such patterns point to hypotheses regarding neurobiologically meaningful Alzheimer's disease subgroups.

Cognitive performance in relatives of patients with probable Alzheimer disease: an age at onset effect?

Cognitive performance of 32 siblings and children of patients with probable Alzheimer disease was assessed longitudinally over an interval averaging 4 years. Mean scores were within normal limits for age on all measures at both test times. However, relatives of patients with early-onset dementia (less than or equal to 67 years) were more likely to show a decline in performance from the first to second testing than relatives of patients with late-onset dementia. Additional follow-up will be needed to determine the reliability of performance trajectories and to assess whether mild cognitive changes are related to future dementia. However, findings suggest that it may be important to consider family history of dementia in studies of normal cognitive aging.

A group of potassium-channel blockers-acetylcholine releasers: new potentials for Alzheimer disease? A review.

This review of the literature examines systematically the data currently available for potassium-channel blockers to reassess their clinical potential in Alzheimer disease. The conclusion is that potassium-channel blockers may have been dismissed prematurely for the treatment of Alzheimer disease, an impression supported by data indicating intimate relationships between potassium-channel blockade and cholinergic transmission.

Commingling analysis of memory performance in offspring of Alzheimer patients.

Dementia of the Alzheimer type (DAT) is a neurodegenerative disorder which afflicts approximately 3% of the population. Genetic influences are indicated from twin and family studies although genetic heterogeneity has been suggested from both pedigree analyses and linkage investigations. Autosomal dominant inheritance with age-dependent penetrance has been suggested in at least some families with DAT. In the present investigation, we examine memory and nonmemory task performance in 106 asymptomatic offspring (mean age 40.6 years) of 54 DAT probands. Intraclass sibling correlations revealed little evidence of sibling similarity for performance on three memory tasks which have been reported to be relatively sensitive to the memory losses accompanying DAT. Subsequent investigations of the distributions of the cognitive task scores in the offspring revealed evidence for a commingling of two distributions for the three memory tasks but not for the nonmemory measures. These findings are consistent with a hypothesis that these distributions reflect genotypic subgroups, carriers, and noncarriers, of a presumed DAT gene.