Decision-making in the ICU: An analysis of the ICU admission decision-making process using a '20 Questions' approach.

Background: Deciding to admit a patient into the intensive care unit (ICU) is a high-stakes, high-stress, time-sensitive process. Elucidating the complexities of these decisions can contribute to a more efficient, effective process. Objectives: To explore physicians' strategic thought processes in ICU triage decisions and identify important factors. Methods: Practitioners (N=29) were asked to decide on ICU referrals of two hypothetic cases using a modified '20 Questions' approach. Demographic data, decisions when full information was available, feedback on questions, rating of factors previously identified as important and influence of faith and personality traits were explored. Results: Of the 735 questions asked, 95.92% were patient related. There were no significant differences in interview variables between the two cases or with regard to presentation order. The overall acceptance rate was 68.96%. Refusals were associated with longer interview times (p=0.014), as were lower ICU bed capacity (p=0.036), advancing age of the practitioner (p=0.040) and a higher faith score (p=0.004). Faith score correlated positively with the number of questions asked (p=0.028). There were no significant correlations with personality trait stanines. When full information was available, acceptances for Case A decreased (p=0.003) but increased for Case B (p=0.026). The net reclassification improvement index was -0.138 (p=0.248). Non-subspecialists were more likely to change their decisions (p=0.036). Conclusion: Limiting information to what is considered vital by using a '20 Questions' approach and allowing the receiving practitioner to create the decision frame may assist with ICU admission decisions. Practitioners should consider the metacognitive elements of their decision-making. Contributions of the study: The study used a novel approach to explore physicians' decision-making process for admitting a patient to the intensive care unit (ICU). Understanding the main factors that influence the decision-making process will allow for streamlining the referral process, more effective selection of patients most likely to benefit from ICU treatment, and prevent inappropriate admissions into the ICU. The findings can also help to improve data capture tools and encourage practitioners to critically reflect on their decision-making processes.

Mild cognitive impairment and dementia in a heterogeneous elderly population: prevalence and risk profile.

OBJECTIVE: To describe the demographic, clinical and risk profile of Mild Cognitive Impairment and dementia in a sample of elderly South Africans within a residential setting. METHOD: One hundred and forty participants residing in a group of residential homes for the elderly were assessed by psychiatrists and assigned diagnoses of dementia or Mild Cognitive Impairment (MCI). Participants diagnosed with dementia were also offered haematological investigations and a CT scan of the brain. RESULTS: The sample consisted of 140 participants comprising 46.4% White, 29.3% Coloured, 20% Asian and 4.3% Black participants. There were 97 (69.3%) females and 106 (75.7%) participants had less than 12 years of education. Eleven (7.9%) dementia and 38 (27.1%) MCI cases were diagnosed. Increasing age was associated with cognitive impairment (MCI and dementia) (p=.020) but there was no association between gender and cognitive impairment (p=.165). MCI was significantly associated with a lower education level (p=.036) and no association was found between depression (current-p=.646; past-p=.719) and dementia or MCI. The presence of vascular risk factors (n=140) ranged from 66.4% (hypertension) to 14.3% (stroke). Subjective memory complaints were significantly associated with cognitive impairment (p=.001). Except for the use of the telephone (p=.225) and the television (p=.08), impairment in all domains of instrumental activities of daily living that were assessed were significantly associated with a dementia diagnosis. CONCLUSION: The study showed that cognitive impairment was associated with increasing age and low education levels. The presence of vascular risk factors places this population at risk for future cognitive decline.

Screening a heterogeneous elderly South African population for cognitive impairment: the utility and performance of the Mini- Mental State Examination, Six Item Screener, Subjective Memory Rating Scale and Deterioration Cognitive Observee.

OBJECTIVE: The aim of this study was to report on the prevalence of cognitive impairment, and to assess the performance and utility of subjective, objective and informant screening tools in a heterogeneous community sample. METHOD: A sample of 302 elderly participants (>60 years) living in residential homes in a large city in South Africa were screened for the presence of cognitive impairment using objective (Mini-Mental State Examination [MMSE] and Six Item Screener-[SIS]), subjective (Subjective Memory Complaint [SMC]and Subjective Memory Rating Scale [SMRS]) and informant (Deterioration Cognitive Observee [DECO]) screening tools. All tools were compared to the MMSE and the influence of demographic variables on the performance on these tools was considered. RESULTS: Significantly lower MMSE scores were found in participants aged 80-89 years (p=.023) and those who had 8-11 years of education (p=.002). For every one additional year of education, participants were 0.71 times less likely to screen positive on the MMSE. Differential item functioning on various components of the MMSE was demonstrated due to the effects of education, race and gender. There was significant differential performance between the recommended and alternate attention/concentration items (p<.001) with the alternate item favouring better performance. Based on the MMSE cutoff score of < 23, the prevalence of cognitive impairment was 16.9%; the prevalence yielded by the remaining tools ranged from 10.5% using the DECO to 46% as determined by the presence of a SMC. Using the MMSE as the reference standard for the presence of cognitive impairment, the SIS, SMC, SMRS and DECO had sensitivities of 82.3%, 54.6%, 17.0% and 37.5%, and specificities of 71.3%, 57.6%, 87.4% and 96.7% respectively. Age and race influenced performance on the MMSE, SIS and SMRS. CONCLUSION: Different types of cognitive screening tools yielded varying sensitivities and specificities for identifying cognitive impairment when compared to the MMSE. The influence of race, age and education on test performance highlights the need for suitable, culture-fair screening tools. Locally, the alternate item for attention/concentration should be preferred.

The sensitivity and specificity of subjective memory complaints and the subjective memory rating scale, deterioration cognitive observee, mini-mental state examination, six-item screener and clock drawing test in dementia screening.

BACKGROUND: The effectiveness of dementia screening depends on the availability of suitable screening tools with good sensitivity and specificity to confidently distinguish normal age-related cognitive decline from dementia. The aim of this study was to evaluate the discriminant validity of 7 screening measures for dementia. METHODS: A sample of 140 participants aged ≥60 years living in a residential facility for the aged were assessed clinically and assigned caseness for dementia using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revised diagnostic criteria. Sensitivity and specificity of a selection of the following screening measures were tested using receiver operating characteristic (ROC) analysis for individual and combined tests: the Mini-Mental State Examination (MMSE), Six-Item Screener (SIS), Subjective Memory Complaint, Subjective Memory Complaint Clinical (SMCC), Subjective Memory Rating Scale (SMRS), Deterioration Cognitive Observee (DECO) and the Clock Drawing Test (CDT). RESULTS: Using ROC analyses, the SMCC, MMSE and CDT were found to be 'moderately accurate' in screening for dementia with an area under the curve (AUC) >0.70. The AUCs for the SIS (0.526), SMRS (0.661) and DECO (0.687) classified these measures as being 'less accurate'. At recommended cutoff scores, the SMCC had a sensitivity of 90.9% and specificity of 45.7%; the MMSE had a sensitivity of 63.6% and a specificity of 76.0%, and the CDT had a sensitivity of 44.4% and a specificity of 88.9%. Combining the SMCC and MMSE did not improve their predictive power except for a modest increase when using the sequential rule. CONCLUSION: The SMCC is composed of valid screening questions that have high sensitivity, are simple to administer and ideal for administration at the community or primary health care level as a first level of 'rule-out' screening. The MMSE can be included at a second stage of screening at the general hospital level and the CDT in specialist clinical settings. Sequential use of the SMCC and MMSE will improve the specificity of the former and the sensitivity of the latter.

Depression in African women presenting for psychological services at a general hospital.

OBJECTIVE: Despite the increase in knowledge of depression, little is known about depression among African populations, especially African woman. In South Africa, inadequate mental health services generally and specifically for African people in our society, has led to under reporting and under diagnosing of the disorder. The object of the study was to understand depression in African women attending a state health service. METHOD: Clinical records of all patients presenting with depression to a general hospital located in a densely populated African township, over a 2 year period, were examined. RESULTS: The epidemiological data is described. Depression in these women was related to poverty, overcrowding, unemployment, high levels of crime, lack of services and sexual abuse. CONCLUSION: African women return to a social context within which depression is increasingly prevalent. Establishing psychological services relevant to needs as well as means of ensuring that therapeutic gains extend to their social context are considered.

Investigating the mental abilities of rural Zulu primary school children in South Africa.

INTRODUCTION: Maximising the full potential of health and educational interventions in South African schools requires assessment of the current level of mental abilities of the school children as measured by cognitive and scholastic tests and the identification of any barriers to improved performance. OBJECTIVES: This study reports on the application and interpretation of a selected battery of mental ability tests among Zulu school children and the methodological and analytical issues that need to be addressed. DESIGN: The test scores of 806 primary school children from a rural community are presented, based on four tests: Raven's Coloured Progressive Matrices (CPM), an Auditory Verbal Learning Test (AVLT), the Symbol Digit Modalities Test (SDMT) and Young's Group Mathematics Test (GMT). RESULTS: Significant gender differences were found in the test scores, and the mean scores of Zulu children in this study were lower than those reported in other studies. The results of this selected test battery provide data for the further development of appropriate test instruments for South African conditions. CONCLUSION: These results can contribute towards the development of a test battery for South African children that can be used to assess and improve their school performance.

Providing mental health services to survivors: a Kwa Zulu-Natal perspective.

The Truth and Reconciliation Commission (TRC) was established to deal with the history and future prevention of the abuse of human rights in South Africa. It aimed to restore relationships between the state and/or other perpetrators and victims of violence. Nevertheless, the process has highlighted the alarming prevalence of psychological trauma in our society. This paper reports on a study of individuals and/or families who presented their testimonies to the TRC in the Kwa Zulu-Natal and Free State Provinces of South Africa. The participants were asked to complete a semi-structured questionnaire designed by the author and a Post-traumatic Stress Disorder Checklist. Most witnesses had recognisable psychiatric disorders. The most common was post-traumatic stress disorder (chronic), followed by either anxiety and mood disorders. The results from this study point to the pervasiveness and seriousness of the sequelae of trauma experienced by individuals and communities (both victims and perpetrators) in South Africa. Health professionals in South Africa have the mammoth task and responsibility to assist in the process of healing and reparation.

Twenty-four hour ambulatory blood pressure monitoring in general practice.

OBJECTIVES: To assess the role of ambulatory blood pressure (BP) monitoring in the diagnosis of hypertension in general practice. BACKGROUND: Hypertension is usually diagnosed by means of casual office BP readings. However, ambulatory BP monitoring has shown that a significant proportion of patients diagnosed as hypertensive do not in fact have hypertension. METHOD: Sixty-four Indian patients diagnosed as having mild to moderate hypertension by means of casual measurements were subjected to 24-hour ambulatory blood pressure monitoring (ABPM). A BP load of > 35% was classified as true hypertension and < 35% as 'white coat' hypertension. White coat hypertensives were compared with the true hypertensive group with regard to various demographic characteristics, as well as to correlate ABPM and casual BP readings. RESULTS: A 23.44% prevalence of white coat hypertension was found. In addition, the demographic profile of such patients showed a preponderance of non-obese females (73.33%), the majority of whom were on concomitant medication (60%). A poor correlation was found between the casual office BP readings and the 24-hour ambulatory BP readings in the white coat hypertensive group compared with the true hypertensive group. CONCLUSION: White coat hypertension is common in patients diagnosed as having mild to moderate hypertension by means of casual BP readings. There are no reliable clinical indicators to identify patients with white coat hypertension. ABPM has been shown to be a useful method for differentiating white coat hypertensive groups from true hypertensive groups.

A double-blind, placebo-controlled, double-centre study of the effects of an oral multivitamin-mineral combination on stress.

OBJECTIVES: To assess the effects of a multivitamin-mineral combination (Berocca Calmag) treatment on stress in a large sample of South Africans. METHOD: This was a multiple-dose, double-blind, placebo-controlled, double-centre study. Patients were drawn from two centres with high stress levels (Durban and Johannesburg), each study recruiting the same number of patients (150) from 1,000 adults with predetermined high stress levels. Dropouts from the study were replaced. Study medication safety was evaluated by recording adverse events. On day 1 (baseline) patients were subjected to an individual in-depth assessment that included a biographical questionnaire, four psychological scales, and collateral information from close relatives. On day 30 (end of the study period) or at the latest 7 days after the last planned medication intake, the assessment was repeated for purposes of pre- and post-response comparison. RESULTS: Thirty-three patients dropped out and were replaced, leaving 300 patients who completed the study--151 in group 1 (multivitamin-mineral combination), and 149 in group 2 (placebo). There were no statistically significant differences between the two groups regarding demographics and baseline stress scores at study entry. Both groups improved between baseline and the end of treatment as assessed. The degree of improvement was statistically significant and greatest in group 1 for all psychometric instruments, with this beneficial effect increasing over the course of the day. Subgroup analyses for age (18-44 and 45-65 years), gender and ethnicity showed no general effect on the overall study outcome. CONCLUSIONS: The multivitamin-mineral combination tested is well tolerated and can be used as part of a treatment programme for stress-related symptoms at the recommended dose.

Cigarette smoking behavior among South african Indian high school students.

OBJECTIVE: The aim of the study was to assess the knowledge, attitude and practice of cigarette smoking behavior (CSB) in a sample of Indian matriculation students. METHODOLOGY: All (N=325) Indian matriculation students, at high schools, in Northern Kwa-Zulu Natal, South Africa, were included in the study. A questionnaire was administered to assess knowledge, attitudes and practice of CSB. RESULTS AND CONCLUSION: The study showed a prevalence of 16.9%. Most smokers (98.2%) had commenced the practice after the age of 10 years. The most common reason given for CSB was experimentation (83.6%). Main influence was family members followed by teachers and advertisements. The association between smoking and lung cancer was well-known by smokers (90.7%). There was very little awareness of anti-smoking programmes or organizations. Alarmingly, there was little formal health education on the dangers of smoking in schools. The implications of these results are discussed and recommendations on decreasing CSB are made.

Parasuicide in a general hospital in South Africa.

The study examined parasuicide behaviour in black (people of African origin) South Africans. The subjects comprised 51 cases of parasuicide, with a mean age of 23.5 yr. (the majority being women), referred over a one-year period. For most patients it was the first parasuicide attempt, and the majority used methods of self-poisoning. In addition, they were mostly single and had experienced early parental loss.

Illness behaviour in live-related and cadaver renal transplant recipients.

Illness behaviour was compared in 10 biologically live-related and 30 cadaver renal donor recipients in respect of their long-term psychological adjustment. The results indicated few long-term statistically significant differences postoperatively in illness behaviour between the two groups of patients, but a factor analysis revealed 8 items that were significantly related to illness behaviour associated with post-transplant psychological adjustment for all 40 transplantees studied. These were feelings of inadequacy; the renal graft being 'alien'; an inability to cope with the transplant; the disease resulting in the transplant being an external imposition beyond their control; responsibility for and acceptance of the transplant as a 'gain'; culpability for what has happened to them; anxious preoccupation with long-term prognosis; and dependence on others. Further analysis of these findings and their relevance for optimal patient management are discussed. Appropriate psychological support for these patients is important and, although long-term illness behaviour of biologically live-related and cadaver-related renal transplant recipients was found to be relatively similar, the various issues related to post-transplant illness behaviour in both groups of patients should be addressed in the provision of a psychonephrology service to a renal unit.

Depression and self-report disclosure after live related donor and cadaver renal transplants.

Important psychological reactions are associated with renal transplantation in general. Differences in psychological adjustment between recipients of kidneys from cadavers (CRs) and recipients of kidneys from live related donors (LRRs), however, have been poorly researched. In this study 10 LRRs (mean age 35,7 years; mean number of years after transplant 4,5) were compared with 30 CRs (mean age 38,6 years; mean number of years after transplant 5,3). The prevalence of depression and self-disclosed stress-inducing factors which might have affected long-term psychological adjustment after the transplant were investigated. The psychological status of each patient was assessed by means of a clinical interview, a mental status examination, the Beck Depression Inventory and a self-report questionnaire. There were found to be no long-term statistically significant differences between the LRR and CR groups in terms of the prevalence of depression, although 20% of the patients overall were depressed to varying degrees. The CR group was more concerned about the psychological and personal characteristics of the donors and their families than the LRR group, who expressed concern about the future well-being of the donors. Many members of both groups expressed having experienced both fear of graft rejection, before and immediately after the transplant, and anxiety, which decreased with time. The therapeutic value of a positive psychological climate in the renal unit and of supportive family relationships was confirmed for both groups. In comparison with their existence while on dialysis, most of the patients, irrespective of donor type, ultimately enjoyed an enhanced quality of life.