Risk of mortality and institutionalization in demented patients with delusions.

Delusions are a common symptom during the course of dementia. Despite their clinical relevance, however, it is still unclear whether they are of prognostic value. This longitudinal study involving, at baseline, 99 demented Alzheimer disease (AD) and multi-infarct dementia (MID) patients, investigates the risk of mortality and institutionalization at 2 years after discharge from a dementia unit in patients with and without delusions at baseline. Results indicate that the presence of delusions is a significant predictor of future institutionalization (odds ratio 3.6, confidence interval 1.3-9.6), even when confounding factors such as age, educational level, and severity of cognitive and functional impairment are statistically controlled. No significant impact on survival was found.

Comorbidity and its effect on mortality in nursing home patients with dementia.

The relation between comorbidity and survival was investigated in an 8-year follow-up study of 606 nursing home dementia patients by means of proportional hazards analysis. Two-year survival rates for women (N = 437) and men (N = 169) were 60% and 39%, respectively. Parkinsonism, atrial fibrillation, pulmonary infection, and malignancies were powerful predictors: they more or less doubled the mortality chances. Stroke patients with a pulmonary infection had a particularly poor prognosis. More severely demented patients had more comorbidity than less severely demented patients, but the impact of comorbidity on survival did not depend on severity of dementia. Patients coming from a hospital had more comorbidity and were more severely demented than patients coming from home, but this did not modify the effects of age, gender and comorbidity in a multivariate survival model. It was concluded that comorbidity and severity of dementia independently influence mortality. Thus a better prognostic judgment is obtained from their combination than from each separately.

Long-term survival and predictors of mortality in Alzheimer's disease and multi-infarct dementia.

Long-term survival was examined for 218 patients with Alzheimer's disease (AD) and 115 patients with multi-infarct dementia (MID). The 14-year survival rate for AD was 2.4% versus an expected rate of 16.6%, and for MID 1.7% versus 13.3% expected. MID showed a more malignant natural course than AD. Men carried a less favourable survival prognosis than women, both in AD and MID: the relative risk of dying for women was half that for men in both diseases. In MID, advanced disability indicated a relative risk of dying over twice as high. In both diseases the risk of death was substantially higher in the event of occurrence of primitive reflexes.

Stroke in the elderly.

The incidence of stroke increases dramatically with advancing age. Progressive carotid atherosclerosis, cardiac arrhythmia and emboli, and vascular changes all contribute to this increasing incidence of stroke in the elderly. Treatment of hypertension and other risk factors have resulted in a decline in stroke over the last 50 years. The decline has been most prominent in the elderly. In recent years, this decline has slowed down or may even be reversing. Early and effective control of risk factors together with comprehensive management of acute stroke in a specialized unit is needed to further improve prognosis. Such an approach is especially important in the elderly, who may suffer from multiple problems. Treatment of hypertension and other risk factors have resulted in a decrease in an overall decline in the incidence of stroke over the last 50 years. This decline has been most apparent in the elderly. In recent years, however, there has been a slowing or possibly a reversal of this trend. Early and effective management of risk factors, aggressive therapy of patients with transient ischemic attacks and comprehensive management of acute stroke patients in specialized units may be required to further improve prognosis.

[Acute prognosis and differentiation of various cerebral infarct groups in comparison with cerebral hemorrhage]. / Akutprognose und Differenzierung verschiedener Hirninfarktgruppen im Vergleich mit Hirnblutungen.

For clinical trials classification of stroke should be possible at the bedside by simple methods that are available every where. In this study are 1105 patients with every first ischaemic strokes and 130 patients with intracerebral haemorrhages. The differences between severity of clinical symptoms, outcome and risk factors of intracerebral haemorrhages, ischaemic stroke caused by cerebral microangiopathy, ischaemic stroke combined with extracranial carotid stenosis, cardiogenic brain embolism and atherothrombotic stroke, were analysed. Intracerebral haemorrhages show the poorest outcome of all groups (mortality 23.8%), due to increased intracranial pressure. Cardiogenic brain embolism is more frequent in older women (mean age 77.8 y.). Main risk factor is atrial fibrillation with absolute arrhythmia. The outcome of this group is the worst of all subgroups of ischaemic stroke and survivors most often in need of institutionalization. Patients with ischaemic stroke combined with extracranial carotid stenosis are significantly younger (mean age 67.6 y.), predominantly male, and smokers. Their mortality is low (0.63%), but recovery of paresis is slower than in other subgroups. Ischaemic strokes caused by cerebral microangiopathy with hypertension as main risk factor recover most quickly but acute mortality is higher than in ischaemic stroke combined with extracranial carotid stenosis because of higher age (mean age 74.5 y.). Institutionalization is more frequent too because of higher incidence of dementia in this subgroup. The main prognostic factors of all groups are age and severity of clinical symptoms. A special subgroup are infratentorial ischaemic strokes.(ABSTRACT TRUNCATED AT 250 WORDS)

[Psychiatric disorders in elderly general hospital patients: incidence and long-term prognosis]. / Psychische Erkrankungen von älteren Allgemeinkrankenhauspatienten: Häufigkeit und Langzeitprognose.

As part of a survey conducted in six general-hospital departments of internal medicine, in the neighbouring cities of Mannheim and Ludwigshafen (total pop. 470,000), 626 patients in the age range 65 to 80 years, all admitted from private addresses, were screened by means of a standardized questionnaire (Cognitive and Affective Screening of the Elderly--'CASE'). All patients whose scores indicated possible mental abnormality, together with a proportion of those having normal scores, were then examined in greater detail, using the Clinical Psychiatric Interview. Following correction, the screening results indicated a frequency of 30.2% for clinically significant psychiatric disturbance, made up of 9.1% with organic mental disorders and 21.1% with functional mental illness only. These rates are considerably higher than could be expected on the basis of a field study of the background population. One year after hospital discharge, the numbers of deaths and of admissions to long-stay care were established for the whole sample, and in addition, individually matched sub-samples of 100 mentally ill and 100 mentally normal patients were reinvestigated. A second follow-up of the matched sub-samples was undertaken after a further interval of 5.6 years on average. The results of follow-up show that 75% of the identified cases ran a chronic or recurring course, while only a small proportion proved to be transient reactions to physical illness or hospital admission. In general, the psychiatrically ill patients had a relatively unfavourable outcome, even after the effects of age, physical disability and other relevant variables had been controlled for. When compared with the matched group of mentally normal patients, they manifested a 43% excess of mortality, and an increase of 157% in the risk for having to be admitted to long-stay care.

[Multi-infarct dementia in nursing home patients; more comorbidity and shorter life expectancy than in Alzheimer's disease]. / Multi-infarctdementie bij verpleeghuispatiënten; meer bijkomende morbiditeit en kortere levensverwachting dan bij de ziekte van Alzheimer.

A retrospective analysis of the medical charts of 117 patients (50 men and 67 women) with multi-infarct dementia took place. All patients admitted to the psychogeriatric nursing home 'Joachim en Anna' in Nijmegen between 1980 and 1989 were studied. The aim of the study was to obtain epidemiological information and to investigate the prevalence of comorbid conditions, prognosis and mortality. The results were compared with patients with Alzheimer's disease. The patients remained in the institute for 1.4 years and the mean total duration of the disease was 5.3 years. About twenty-five percent died in the first three months of admission. Life expectation, counted from time of admission, was 6 years shorter in comparison with Dutch mortality tables. Morbidity frequently seen at admission included circulatory system diseases and cerebrovascular accidents. The risk factor hypertension was seen in a smaller percentage of patients than expected. During the stay the diseases most frequently diagnosed were respiratory and urinary tract infections, adverse effects of drugs, constipation and chronic ulcers of the skin. About twenty percent of the patients were struck by a (recurrent) cerebrovascular accident or a transient ischaemic attack. Most patients died of dehydration or bronchopneumonia. There was, apart from the diagnosis of multi-infarct dementia, no single patient aspect that could predict a poor prognosis. Nursing home patients with multi-infarct dementia are clearly different from patients with Alzheimer's disease. Time spent in the nursing home and duration of disease are shorter. They have more comorbid conditions, especially of a cardiovascular nature, and they have a poor life expectation.

Vascular dementia: a clinical and death certificate study.

We compared the extent of documentation of the diagnoses, vascular dementia and stroke, on inpatient (hospital) medical records and death certificates among 23 multi-infarct dementia index cases and 14 multi-infarct controls without cognitive dysfunction who were enrolled in a hospital-based case-control study and were followed longitudinally. Both the inpatient medical records and the death certificates markedly under-diagnosed vascular dementia when compared to the case-control study diagnosis. Furthermore, the diagnosis of stroke was grossly underdiagnosed on the death certificates. In lieu of the lack of medical record and death certificate documentation of vascular dementia, studies that utilize such information may be in considerable error. Clarification of the criteria for the diagnosis of vascular dementia and greater physician and public awareness of vascular dementia are needed.

Prognosis of transient global amnesia: a long-term follow-up study.

A long-term follow-up study was performed on patients with transient global amnesia (TGA) in order to evaluate the prognosis, the recurrence rate and the occurrence of stroke and dementia. 102 patients (57 women, 45 men; mean age 62.8 +/- 9.4 years) were prospectively included and followed up. The follow-up duration ranged between 12 and 241 months with an average value of 82.2 +/- 51.1 (mean +/- SD). The death rate showed no difference from that of sex- and age-matched subjects. TGA recurred in 19 cases (18.63%). Only 4 patients suffered subsequent stroke, and only 3 showed intellectual deterioration. TGA prognosis was shown to be better than that of RIA and lacunar patients.

Survival in presenile Alzheimer's and multi-infarct dementias.

Duration of survival in patients who had died of presenile Alzheimer's disease (AD) or presenile multi-infarct dementia (MID) in 13 mental hospitals in Scotland are described and contrasted. The duration of survival was significantly longer from symptom onset to death in AD (mean 7.4 years) than in MID (mean 5.8 years). Most of this difference was accounted for by a longer duration between symptom onset and presentation to hospital care in AD (mean 3.2 years) than in MID (mean 2.4 years). Age at onset and gender did not influence survival duration in AD or MID.

Survival of patients with dementia.

The evidence on survival in dementia is summarized. There are no reliable data on survival after onset of dementia or after first contact with medical services. People with dementia in outpatient clinics and nursing homes have 2-year survival rates of 75% (range 60%-95%) and 50% (range 30%-65%), respectively. Differences in survival between patients with senile dementia of the Alzheimer's type (SDAT) and multi infarct dementia (MID) are small. Women in nursing homes have a better prognosis than men (2-year survival rates, 60% vs 40%). Dementia patients have a considerable excess mortality when compared to the vital statistics. There is no evidence for improvement of survival rates during recent decades. Recommendations for future studies are made.

Parietal signs and sinister prognosis in dementia. A four-year follow-up study.

Thirty elderly demented subjects were assessed in 1985 using a neuropsychological test battery which included tests of parietal lobe function that are allegedly predictive of outcome. Four years later, 29 out of the 30 subjects were followed up. Twelve had died. There were no differences between survivors and deceased in terms of age, pre-morbid intelligence, years of full-time education, or scores on parietal tests. However, proportionally more of the women had died, and those subjects with more global cognitive impairment in 1985 were significantly more likely to have died by 1989. Those who scored lower on an aphasia measure in 1985 were more likely to have died. None of the variables differentiated between survivors and deceased Alzheimer subjects.

[Dementia and internal diseases: incidence of internal diseases in Alzheimer dementia, vascular dementia and other dementing diseases]. / Demenz und internistische Erkrankungen: Die Häufigkeit innerer Krankheiten bei Alzheimer-Demenz, vaskulärer Demenz und anderen dementiellen Erkrankungen.

The medical histories and postmortems of 30 patients with neuropathologically verified Alzheimer's disease were compared with a group of 20 patients suffering from vascular dementia and a group of 10 patients with other forms of dementia. The total numbers of clinically or pathologically diagnosed medical disorders did not show significant differences between the different forms of dementia. Metabolic, infectious, degenerative, and malignant disorders occurred with similar frequency in all investigated groups. Cardiovascular diseases were only slightly more common in patients with vascular dementia. In contrast to several earlier clinical or epidemiological studies, it has to be concluded that patients with Alzheimer's dementia cannot be considered physically "healthier" than patients with other forms of dementia. Therefore, they need the same medical attention as do other elderly demented patients.

Cost effectiveness of a training program for dementia carers.

An intensive 10-day residential training program for dementia carers has previously been shown to be associated with increased patient survival at home and decreased psychological morbidity in carers (Brodaty & Gresham, 1989). Results from a further follow-up, about 39 months after entry into the trial, were even more impressive. Patients whose carers had trained in the program had much higher adjusted rates of survival at home (53% versus 13%) and, unexpectedly, fewer deaths (20% versus 41%) than those whose carers did not have training. Patients whose carers had delayed training achieved intermediate results (31% surviving at home and 21% dying). These results were achieved with an average saving of $A7,967 ($U.S.5975) per patient over the first 39 months.

Prediction of survival by the Clifton Assessment Procedures for the Elderly (CAPE).

A sample of 261 elderly patients, most with a diagnosis of dementia, consecutively admitted to a geriatric psychiatry assessment ward, was assessed using the cognitive assessment scale (CAS) and behaviour rating scale (BRS) of CAPE. Scores of patients alive at four follow-up intervals were compared with those of non-survivors. On CAS, survivors scored significantly better at 18- and 48-month follow-up; and better, but not significantly so, at nine- and 36-month follow-up. On BRS, survivors scored significantly better at all four follow-up intervals. Only at 36-month follow-up did the scales predict survival of individual patients more efficiently than did base rates.

Predictors of survival in clinically diagnosed Alzheimer's disease and multi-infarct dementia.

Duration of survival from time of first evaluation was studied in 61 patients with clinically diagnosed Alzheimer's disease (senile dementia of the Alzheimer type [SDAT]) and 34 patients with clinically diagnosed multi-infarct dementia (MID). Duration of survival did not differ significantly between MID and SDAT. However, since MID patients were younger at onset, MID patients had a lower life quotient than SDAT patients. Race, sex, and age at onset were not predictive of survival in SDAT. History of hypertension, elevated systolic blood pressure, lower scores on tests of Block Designs, and Logico-Grammatical Comprehension predicted shorter survival in SDAT. Age at onset and race were not predictive of survival in MID. Male sex, lower educational attainment, as well as low scores on tests of Logico-Grammatical Comprehension, Digit Span, Naming, Verbal Fluency, and receptive vocabulary, predicted shorter survival in MID.

Mortality of demented patients in a geriatric institution.

A group of 237 elderly patients with dementia of Alzheimer type (DAT) or multi-infarct dementia (MID) was randomly selected in a large geriatric institution in Milan. Mean age of the sample was 78.9 years, 160 (67.5%) were DAT patients and 77 (32.5%) were MID patients. Half of the sample had low levels of autonomy and after 4 years 183 (77.2%) patients were dead. Predictors of mortality, according to a univariate analysis, were age, level of autonomy and type of diagnosis (DAT vs. MID). Mortality rate after 4 years was significantly higher (p less than 0.001) in DAT (86.9%) than in MID (57.1%) patients.