Equity in the new NHS. Evidence cannot help in all situations.
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Donepezil↗
Biomedical subjects
A J Macdonald
Publications and source records attributed to A J Macdonald.
Maintaining older people's dignity and autonomy in healthcare settings. Whole system must be looked at to prevent degrading treatment.
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Aged↗
HoNOS 65+ glossary.
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Health Status Indicators↗
ABC of mental health. Mental health in old age.
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Aged↗
Outcome of delirium: Part 1. Outcome of delirium diagnosed by DSM-III-R, ICD-10 and CAMDEX and derivation of the Reversible Cognitive Dysfunction Scale among acute geriatric inpatients.
OBJECTIVE: To study performance of DSM-III-R, ICD-10 and CAMDEX diagnoses of delirium as predictors of improvement in mental state in survivors, and to develop a brief rating scale which will predict reversibility of cognitive dysfunction. DESIGN: Prospective cohort study. SETTING: Acute geriatric inpatient units. PATIENTS: A random sample of consecutive acute admissions of patients over the age of 65 (N = 80). MAIN MEASUREMENTS: Serial assessments of mental state and cognitive function and observational data. Establishment of DSM-III-R, ICD-10, CAMDEX diagnoses. OUTCOME MEASURE: Patients with more than five points of 20% improvement in Mini Mental State Examination following the most severely impaired assessment operationally designated 'reversible cognitive dysfunction'. MAIN RESULTS: Diagnoses of delirium by DSM-III-R and ICD-10 do not predict improvement in cognitive function well; CAMDEX does rather better. Discriminant function analysis yielded the Reversible Cognitive Dysfunction Scale (RCDS), a simple clinical scale which accurately predicted improvement. This comprised reduced conscious level, poor attention, poor contact with the patient, incoherent speech, reduced psychomotor activity, lack of awareness of surroundings and poor orientation and memory. CONCLUSIONS: The concept of and diagnostic criteria for delirium should be reconsidered. The RCDS merits further evaluation.
Acute Disease↗
Outcome of delirium: part 2. Clinical features of reversible cognitive dysfunction--are they the same as accepted definitions of delirium?
OBJECTIVE: To describe the clinical features of reversible cognitive dysfunction. DESIGN: Prospective cohort study. SETTING: Acute geriatric inpatient units. PATIENTS: A random sample of consecutive acute admissions of patients over the age of 65 (N = 80). MAIN MEASUREMENTS: Serial assessments of mental state and cognitive function and observational data. OUTCOME MEASURE: Patients with more than five points of 20% improvement in Mini Mental State Examination following the most severely impaired assessment operationally designated 'reversible cognitive dysfunction'. The clinical features of those with RCD are compared with those with non-reversible cognitive dysfunction. MAIN RESULTS: Delusions, hallucinations, aggression, excitement, irritability and other 'active' symptoms were not commoner in RCD than in non-reversible cognitive dysfunction (non-RCD). By contrast, 'quiet' signs, such as plucking at bedclothes, poor attention, incoherent speech, abnormal associations, slow, vague thought and fluctuating mental state were more marked in RCD than in non-RCD. CONCLUSIONS: Reversible cognitive dysfunction is a quiet and unobtrusive disorder.
Acting Out↗
Randomised controlled trial of effect of intervention by psychogeriatric team on depression in frail elderly people at home.
OBJECTIVE: To investigate the efficacy of intervention by a psychogeriatric team in the treatment of depression in elderly disabled people receiving home care from their local authority. DESIGN: Randomised controlled trial with blind follow up six months after recruitment. SETTING: Community of south east London. SUBJECTS: 69 people aged 65 or over who received home care and were depressed according to criteria of the standardised automatic geriatric examination for computer assisted taxonomy (AGECAT). 33 were randomly allocated to an intervention group and 36 to a control group. INTERVENTION: Members of the intervention group received an individual package of care that was formulated by the community psychogeriatric team in their catchment area and implemented by a researcher working as a member of that team. The control group received normal general practitioner care. MAIN OUTCOME MEASURES: Recovery from depression (AGECAT case at recruitment but non-case at follow up). RESULTS: Data were analysed on an intention to treat basis. 19 (58%) of the intervention group recovered compared with only nine (25%) of the control group, a difference of 33% (95% confidence interval 10% to 55%). This powerful treatment effect persisted after controlling for possible confounders in logistic regression analysis, with members of the intervention group more likely than members of the control group to have recovered at follow up (odds ratio 9.0 (2.0 to 41.5)). This did not seem to be a simple effect of antidepressant prescription: use of antidepressants at follow up did not have a significant effect (multiply adjusted odds ratio 0.3 (0.0 to 1.9)). CONCLUSIONS: Depression is treatable in elderly people receiving home care. Therapeutic nihilism based on an assumed poor response to treatment in these socially isolated, disabled elderly people in the community is not supported.
Aged↗
Pupillary response to topical tropicamide as a marker for Alzheimer's disease.
The mydriatic response to eyedrops of the anticholinergic drug tropicamide at very low concentration (0.01%) was studied in subjects with Alzheimer's disease (AD, n = 10) and multi-infarct dementia (MID, n = 10). There was no significant difference in pupillary response between the two groups. The test is unlikely to be useful in differentiating different types of dementia.
Administration, Topical↗
Delirium and dementia; are they distinct?
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Aged↗
The impact of an integrated haematology screening system on laboratory practice.
The haematology laboratory of the Royal Postgraduate Medical School is required to handle an increasing workload with decreasing financial resources. An investment in technology was made in order to improve efficiency, meet future demands and to meet high technical standards. This required an increase in automation in the Full Blood Count section with staff redeployed into growth areas. The Sysmex HST 330, comprising an SE 9000 full blood count analyser, R 3000 reticulocyte counter, SP 1 film preparation unit, linked by a transport system was chosen as a comprehensive system. To fully exploit the reflex-testing capabilities and maximize the potential of the HST a computerized decision-making algorithm was developed. We have been able to evaluate the impact of a highly automated approach to FBC screening in a busy diagnostic laboratory.
Algorithms↗
Johne's disease in a herd of farmed red deer.
An outbreak of Johne's disease in a herd of farmed red deer was studied for four years. Serological, histopathological and cultural techniques were used to monitor the progress of the disease, and delayed type hypersensitivity skin tests were also applied. The results of the serological tests showed that they were poor predictors of future clinical cases and did not consistently identify animals harbouring mycobacteria. The histopathological methods provided a sensitive and specific means of confirming the infection. The skin tests had a low sensitivity and the results were poorly correlated with the serological results in seropositive animals. A vaccination policy was instituted which was accompanied by a change in the pattern of disease. Although the histopathological evidence suggested that the infection was still occurring, there was a marked reduction in the incidence of clinical disease. Vaccinated animals showed a good response to the skin test.
Animals↗
Recognition of cognitive impairment by day and night nursing staff among acute geriatric patients.
The recognition of cognitive impairment by day and night nursing staff was studied in an acute geriatric unit. Seventy-six patients were randomly selected from a prospective sample of admissions. DSM-III-R diagnoses were established on all patients. Day and night staff were interviewed about each patient's clinical condition and asked to state whether or not they thought they were cognitively impaired or confused. Day staff were reasonably good at differentiating cognitively unimpaired from those with dementia and or delirium [kappa = 0.62, 95% confidence interval (CI) = 0.46-0.78]. All patients thought by day staff to be cognitively impaired were found to be so, although day staff did fail to identify some patients with cognitive impairment. Night staff performed less well (kappa = 0.37, 95% CI 0.18-0.57) and identified cognitively normal patients as being cognitively impaired, as well as failing to identify patients who were cognitively impaired. Night nursing interviews were not thought to have contributed to the management of any patient. The usefulness of night-time nursing interviews for research and general inpatient management purposes is questioned and the importance of daytime nursing interviews emphasized.
Aged↗
Systemic family therapy in adult psychiatry.
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Adult↗
Release of leukotriene C4 (LTC4) from human eosinophils following adherence to IgE- and IgG-coated schistosomula of Schistosoma mansoni.
The release of leukotriene C4 (LTC4) from human low-density eosinophils following adherence to live or formalin-fixed schistosomula of Schistosoma mansoni coated with parasite-specific IgE or IgG obtained from pooled human anti-S. mansoni serum has been studied. IgE-rich fractions were obtained after fractionation of pooled immune sera on fast-protein liquid chromatography (FPLC; polyanion SI-17 column) and were identified by parasite-specific RAST. Contaminating IgG was removed by adsorption on a Staphylococcus aureus-protein A affinity column. IgG-rich FPLC fractions were identified by a specific ELISA assay. IgG-dependent activities were confirmed by protein A adsorption. Low-density eosinophils adhered to live and formalin-fixed schistosomula coated with specific antisera and released 11.7 +/- 2.7 and 16.5 +/- 3.5 pmoles of LTC4/10(6) cells, respectively. LTC4 release induced by A23187 (5 x 10(-6) M) from the same cells was 80 +/- 24 pmoles/10(6) cells and 9.9 +/- 1 pmoles/10(6) cells in the presence of Sepharose particles (CNBr-activated 4B beads) covalently coated with normal human IgG. Fixed schistosomula coated with FPLC-purified IgE and IgG gave 7.6 +/- 0.4 and 6.0 +/- 0.1 pmoles of LTC4 per 10(6) low-density eosinophils, respectively. The same IgE- and IgG-rich fractions induced eosinophil-mediated cytotoxicity of live schistosomula in vitro. Removal of IgE by an anti-IgE affinity column abolished both the IgE-dependent release of LTC4 and the in vitro killing of larvae. Conversely, IgG-dependent activities were abolished by protein A, but not anti-IgE, adsorption. Normal density eosinophils generated undetectable amounts of LTC4 when incubated with IgE-coated schistosomula, whereas with IgG-coated larvae 4.6 pmoles/10(6) cells were obtained. Following preincubation with platelet-activating factor (PAF) (10(-7) M) and leukotriene B4 (LTB4) (10(-7) M), normal density eosinophils released LTC4 when in contact with larvae coated with antigen-specific IgE. Lyso-PAF had no effect in any of the systems tested. The synthetic chemotactic tripeptide formyl-methionyl-leucyl-phenylalanine (FMLP) had no influence on IgE-dependent release of LTC4 from eosinophils. In contrast, FMLP (10(-7) M) enhanced the IgG-dependent LTC4 release, with PAF and LTB4 also showing a small enhancing effect. None of these agents substantially altered the release potential of low-density eosinophils in either IgE- or IgG-dependent events. Thus the results presented here indicate that in an IgE-dependent system, human low-density eosinophils can be induced to adhere to and kill IgE-coated helminthic targets and release biologically relevant amounts of LTC4.(ABSTRACT TRUNCATED AT 400 WORDS)
Animals↗
Paradoxical intervention.
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Behavior Therapy↗
Performance of lambs on a clean grazing system compared with lambs on a traditional system.
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Animal Feed↗
Effect of disodium cromoglycate on activation of human eosinophils and neutrophils following reversed (anti-IgE) anaphylaxis.
Immunological release of histamine and lipid mediators is known to occur when basophils, contained in whole blood human leucocytes, are incubated with anti-IgE (reversed anaphylaxis). In the present study we show that IgE-dependent stimulation of basophils was associated with activation of bystander eosinophils and neutrophils, as assessed by enhanced complement (C3b) and IgG (Fc) rosettes, and increased cytotoxicity for complement-coated schistosomula of Schistosoma mansoni. These changes in eosinophil and neutrophil function were totally inhibited in a dose-dependent fashion by prior incubation with disodium cromoglycate (DSCG). In all in vitro systems examined, complete inhibition of enhancement was observed with concentrations as low as 10(-7) moles/l. In contrast, DSCG had no effect on histamine release, or the percentage of rosettes or cytotoxicity prior to anti-IgE stimulation. These results suggest that DSCG inhibits activation of inflammatory cells consequent to an IgE-dependent stimulus.
Anaphylaxis↗