Biomedical subjects
Publications and source records attributed to B V Reifler.
In both Japan and the United States, families provide most of the care to Alzheimer patients, but in Japan, the patient is more likely to live in a multi-generational setting. Three types of programs are described and compared: support groups, day care centers, and institutional care. Despite rapid growth in services, neither country yet provides a uniformly satisfactory level of service.
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Adverse drug reactions causing cognitive impairment are an important problem in the elderly. Thirty-five patients with adverse drug reaction were identified among more than 300 patients evaluated for cognitive impairment and compared with patients without adverse drug reaction. Sedative hypnotic agents, especially long-acting benzodiazepines, were the commonest drugs associated with cognitive impairment in this population. The number of drugs used, use of sedative hypnotics and antihypertensives, and falling were strongly associated with adverse reactions in logistic regression analyses. The relative odds of an adverse reaction associated with cognitive impairment increased as the number of prescription drugs increased, exceeding 9.0 for patients taking four or more prescription drugs. Adverse drug reactions are an important source of excess morbidity in patients with dementia or suspected dementia. Strategies that could minimize this problem include a high index of suspicion, drug-free trials in suspected cases, and careful monitoring of drug therapy.
An outpatient evaluation and treatment program for cognitively impaired elderly and their families opened at the University of Washington in 1978. The multidisciplinary approach includes psychiatric, medical, psychological, social, and environmental assessments. The program has been well received by the public and has served as a model for similar programs elsewhere. An important finding from the clinic has been to demonstrate the high frequency of excess disability in patients with dementia of the Alzheimer's type.
This retrospective review of medical records was designed to address three questions: 1) Can the depression seen in some patients with Dementia of the Alzheimer's Type (DAT) be successfully treated? 2) Does this treatment lead to any long-term improvement in the patient's cognitive status? and 3) Do patients with coexisting DAT and depression have a different long-term clinical course than nondepressed DAT patients? In the authors' sample of 131 DAT subjects, 41 (31%) also met DMS-III criteria for a major affective disorder. Of those DAT plus depression patients whose records reflected treatment (usually with a tricyclic antidepressant), 85% (17 of 20) showed clear evidence of improvement in mood, vegetative signs, or activities of daily living (ADLs) based on review of the medical record. An analysis of change in cognitive function (measured by the Folstein Mini-Mental State) and five global measures failed to reveal any differences between the depressed and nondepressed groups after a mean interval of 17 months. The depression that occurs in approximately one-quarter to one-third of DAT patients appears to respond to appropriate therapy. These patients often show improvement in their mood and ADLs but remain demented.
A new classification for mixed cognitive-affective disorders in the elderly is proposed. In Type 1, patients have depression as their only diagnosis, and the cognitive impairment resolves with treatment for the affective disorder. In Type 2, patients have two diagnoses--depression and dementia--and when the depression is treated, there is usually improvement in mood but not in cognitive ability. A review of the literature suggests that the number of Type 1 cases has been overestimated, and the number of Type 2 cases, underestimated.
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We studied the components of the diagnostic evaluation in 200 patients older than 60 years of age with suspected dementia who received standardized diagnostic evaluation and follow-up. The most common dementia diagnoses were Alzheimer's-type dementia (74.5%) and dementia due to toxic effects of drugs (9.5%). Eleven patients with hypothyroidism, metabolic encephalopathies due to hyponatremia, hyperparathyroidism, and hypoglycemia required laboratory tests for diagnosis, whereas the other dementia diagnoses were made primarily on the basis of data available on the history and physical and neurologic examinations. The complete blood cell count, blood chemistry battery (especially sodium, calcium, and glucose concentrations), and thyroid function tests were of definite value for the diagnosis of unsuspected disease and were useful as routine tests in evaluating patients for dementia. A careful history and physical examination accompanied by complete blood cell count, chemistry battery, and a thyroid function test would have been effective in diagnosing treatable illnesses causing cognitive impairment. Other diagnostic tests could have been used selectively based on results of the examination and screening tests. Estimated diagnostic charges from a selective approach would be 25% to 34% of those for the "routine" evaluation.
A standardized evaluation was carried out in two separate groups of patients with dementia to determine the features that characterize those with potentially reversible or treatable dementia. In both groups, Alzheimer's-type dementia was the most common diagnosis (65% and 70%); the most common cause of potentially reversible cognitive impairment was medication toxicity. In both groups, patients with potentially reversible dementia had a shorter duration of symptoms, less severe dementia and used more prescription drugs. Because of this association, these features may be considered risk factors but are not distinguishing or diagnostic features of patients with potentially reversible dementia. Other, previously undetected, treatable illnesses not often considered in the differential diagnosis of potentially reversible or treatable dementia were also prevalent in these patients.
A standardized diagnostic evaluation was performed on 200 consecutive patients over age 60 with suspected dementia. Diagnoses were confirmed by consensus and subsequently by follow up. Over 70% had Alzheimer's type dementia; 31% had more than one illness contributing to the dementia state, with overlap between the two groups. The most common so-called "treatable" illnesses were drug toxicity, hypothyroidism, and other metabolic diseases; 248 other medical diseases were recognized in 124 patients. Improvement occurred in 55 patients (27.5%) and persisted in 28 (14%) for at least a year during follow up, but only 2 patients recovered normal mental function. Our results emphasize the importance of recognizing and treating the multiple illnesses that contribute to dementia in elderly adults. The distribution of illnesses in demented elderly outpatients is different from that reported in younger patients with dementia. Diagnostic strategies and expectations need to be based on data obtained from studies of elderly patients with suspected dementia.
We briefly touched on the excitement, then quickly moved into the trenches. There are models for providing accurate assessments, both for patients with dedicated families and for those who are isolated. The models are imperfect, and await improvement from our colleagues and students. We have also documented the fact that families know what they are talking about (hardly a revelation to experienced clinicians). A refinement in the diagnosis of Alzheimer's disease is that depression and medical illness are more likely to aggravate Alzheimer's than to imitate it. An understanding of this element will help in keeping our evaluation and treatment plans accurate and useful. There is plenty of work for all of us--scientists, clinicians, and caretakers--who are involved with the assessment and long-term care of those with Alzheimer's. We may use different means toward the common goal of reducing suffering, but we all need each other.
Assessment was made of the impact of depression on the intelligence, memory, and functional competence of elderly community residents (aged 57-88 years) with senile dementia of the Alzheimer's type. Outpatients with either dementia (n = 21) or dementia coexisting with depression (n = 14) were given the Wechsler Adult Intelligence Scale (WAIS), Wechsler Memory Scale (WMS), and Dementia Rating Scale (DRS). No significant group differences were found for verbal IQ, performance IQ, or WMS memory quotient. Patients with coexisting dementia and depression earned significantly lower full scale IQ scores than patients with only dementia. Analysis of WAIS and WMS subtest scores and profiles revealed no difference between the two groups. Significant associations were found among the various cognitive measures and functional competence in both groups, but the patterns of these relationships differed. Intellectual measures accounted for the greatest proportion of functional competence variance in the patients with dementia, whereas memory measures accounted for the greatest proportion of variance in the patients with coexisting dementia and depression.
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We prospectively studied the evaluation of dementia in 107 unselected outpatients; 83 had so-called "irreversible" dementias, including 74 who had an Alzheimer-type dementia. Fifteen patients had potentially reversible dementias, of which hypothyroidism and drug toxicity were the commonest causes. Distinguishing features of reversible dementia were shorter duration, use of more prescription drugs, and less severe dementia. Almost half of the patients had other previously unrecognized treatable medical diseases. Most diagnoses were made from patient history and physical and mental status examination. Patients with reversible dementia improved but rarely reverted to normal. Objective improvement occurred in 25 patients after treating unrecognized coexistent medical and psychiatric diseases, or stopping unnecessary medication. Careful clinical observation is the most useful part of the evaluation and extensive testing may not be required for all patients. Overemphasis on distinguishing reversible from irreversible forms of dementia may detract from recognition of commoner, treatable causes of dysfunction and suffering.
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The term pseudodementia should be avoided in clinical practice. Its importance lies in the fact that it has alerted clinicians to the existence of potentially reversible, or at least treatable, cases of intellectual dysfunction. However, two major problems are associated with its use. First, it implies that the patient has either an organic or a functional illness, whereas many patients have elements of both, especially when depression is superimposed on a true dementia. Second, the term is often mistakenly used diagnostically, whereas it is only descriptive. The term cognitive impairment is preferable to pseudodementia.
The authors report on more than 2,000 impaired elderly people who were referred to a geriatric outreach program during its first 5 years of operation. These patients were referred by a wide variety of professionals and private citizens, who were usually concerned about the person's ability to care for himself or herself or about psychiatric symptoms. The most common diagnosis was dementing illness (21% of the patients), followed by depression (13%). Intervention usually involved making appropriate plans based on an accurate diagnosis, often including coordinating the services of other agencies. A follow-up of 100 patients showed that most of the patients who were still living had maintained their independence.
The authors diagnosed depression in 20 (23%) of 88 cognitively impaired geriatric outpatients. Three (20%) of these patients had depression only, and 17 (85%) had depression superimposed on an underlying dementia. The rate of coexisting depression decreased significantly with greater severity of the cognitive impairment: 9 (33%) of 27 mildly impaired patients were depressed, compared with 8 (23%) of 35 moderately impaired and 3 (12%) of 26 severely impaired patients. There was a nonsignificant trend for cognitively impaired women to be more likely to be depressed than for similarly impaired men. The authors conclude that although depression must be differentiated from dementia, it is equally important to consider the possibility that the diagnoses coexist.