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Biomedical subjects

D A Drachman

Publications and source records attributed to D A Drachman.

At least 19 recordsLinked to original sources
PubMed1996

Screening for dementia: Cognitive Assessment Screening Test (CAST).

The Cognitive Assessment Screening Test (CAST) is a self-administered paper-and-pencil test that can be used to screen geriatric patients for dementia. The test is composed of three one-page sections; Part A has 10 simple questions; Part B has five more demanding questions, and Part C has 13 self-report questions. Parts A and B determine whether cognition falls within the normal range or below the threshold for dementia. Part C assesses the patient's perception of a decline in memory and competence. Designed for office use, the CAST requires minimal examiner time and little training or experience to administer. This test is as sensitive and specific as other relatively brief screening instruments for dementia.

Aged↗
PubMed1996

Benchmarking patient satisfaction at academic health centers.

BACKGROUND: In 1991 the University HealthSystem Consortium (UHC), an alliance of 70 academic health centers, began its patient satisfaction benchmarking project. The survey, adapted from the Picker Institute survey, was pilot tested in 1992 and has been in use since 1993. Each year the project's steering committee refines the survey on the basis of member needs and survey item performance. KEY FINDINGS: Findings have shown that the survey can document the effects of specific quality improvement efforts, that patients from different medical services report different levels of satisfaction with their care, and that physician and nursing care have had the greatest impact on overall satisfaction. USING THE RESULTS: Each participating organization receives concise narrative reports of the survey results, with priorities for improvement efforts clearly highlighted. A five-to six-page Executive Summary provides the organization's executive team with a quick overview of the results, as well as a summary of the areas where quality improvements are most needed. A longer Managers' Report provides a more detailed analysis of the findings for quality managers and department heads. Sections for each major area of care can be copied and distributed as "stand alone" reports to the appropriate decision makers. For example, the section on nursing care can be distributed to the chief nursing officer and nurse managers. For each key aspect of the patient's experience, best practices for maintaining patient satisfaction are identified from across the hospitals and compiled into a catalogue. LESSONS LEARNED: The UHC patient satisfaction benchmarking program has created ongoing communication among the participating hospitals, whose staff members have been willing to share problems encountered and possible solutions.

Academic Medical Centers↗
PubMed1996

Rate of progression in familial Alzheimer's disease.

The clinical course of early-onset, dominantly inherited, familial Alzheimer's disease (FAD) was contrasted with late-onset, sporadic Alzheimer's disease (AD). Eight FAD and 23 sporadic AD patients were followed over a mean of 63 months from estimated disease onset. The two groups did not differ notably in duration of symptoms from onset, global disease severity, or degree of cognitive deficits on initial evaluation. The Kaplan-Meier lifetable method was used to assess time from estimated disease onset to dependence in self-care, institutionalization, and death. A greater percentage of FAD patients became dependent in self-care and died earlier than did sporadic AD patients. The lifetable results suggest that FAD may have a more rapid course than dose late-onset sporadic AD.

Activities of Daily Living↗
PubMed1996

Familial and sporadic Alzheimer's disease: neuropathology cannot exclude a final common pathway.

Whether all etiologic forms of Alzheimer's disease (AD) share a final common pathway is a major issue. We determined the severity and regional distribution of neuronal loss, amyloid plaques, neuritic plaques (NPs), and neurofibrillary tangles (NFTs), and calculated the ratio of neuronal loss to NPs and NFTs in brains of 19 familial AD (FAD) patients with linkage to chromosome 14, six AD patients with mutations of chromosome 21 (codon 717 of the beta-amyloid percursor protein gene), and 11 sporadic AD (SAD) patients. There was no difference in the pattern of distribution of the various pathologic features or in the ratio of neuronal loss to NPs or NFTs in any AD group. However, FAD groups could be distinguished from SAD by the greater severity and the lack of influence of apolipoprotein E genotype on pathology. These differences may reflect differences in age at onset rather than different etiopathologic mechanisms. The similarity of pathologic findings in the different AD groups provides evidence for a final common pathophysiologic pathway in AD.

Age of Onset↗
PubMed1995

Apolipoprotein E epsilon 4 allele and the lifetime risk of Alzheimer's disease. What physicians know, and what they should know.

BACKGROUND: Published studies now show a clear association between Alzheimer's disease (AD) and the apolipoprotein E epsilon 4 allele (APOE* epsilon 4). The clinical value of this information to estimate a healthy individual's lifetime risk of AD has not been well delineated. Physicians dealing with AD may not know either the lifetime risk of developing AD or the effect of the APOE genotype on this risk. Because the lifetime risk of AD depends in part on life expectancy, and available figures on APOE are not population based, a computation is necessary to derive risk estimates useful to physicians. OBJECTIVES: To estimate the lifetime risk of AD and the effect of APOE genotype information on that risk and to assess the knowledge of these risks among physicians who manage patients with dementia. DESIGN: Estimation of risk of AD and survey of physician awareness. The lifetime risk of developing AD without APOE genotype information was first computed for 65-year-olds from existing epidemiologic studies of age-related AD incidence and an actuarial life-table analysis. Using this computed a priori risk of AD and published studies of APOE genotypes in individuals with and without AD, we used a Bayesian analysis to determine the risk of developing AD, with and without an APOE* epsilon 4 allele, for unaffected 65-year-olds. To assess physician knowledge of the lifetime risk of AD and the effect of APOE genotyping on the risk, 50 neurologists, internists, geriatricians, geriatric psychiatrists, and family physicians who manage patients with dementia were randomly selected to participate in a questionnaire-driven telephone survey. RESULTS: In a person with no family history of AD, the epidemiologic/actuarial lifetime risk of AD is approximately 15%. Based on a Bayesian calculation and published APOE data, the lifetime risk of AD is 29% for individuals with one APOE* epsilon 4 allele and it is 9% if no APOE* epsilon 4 allele is present. Physician awareness survey results were as follows: 42% of physicians correctly estimated the approximate lifetime risk of AD; of these, only one third were moderately sure of their response. Only three physicians correctly estimated the change in risk given the APOE* epsilon 4 genotype; only one of these was at least moderately sure. CONCLUSIONS: Determining the APOE* epsilon 4 status of healthy adults with no family history of AD approximately doubles (for the epsilon 4 allele) or reduces by 40% (for the non-epsilon 4 allele) the uninformed lifetime risk of developing AD. Even with an APOE* epsilon 4 allele, the lifetime risk remains below 30%. Most physicians managing patients with AD do not know the lifetime risk of AD, and very few know how APOE* epsilon 4 status modifies the risk. These clinically relevant risk figures should be more widely disseminated among physicians.

Actuarial Analysis↗
PubMed1995

ERP indices and neuropsychological performance as predictors of functional outcome in dementia.

We compared the relative value of neuropsychological and event-related potentials (ERPs) obtained during both passive and active auditory oddball paradigm measures for determining functional outcome in dementia 4 years following initial assessment. Functional outcome was assessed by structured interview of family members of 29 patients with dementia, and patients' functional status was rated in seven areas: mortality, incontinence, institutionalization, ADL dependence, verbal responsiveness, recognition of family members, and capacity for social interaction. A total functional outcome score (ADLTOTAL) was obtained by summing across these individual outcome measures. Many of the neuropsychological measures correlated strongly with overall functional outcome, whereas P3 amplitude and latency on the active ERP condition were the only ERP indices to predict functional outcome. When ERP and neuropsychological measures were considered simultaneously using stepwise multiple regression analyses, the neuropsychological measures were better predictors of most functional outcomes, although P3 latency was the best predictor of mortality. However, neuropsychological performance and ERPs appear to be sensitive to different functional outcomes. Therefore, evaluation of both ERPs and neuropsychological performance may ultimately have prognostic utility in the assessment of patients with dementia.

Aged↗
PubMed1995

Role of the dorsomedial nucleus of the thalamus in Alzheimer's disease.

It is not known whether changes in the thalamus play a role in the memory loss or dementia of Alzheimer's disease (AD), although trauma, infarction, and hemorrhage to the thalamus, particularly the dorsomedial nucleus (DMN), can cause these cognitive changes. To determine the pathologic changes in the DMN in AD, we examined the DMN in 16 cases of AD and 7 age-matched controls, with quantitative assessments of the total neuronal population and synaptic density, Alz-50-positive neurons, neurofibrillary tangles (NFT), and senile plaques (SP). We examined sections after staining with cresyl violet, a silver stain, and immunocytochemical staining for Alz-50 and synapsin I. Stereologic analysis demonstrated a mean loss of 29% of DMN neurons in AD and a synaptic density decrease of 21%. Alz-50 staining and NFT were present in all AD cases but in none of the controls. Senile plaques were 52 times more frequent in the DMN in AD than in the age-matched controls. The large variation in pathologic changes among our AD cases suggests that neuronal losses and other pathology in the DMN in AD may contribute to the total brain burden of pathology resulting in dementia in some AD patients, but not in others.

Aged↗
PubMed1993

Vascular amyloid deposition in Alzheimer's disease. Neither necessary nor sufficient for the local formation of plaques or tangles.

OBJECTIVE: To determine the relationship between vascular beta-amyloid (beta A4) and senile plaques (SPs) and neurofibrillary tangles (NFTs). DESIGN: We counted vascular amyloid deposition with SP and NFT density in the medial temporal lobe (CA1 plus the subiculum) and the cerebellum. PATIENTS: The brains of seven patients with Alzheimer's disease and of three age-matched nondemented control subjects were studied. RESULTS: In Alzheimer's disease, the density of beta A4-laden blood vessels was significantly higher in the cerebellum than in CA1 plus the subiculum. Conversely, the densities of SPs and NFTs were much greater in the CA1 plus the subiculum than in the cerebellum. CONCLUSIONS: This study indicates that local vascular beta A4 deposition is not directly correlated with SP and NFT densities. Deposition of beta A4 in blood vessel walls may not be instrumental in the formation of SPs and/or NFTs in the brain.

Aged↗
PubMed1993

Electrical source analysis of auditory ERPs in medial temporal lobe amnestic syndrome.

Auditory event-related potential (ERP) components have been anatomically linked to temporal lobe structures and functionally related to attentional and memory processes. We recorded auditory ERPs using an "oddball" paradigm from two patients with amnestic syndromes secondary to medial temporal lobe encephalitic infections. The oddball paradigm elicits the exogenous N1 and P2 components, and the endogenous N2 and P3 components. Electrical source analysis was used to test for alterations in source strength and orientation in these patients compared to control subjects. Symmetric dipoles placed in the temporal lobe region were used to measure ERP component activity. In the patient with a lesion confined to the left, medial temporal lobe, including the posterior hippocampus, dipole orientation was displaced anteriorally. In the patient with lesions to the anterior medial temporal lobe, temporal poles, and orbital frontal cortex, the negative components of the ERP (N1 and N2) were reduced in the right hemisphere, accompanied by disturbed orientation. These findings are consistent with other evidence that the different components of the auditory ERP can be dissociated on the basis of lesion effects, and that the antero-posterior extent of encephalitic lesions may play an important role in modulating ERP abnormalities.

Acoustic Stimulation↗
PubMed1993

Driving and Alzheimer's disease: the risk of crashes.

We designed this questionnaire-based study to determine the risk of auto crashes among Alzheimer's disease (AD) patients who continued to drive after the onset of AD, compared with normal age-matched control subjects and other drivers' statistical records. While ultimately all AD patients will become incapable of driving, it is not known whether, under current licensing regulations and self-imposed limitations, patients with AD present a definably increased risk of being involved in crashes, and if so, the relative magnitude of the risk and at what point in the course of the disease the risk may become significantly increased. We administered a brief questionnaire to the caregivers of 130 AD patients and to 112 age-matched, nondemented control subjects and their spouses. Annual rates of occurrence and severity of all crashes, and of crashes reported to the authorities, were determined from spousal or other caregiver responses. For all years of driving following the onset of dementia, AD patients had a mean of 0.091 reported crashes per year compared with matched controls, who had an average of 0.040 reported crashes per year in the same period of time. The average number of crashes per year changed with each year of driving following the onset of AD, with considerably lower reported crash rates during the initial years of dementia: in year 1, the crash rate was 0.068; in year 2, 0.097; in year 3, 0.093; in year 4, 0.159; in year 5 and beyond, 0.129.(ABSTRACT TRUNCATED AT 250 WORDS)

Accidents, Traffic↗
PubMed1992

A double-blind, placebo-controlled multicenter study of tacrine for Alzheimer's disease. The Tacrine Collaborative Study Group.

BACKGROUND: In Alzheimer's disease, there is a marked decline in the function of cholinergic neurons in the brain. However, studies of treatment with cholinesterase inhibitors have produced conflicting results. We conducted a multicenter trial to evaluate whether the cholinesterase inhibitor tacrine (1,2,3,4-tetrahydro-9-acridinamine monohydrochloride monohydrate) could improve cognition in patients with Alzheimer's disease. METHODS: Of 632 eligible patients with probable Alzheimer's disease, 215 improved while receiving tacrine during a preliminary crossover phase to determine responsiveness and the best dose. The 215 patients were randomly assigned to receive either placebo or their best dose of tacrine (10 or 20 mg four times a day) in a six-week, double-blind trial. The primary measures of efficacy were the cognitive subscale of the Alzheimer's Disease Assessment Scale and the Clinical Global Impression of Change scale; the secondary measures included the Mini-Mental State Examination and the assessment of the activities of daily living. RESULTS: At the end of the six-week trial, the patients receiving tacrine had a mean adjusted cognitive-subscale score of 30.3 (Alzheimer's Disease Assessment Scale) as compared with 32.7 in patients receiving placebo. This represents a smaller decline (by 2.4 points) in cognitive performance in the tacrine group (P < 0.001). There were no differences between the groups in their global-rating scores. The tacrine group had a significantly smaller decline in the activities of daily living. The results of the Mini-Mental State Examination favored tacrine, but the differences were small and not statistically significant (a score of 16.0 with tacrine vs. 15.3 with placebo; P = 0.08). Gastrointestinal symptoms, elevation of aminotransferase levels, and headache were the most frequent side effects; all could be reversed by reducing the dose or discontinuing treatment. CONCLUSIONS: In this short-term study in patients with Alzheimer's disease who were selected for apparent responsiveness to tacrine, treatment with tacrine resulted in a statistically significant reduction in the decline of cognitive function, although this reduction was not large enough to be detected by the study physicians' global assessments of the patients.

Activities of Daily Living↗
PubMed1992

Neuropsychological features of familial Alzheimer's disease.

It has been proposed that early-onset familial Alzheimer's disease (FAD) and sporadic Alzheimer's disease (AD) have different causes, with FAD due to a single dominant gene with disease onset before the sixth decade, whereas sporadic AD has a later onset and is not associated with a dominant pattern of inheritance. Given these differences, we questioned whether these etiologically distinct forms of AD also differ neuropsychologically. In this study we performed neuropsychological evaluations on patients from two well-documented families with FAD and a group of patients with sporadic AD. The groups were matched on global disease severity at entry. Two groups of education- and age-matched normal controls were recruited for comparison. The groups were analyzed for psychometric findings and pattern of deficits. Both patients with FAD and patients with sporadic AD showed a similar pattern of neuropsychological impairment relative to age-matched controls, i.e., mildly to moderately impaired verbal performance and concentration, severely slowed psychomotor speed, and severely impaired delayed recall of verbal material. There were no differences in pattern suggestive of disproportionately severe anomia, amnesia, agnosia, or apraxia in the early onset FAD group, as has been reported previously.

Adult↗
PubMed1992

Active and passive P3 latency and psychometric performance: influence of age and individual differences.

The relationship of P3 latency of the event-related potential (ERP) to psychometric performance was investigated in 41 subjects who ranged in age from 20 to 88 years. P3 responses were recorded from subjects using an auditory oddball paradigm with and without task-demands. Subjects also received psychometric tests of verbal performance, visuospatial performance, concentration, and immediate, recent and remote memory. Factor analysis was used to reduce the set of psychometric measures to four factors (Verbal learning, general intelligence, narrative recall/fluency, and concentration). Both passive and active P3 latency showed a linear increase with age. Age was inversely correlated with verbal learning performance. After accounting for the influence of age, passive P3 latency correlated with the psychometric factor associated with narrative recall and verbal fluency. Active P3 latency was correlated with factors reflecting general intelligence and concentration. These findings suggest that cognitive processing speed contributes to psychometric performance in adults. The psychological or biological basis for this relationship remains to be identified.

Adult↗
PubMed1992

The Caretaker Obstreperous-Behavior Rating Assessment (COBRA) Scale.

OBJECTIVE: To evaluate the usefulness and reliability of the Caretaker Obstreperous-Behavior Rating Assessment (COBRA), a new test instrument for caretaker assessment of types and severity of "obstreperous behaviors" (OBs) in demented patients. DESIGN: COBRA was completed by caretakers of 31 outpatients and 36 nursing home inpatients with dementia. Test-retest reliability was determined when 25 of the outpatient caretakers re-evaluated their demented relative 1 week later; inter-rater reliability was determined on nursing home inpatients by comparing the reports of two nurse's aids with equivalent knowledge of seven of the patients. SETTING: (1) University medical center Alzheimer's Disease and Related Disorders Clinic; (2) community nursing home. PATIENTS: Thirty-one sequentially-seen outpatients with dementia; 36 nursing home patients with dementia. INTERVENTION: Following instruction in the use of the COBRA Scale, caretakers provided scores for their demented patient. The instrument has three unique features: (1) it divides OBs into four categories for ease of comprehension: Aggressive/Assaultive; Mechanical/Motor; Ideational/Personality; and Vegetative; (2) a companion videotape shown to caretakers in advance illustrates each behavior to improve reliability of reporting; (3) the significance of each OB is estimated with severity and frequency measures. MAIN OUTCOME MEASUREMENTS: Frequency and severity of OBs are epitomized in 12 summary scores. Test-retest correlations (for outpatients) and inter-rater correlations (for inpatients) were analyzed with Pearson Product Moment and Spearman Rank Order correlations. RESULTS: Prevalence of OBs and severity was reported for the experimental groups. Summary scores revealed test-retest correlations of .95 to .73 for 11 of 12 scores (outpatients), and inter-rater correlations of .99 to .73 for 8 of 12 scores (inpatients). Age, gender, and disease etiology were not significantly related to OBs; clinical severity correlated with type and severity of OBs. CONCLUSIONS: The COBRA scale provides a convenient, comprehensive, and reliable means for caretakers to identify the types and measure the severity of OBs in demented outpatients and nursing home inpatients. If additional studies confirm these observations, COBRA will be a useful instrument for assessing the effects of interventions on OBs in patients with dementia.

Aged↗