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Biomedical subjects

S D Fields

Publications and source records attributed to S D Fields.

11 recordsLinked to original sources
PubMed1992

Usefulness of the Neurobehavioral Cognitive Status Examination in the hospitalized elderly.

A prospective pilot study compared the Neurobehavioral Cognitive Status Examination (NCSE) to the Folstein Mini-Mental State Examination (MMSE) to determine the usefulness of the NCSE as a cognitive screen in a geriatric inpatient population. All patients directly admitted to the geriatric evaluation and treatment unit (GETU) of a university teaching hospital over a two-and-a-half-month period were eligible for the study, in which 42% participated. Within 72 hours of admission, patients were given the MMSE and the NCSE in a nonrandom order by a trained psychologist and a structured interview by a psychiatrist. The ability of the NCSE to detect global cognitive impairment was compared to the MMSE and psychiatrist's assessment. Differences in sensitivity were examined by discordant pair analysis. The psychiatrist's determination of the presence of cognitive impairment was used as the criterion standard. Comparisons of the MMSE and NCSE, respectively, revealed the following: sensitivity 83% versus 100%; specificity 78% versus 11%; positive predictive value 83% versus 43%; and negative predictive value 78% versus 100%. Seven patients who were cognitively impaired by the NCSE were not impaired by the MMSE (p less than 0.05 by discordant pair analysis). The time of administration for the two tests was significantly shorter for the MMSE (14.75 +/- 5.7 minutes) than for the NCSE (38.9 +/- 12.9 minutes). The NCSE was found to be more sensitive than the MMSE in detecting cognitive impairment among geriatric inpatients, but its specificity and positive predictive values were lower. Beyond this pilot study, additional work examining the utility of the NCSE in other geriatric settings and for different purposes (e.g., as part of comprehensive assessment) needs to be performed.

Aged↗
PubMed1992

Geriatric education. Part I: Efficacy of a mandatory clinical rotation for fourth year medical students.

OBJECTIVES: To describe the curriculum of a mandatory, fourth-year geriatrics clerkship and assess its impact on medical students' knowledge of geriatric medicine and attitudes toward the elderly. DESIGN: One group, before/after trial. SETTING: Mount Sinai School of Medicine of the City University of New York. PARTICIPANTS: Entire fourth year class of medical students (n = 127). INTERVENTION: Four-week-long clinical geriatrics clerkship. MEASUREMENTS: Pre- and post-rotation: test of knowledge; Aging Semantic Differential (ASD) attitude scale; Modified Maxwell-Sullivan attitude scale; questionnaire. MAIN RESULTS: Seventy percent of students found the rotation to be educationally valuable; however, only one-third of students would have taken the clerkship had it not been required. Mean geriatric knowledge score increased by 18.7% (P less than 0.001). Mean ASD attitude score did not change significantly (130.5 +/- 19.2 pre-rotation versus 126.6 +/- 18.8 post-rotation, P = 0.15), but students started the rotation with a neutral attitude. Over 90% of students agreed they would welcome elderly into their future practice. CONCLUSION: If a national curricular goal is to improve medical students' knowledge of geriatric medicine, required rather than elective rotations may be in order.

Adult↗
PubMed1992

Geriatric education. Part II: The effect of a well elderly program on medical student attitudes toward geriatric patients.

OBJECTIVE: To assess impact of exposure to healthy elderly on medical students' attitudes toward the elderly. DESIGN: Prospective, randomized, controlled intervention trial. SETTING: Community-based Well Elderly Program. PARTICIPANTS: Ninety-three fourth year medical students on a required Geriatric Medicine clerkship who were assigned to either a tertiary care university medical center or a teaching nursing home. INTERVENTION: Thirty-five students were randomly assigned to participate in a Well Elderly Program and were compared to a control group of 58 students at equivalent sites who did not participate. MEASUREMENTS: Pre- and post-rotation, students were given the Aging Semantic Differential (ASD), a validated geriatric attitudinal scale. MAIN RESULTS: By repeated measures analysis of variance, the difference between pre- and post-rotation ASD scores were most significant for students who participated in the Well Elderly Program; site did not exert a significant interaction effect. CONCLUSION: These results underscore the importance of exposure to healthy older people on effecting positive attitude changes among medical students on geriatrics rotations.

Adult↗
PubMed1991

History-taking in the elderly: obtaining useful information.

Although the medical history in the average adult can approach a diagnostic yield of 90%, its utility in geriatric patients is often much lower. Potential barriers to communication with the elderly include cognitive, behavioral, and physical problems. This article suggests techniques the primary care physician can use to overcome these obstacles and get the maximum diagnostic information from the patient history.

Activities of Daily Living↗
PubMed1991

Special considerations in the physical exam of older patients.

For diagnostic utility, aspects of the standard physical examination are modified for elderly patients. Special attention is paid to problems that interfere with function, such as gait disorders, incontinence, and hearing and visual loss. Certain findings in cardiac and pulmonary examinations of the elderly require different interpretations. The examination should include the head and neck, chest, back, abdomen, breasts and pelvic area in women, prostate in men, extremities, and skin, as well as mental status. A number of diagnostic maneuvers are used to distinguish changes of normal aging from those associated with disease.

Aged↗
PubMed1987

Morbidity during hospitalization: can we predict it?

Physicians use the concept of stability to estimate the likelihood that a patient will deteriorate during a hospitalization. To determine whether physicians can accurately predict a patient's risk of morbidity, 603 patients admitted to the medical service during a one month period were rated prospectively as to how stable they were. Overall, 15% of patients had deterioration of already compromised systems, while 17% had new complications, such as sepsis. Eight percent of patients had both. Twelve percent of stable patients experienced morbidity; 39% of the somewhat unstable and 61% of the most unstable. When all of the demographic and clinical variables were taken into account including the reason for admission and comorbid diseases, the residents' estimates of the patient's stability was the most significant predictor of morbidity (p less than 0.001). The judgment that a patient was stable had an 87% negative predictive accuracy, while the judgment unstable had a 46% positive predictive accuracy.

Aged↗
PubMed1986

Resuscitation: how do we decide? A prospective study of physicians' preferences and the clinical course of hospitalized patients.

Physicians have to address the question of the measures to be employed in the event that a patient's condition deteriorates after admission to the hospital. To identify the information that physicians use in making such decisions, all 604 patients admitted to the medical service during a one-month period were studied. The patient's age and residents' estimates of the patient's long-term prognosis and ability to function were the three primary factors that correlated with intervention preferences. When illness severity, the reason for admission, comorbidity, and poor function were taken into account, mortality and morbidity rates did not differ between patients for whom full vs not-full intervention was favored. Apart from differential rates of admission to critical care units, there were no important differences in the care, course, or mortality of patients for whom less than full intervention was initially favored. Suggestions that physicians should discuss resuscitation with all or most patients who may die are unrealistic. A more prudent strategy is to discuss the issue with patients whose hospital course is marked by a steady deterioration.

Age Factors↗
PubMed1986

Assessing illness severity: does clinical judgment work?

Accurate classification of clinical severity is important for interpreting casemix in clinical studies and for stratifying patients for clinical trials. To evaluate whether clinical judgment might be an effective method of estimating severity, all 604 patients admitted to the medical service in a one month period were rated at the time of admission by the responsible resident as to how sick they were. Within the 13 comorbid disease groups, and within the 15 basic categories of reason for admission, the physicians' severity ratings were the most significant predictor of in-hospital mortality. Death rates rose from 0% in those rated as not ill, to 2% in the mildly ill, to 6% in the moderately ill, to 23% in the severely ill, and to 58% in those rated as moribund (p less than 0.001). Sickness ratings also predicted time to death: mildly ill patients died after prolonged hospitalizations, while the moribund died shortly after admission. The patients' age, sex, race, the number of comorbid diseases or problems did not predict mortality. Patients with serious comorbidity (metastases, AIDS, or cirrhosis) had a higher mortality rate than other patients (p less than 0.001); however, the severity ratings predicted outcomes within this group (p less than 0.001) as well as among those without such serious comorbidity (p less than 0.001). Patients who were admitted with acute neurologic (p less than 0.05) or acute cardiovascular (p less than 0.01) events did have an independently worse prognosis. In conclusion, physicians' estimates or sickness provided an accurate estimate of illness severity, with mortality rates that essentially tripled from one stratum to the next. Clinical judgment may suffice to classify the clinical severity of patients at the time of enrollment in prospective trials and can provide a useful method of controlling for casemix.

Acute Disease↗
PubMed1986

Cognitive impairment. Can it predict the course of hospitalized patients?

All patients admitted to three medical services at the New York Hospital during a one-month period were screened with Folstein's Mini-Mental State Examination. The prevalence of cognitive impairment was 19.8% (23 of 116). Cognitively "impaired" patients, ie, those with a Folstein score less than 24, were older, sicker, and less physiologically stable than the cognitively "intact." The in-hospital mortality (17 versus 5%) and morbidity (39 versus 18%) rates were higher for the cognitively "impaired" patients; these differences could be explained by the greater severity of illness, instability, and comorbidity found in these patients. Cognitively "impaired" patients were particularly susceptible to respiratory complications. Cognitively "impaired" patients had longer lengths of hospital stay, spent more time in hospital awaiting placement, and were more likely to be discharged to a nursing home or require home assistance than their cognitively "intact" counterparts. Three-month mortality rates were also higher for the cognitively "impaired" patients (30 versus 15%). These findings suggest that cognitive impairment on admission may be regarded as a marker for patients with poorer prognoses.

Aged↗
PubMed1986

Reversibility of cognitive impairment in medical inpatients.

To determine outcomes of patients admitted to the hospital with global cognitive impairment and to identify factors that might predict improvement, we screened all medical ward admissions over a one-month period with Folstein's Mini-Mental State Examination. Of 115 patients, 23 (20%) scored less than 24, indicating that they were cognitively impaired. Nineteen patients survived to discharge and were followed up for three months; three additional patients died in this period. Nine (47%) of the 19 patients significantly improved their Mini-Mental State scores. Five (26%) of the 19 improved to normal. They scored better on the initial Mini-Mental State Examination and lower (less dementia) on Blessed's Dementia Rating Scale. Age, severity and stability of medical illness, presence of neurologic abnormalities, clinical course, extensiveness of medical evaluation, and psychiatric criteria for delirium did not predict improvement.

Adult↗