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Biomedical subjects

T Hope

Publications and source records attributed to T Hope.

At least 37 records · Page 2Linked to original sources
PubMed2000

Cholinergic deficits contribute to behavioral disturbance in patients with dementia.

BACKGROUND: Noncognitive behavioral changes such as depression, aggressive behavior, psychosis, and overactivity occur frequently in patients with dementia, in addition to cognitive impairment, and often determine the need for institutionalization. The biochemical basis of such changes is poorly understood. Clinical trial data indicate that cholinomimetics improve noncognitive behaviors. This study investigated the relationship between markers of the cholinergic and dopaminergic neurotransmitter systems and noncognitive behavioral symptoms assessed during the course of dementing illness. METHOD: Brains from 46 patients with dementia (36 with AD and 10 with mixed or other dementias using Consortium to Establish a Registry for AD criteria) were examined together with 32 normal controls. The patients with dementia had been evaluated every 4 months, often over several years, for cognitive performance (Mini-Mental State Examination) and behavior (Present Behavioral Examination). Concentrations of dopamine (DA) and major metabolites, choline acetyltransferase activity (ChAT), and density (Bmax) of DA D1 receptors in frontal and temporal cortex were studied by radioligand binding protocols. None of the patients was receiving cholinomimetic drugs. RESULTS: ChAT activity, but no other neurochemical markers, was reduced in AD compared with controls. Loss of ChAT activity correlated with cognitive impairment. Lowered ChAT activity also correlated with increasing overactivity in patients with dementia in both frontal and temporal cortex whereas ChAT:DA and ChAT:D1 ratios in temporal cortex correlated negatively with aggressive behavior. CONCLUSIONS: Disturbance of the cholinergic system may underlie both cognitive and some noncognitive behavioral changes in dementia, providing a basis for rational therapy.-1467

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PubMed2000

Suicide in older people: mode of death, demographic factors, and medical contact before death.

OBJECTIVE: To determine the demographic characteristics, mode of death, and nature and timing of medical contacts in the year before death in a sample of suicides in older people. DESIGN: Descriptive study of a case series of 195 suicides in older people. SETTING: Four counties and one large urban area in central England, UK. SUBJECTS: Individuals 60 years old and over at time of death, who had died between 1 January 1995 and 1 May 1998, and whose deaths has received a coroner's verdict of suicide, or an open or accidental verdict where the circumstances of death indicated probable suicide. MAIN OUTCOME MEASUREMENTS: Demographic details and information on mode of death and medical contact prior to death derived from coroners' inquest notes, General Practitioners' (GP) case-notes and psychiatric records. MAIN RESULTS: 67.7% were male. A higher proportion of men than women were single or divorced. The commonest methods of suicide were hanging in men and drug overdose in women, 49.8% had seen their GP in the month before death, although over half these last consultations were for physical complaints. Only 15.4% were under psychiatric care at the time of death. CONCLUSIONS: Older men are at higher risk of suicide than women. Given the high proportion of drug overdoses in the sample, effective strategies to prevent suicide in older people might include improving the prescribing of analgesics and antidepressants. Although older people at risk of suicide often consult their GP shortly before death, GPs may have difficulty identifying those at risk because of the high proportion of physical complaints.

Age Distribution↗
PubMed2000

Medical ethics in the 21st century.

OBJECTIVES: To foresee how medical ethics may develop in the 21st century. DESIGN: We have looked into our crystal ball to see what factors are likely to drive medical ethics over the next few decades. We have given examples of how such factors might affect specific issues. RESULTS: Those factors that we identified as likely to shape the future of medical ethics are: Globalization: Medical ethics is likely to have to grapple increasingly with ethical issues arising from the huge discrepancies in the level of health care available in different countries. Increase in longevity: We predict that there will be, at least amongst the richer nations, a significant increase in life expectancy. This will result in issues of resource allocation becoming increasingly problematic within medicine. Child enhancement: Developments in genetics combined with control of reproduction will make it possible to select our children for a broad range of characteristics. There are optimistic and pessimistic predictions as to how such power will be used. In either case, this area will be an important focus of concern in medical ethics. The biological determination of behaviour: Genetic research will lead to an increasing sense that undesirable behaviour is genetically determined. This will lead to a re-examination of such concepts as criminal responsibility. Therapeutic research and clinical practice: We predict that an increasing amount of clinical practice will be within the setting of clinical trials. The ethics of therapeutic research and clinical practice will need to be brought within a coherent framework.

Clinical Medicine↗
PubMed2000

Immunocytochemical study of the dorsal and median raphe nuclei in patients with Alzheimer's disease prospectively assessed for behavioural changes.

The dorsal and median raphe nuclei were examined with immunocytochemistry to display the 5-HT neurones in 16 cases of post-mortem-proven Alzheimer's disease (AD) and 12 age and sex-matched controls. The AD cases had been prospectively assessed during life for expression of behavioural changes as well as for cognitive decline. A significant (P < 0.001) 41% reduction in density of dorsal raphe neurones was found along with a significant (P < 0.02) 29% reduction in density of median raphe neurones in AD. There were significantly more neurofibrillary tangles in both dorsal and median raphe nuclei in AD than in controls (P < 0.001). There was no correlation between reduction in neurone density in these nuclei and behavioural change, cognitive decline, neurofibrillary tangle counts in these nuclei or plaque and tangle pathology in frontal and temporal cortex. It was concluded from these findings that the raphe nuclei are significantly affected by the pathology of AD and that plasticity in the 5-HT system is the probable reason for the lack of correlation of reduced 5-HT neurone density and clinical disease parameters.

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PubMed2000

Progressive decline in NART score with increasing dementia severity.

Although the National Adult Reading Test (NART) is widely used to estimate premorbid intellectual ability in adults with possible or probable dementia, it may be less resilient to the progress of Alzheimer's Disease (AD) than was initially assumed. This paper reports performance at four annual assessments of 78 people with either autopsy confirmed (n = 50) or clinical diagnosis of AD (n = 28). Results indicate that NART score does decline over time and that extent of decline is a function of MMSE score on entry to the study but is not dependent on age, education or time post onset of dementia.

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PubMed2000

Effect of cognitive impairment and premorbid intelligence on treatment preferences for life-sustaining medical therapy.

OBJECTIVE: This study examines the influence of cognitive impairment, premorbid intelligence, and decision-making capacity to complete advance directives on the treatment preferences for life-sustaining medical therapy in the elderly. METHOD: One hundred elderly individuals were recruited. Fifty were first referrals to specialist services with a DSM-IV diagnosis of dementia, and 50 were volunteers. Each person was asked about treatment preferences in three clinical vignettes. RESULTS: Elderly individuals who had cognitive impairment and were incapable of completing advance directives were significantly more likely to opt for life-sustaining interventions. There was no association between premorbid intelligence and treatment preferences. CONCLUSIONS: Cognitive impairment appears to influence treatment preferences for life-sustaining medical therapy. With increasing cognitive impairment, elderly individuals tend to opt for treatment interventions.

Advance Directives↗
PubMed1999

Assessment of competence to complete advance directives: validation of a patient centred approach.

OBJECTIVE: To develop a patient centred approach for the assessment of competence to complete advance directives ("living wills") of elderly people with cognitive impairment. DESIGN: Semistructured interviews. SETTING: Oxfordshire. SUBJECTS: 50 elderly volunteers living in the community, and 50 patients with dementia on first referral from primary care. MAIN OUTCOME MEASURES: Psychometric properties of competence assessment. RESULTS: This patient centred approach for assessing competence to complete advance directives can discriminate between elderly persons living in the community and elderly patients with dementia. The procedure has good interrater (r=0.95) and test-retest (r=0.97) reliability. Validity was examined by relating this approach with a global assessment of competence to complete an advance directive made by two of us (both specialising in old age psychiatry). The data were also used to determine the best threshold score for discriminating between those competent and those incompetent to complete an advance directive. CONCLUSION: A patient centred approach to assess competence to complete advance directives can be reliably and validly used in routine clinical practice.

Dementia↗
PubMed1999

Natural history of aggressive behaviour in dementia.

OBJECTIVE: This article analyses changes in aggressive behaviour throughout the course of dementia. DESIGN: Prospective, 10 year, longitudinal study of aggressive behaviour in dementia, with autopsy follow-up. SETTING: Subjects with dementia, living at home with a carer, Oxfordshire, UK. PARTICIPANTS: Ninety-nine people with dementia (Alzheimer's disease and/or vascular dementia) who were living at home with a carer. MEASURES: At 4-monthly intervals, the carers were interviewed about the subjects and the subjects were assessed cognitively. Subjects' behaviour was assessed using the Present Behavioural Examination. This is an investigator-based, semi-structured interview consisting of eight main sections monitoring behavioural and psychological change. Eight different aspects of aggressive behaviour were assessed in detail and comparison made with other relevant factors. RESULTS: Verbal aggression is the most common and longest lasting form of aggressive behaviour. Aggressive resistance and physical aggression are most likely to persist until death. Intimate care is the main factor precipitating aggressive behaviour. There are no correlations between any type of aggressive behaviour and age, gender or time since onset of dementia. CONCLUSIONS: Aggressive behaviour creates problems for carers. In general, the physical types of aggressive behaviour are most prevalent in people with more severe dementia.

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PubMed1999

The development of a structured rating schedule (the BAS) to assess skills in breaking bad news.

There has been considerable interest in how doctors break bad news, with calls from within the profession and from patients for doctors to improve their communication skills. In order to aid clinical training and assessment of the skills used in breaking bad news there is a need for a reliable, practical and valid, structured rating schedule. Such a rating schedule was compiled from agreed criteria in the literature. Video-taped recordings of simulated consultations breaking bad news were independently assessed by three raters using the schedule and compared to three experts who gave global ratings. The primary outcome measures were internal consistency of the schedule and level of agreement between raters. The internal consistency was high with a Cronbach's alpha of 0.93. Agreement between raters using the schedule was moderate to good. The majority of the variation in scores was due to the differences in skills demonstrated in the interviews. The agreement between raters not using the schedule was poor. The BAS provides a simple to use, reliable, and consistent rating schedule for assessing skills used in breaking bad news. It could be a valuable aid to teaching this difficult task.

Adult↗
PubMed1999

Evaluating ethics competence in medical education.

We critically evaluate the ways in which competence in medical ethics has been evaluated. We report the initial stage in the development of a relevant, reliable and valid instrument to evaluate core critical thinking skills in medical ethics. This instrument can be used to evaluate the impact of medical ethics education programmes and to assess whether medical students have achieved a satisfactory level of performance of core skills and knowledge in medical ethics, within and across institutions.

Clinical Competence↗
PubMed1999

Natural history of behavioural changes and psychiatric symptoms in Alzheimer's disease. A longitudinal study.

BACKGROUND: Alzheimer's disease and other types of dementia are characterised by numerous psychiatric and behavioural changes. Little is known of their natural history. AIMS: To investigate the sequence and pattern of these changes throughout the course of dementia. METHOD: One hundred people, initially living at home with carers, entered a prospective, longitudinal study. At four-monthly intervals, behavioural and psychiatric symptoms were assessed using the Present Behavioural Examination and Mini-Mental State Examination. Follow-up continued for up to nine years (mean 3.3 years; s.d. 2.4). Patterns of onset and disappearance of these symptoms, their sequence and association with time of death and cognitive decline were analysed. Autopsy confirmed a diagnosis of pure Alzheimer's disease in 48 subjects. Data for this subgroup are presented. RESULTS: Some changes tend to occur earlier than others but changes can occur at almost any time in the course of dementia. CONCLUSIONS: The natural history of behaviour changes in Alzheimer's disease shows great individual variation although some changes tend to follow a recognisable sequence.

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PubMed1999

Can an informant questionnaire be used to predict the development of dementia in medical inpatients?

OBJECTIVE: To determine whether elderly medical inpatients without dementia who score >3.31 on the short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) are at an increased risk of developing dementia. DESIGN/PARTICIPANTS: Twenty-nine patients with an IQCODE score of >3.31 without dementia and 29 age- and sex-matched controls, from an original sample of 201 medical inpatients over 65, were examined 17-24 months after initial assessment. SETTING: Interviews took place in patients' homes, but all subjects had been recruited while medical inpatients in a general hospital 17-24 months previously. MEASURES: The IQCODE and clinical interview to make DSM-III-R diagnosis of dementia. RESULTS: Ten of the study group and one control had developed dementia since the original assessment. CONCLUSIONS: Non-demented elderly medical inpatients with an admission IQCODE score of >3.31 are more likely to develop dementia than those with an IQCODE score of <3.31. The IQCODE is a sensitive tool for detecting early dementia.

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