Acute Physical Illness Research Articles

Dialysis in the elderly, to treat or not to treat?

The population on renal replacement therapy (RRT) currency, but rather describes the approach to probhas become older and beset by more co-morbidity than lems by thinking citizens in a given society and, for was thought possible when dialysis was introduced. each of us, is influenced by our religious beliefs and About half of the stock is over the normal retirement by the different ethical considerations ( libertarian, age, and over the last decade there has been at least a egalitarian, utilitarian) of the society in which we live. four-fold increase in the number of patients entering The Oxford English Dictionary gives a definition of dialysis over the age of 74 years [1]. A growing Medical Ethics first enunciated in 1884—the duty of proportion of the RRT population is over the age of medical men to the public, to each other and to 85 years. themselves in regard to the exercise of their profession. Indeed, RRT could almost be considered as a branch In a given society, for each doctor, these are a subset of geriatric medicine. Viewed in this context, the nature of and influenced by, the ethics of that society. And of an elderly population is germane. Medically it is each doctor will properly be influenced also by his or very heterogeneous. Some individuals remain fit and her religious and other convictions. active into their ninth or tenth decades, whilst others Thus ‘medical ethics’ cannot offer a global solution show evidence of frailty during their early 60s in the either to a particular medical dilemma or to the absence of an acute physical illness ([2] and Table 1). distribution of health-care resources in a given society. The survival of elderly patients on RRT is much In an insurance-funded health-care system, only those shorter than that of younger patients; the annual cost with the insured funds can benefit—a libertarian soluof treating end-stage renal failure (ESRF) is ~2% of tion. In a state-funded system, it is difficult to see how the health-care budget in some developed countries an outcome-based, utilitarian solution can be avoided. and in some countries approximately half of the state’s It is imprecise to consider the decision to offer or expenditure on the health of its citizens is consumed withhold RRT as an ‘ethical’ dilemma. Rather, it is a in the last year of their lives [3]. pragmatic one, to be addressed within the health-care While these considerations may appear to make a system of the society in which it arises. As already case for excluding older patients as such from RRT, stated it is biological and not chronological age which this is hardly acceptable, for it is biological rather than influences the value of RRT to the individual. This of chronological age that determines whether a person becomes more of an issue in the older patient, since will benefit from RRT. co-morbidity is common in the elderly. Eighty per cent The issue of ‘who to treat’ is debated nevertheless, of individuals over 65 years of age have one and 30% and some place it predominantly in an ethical context. three or more chronic illnesses [4,5]. Malnutrition This is difficult, since the term ‘ethics’ is not a universal occurs. Osteoporosis and atherosclerosis are constitutional and may not readily be corrected. More than Table 1. The definition of the ‘fit’ to ‘frail’ elderly adapted from [2] 10% of the elderly show depressive symptoms and these are related to life stresses and physical deficits Fit elderly Frail elderly [6 ] (Table 1). In renal failure, the incidence of co-morbidity is Live independently Yes No even greater. In a recent study [7] in our centre, we Freely mobile Yes No found that 90% of patients over 65 years of age who Regular medication No Yes were on haemodialysis had two or more co-morbidities. Co-morbiditya No Yes Mental deficitb No Yes Cardiovascular, musculo-skeletal and neurological problems predominate (Table 2). These factors are

Vegetative and psychological symptoms associated with depressed mood over the first two years after stroke.

In patients with acute physical illness, symptoms used in the diagnosis of major depression such as sleep or appetite disturbance may be nonspecific for depression. This study was undertaken to examine the association of depressed mood with other depressive symptoms to determine which symptoms were most useful in the accurate diagnosis of major depression after stroke. Using a structured mental status examination, 142 patients with acute stroke were followed at three, six, twelve, and twenty-four months. The median number of vegetative and psychological symptoms among patients with depressed mood was more than three times the respective rates among nondepressed patients at all time points over two years. Autonomic anxiety, morning depression, subjective anergia, worrying, brooding, loss of interest, hopelessness, and lack of self-confidence were significantly more frequent among depressed patients than nondepressed patients throughout the entire two-year period. Some symptoms such as anxious foreboding and loss of libido, as well as self-depreciation, feelings of guilt, and irritability were no longer significantly more common among depressed compared with nondepressed patients after six months. Standard DSM-IV diagnostic criteria and modified DSM-IV diagnostic criteria which included only specific symptoms of depression (i.e., symptoms which were significantly more frequent among depressed than nondepressed mood patients) yielded similar frequencies of major depression diagnosis. There were only a few patients (i.e., 2% to 3%) with depressive symptoms without a depressed mood (perhaps "masked" depression). Vegetative and psychological depressive symptoms are significantly more common in depressed patients over the first two years after stroke and DSM-IV criteria do not overdiagnose major depression even in this population with chronic physical illness. The symptoms which characterize major depression appear to change between the subacute and chronic post-stroke periods.

The nature of parasuicide in Dar es Salaam, Tanzania

In a two year period, 300 parasuicides were admitted at Muhimbili Hospital. Socio-demographic, clinical characteristics, trigger factors and employed methods were analyzed and discussed with reference to other studies. Parasuicides were found to be young adults of mean age 23.7 years. The ratio of females to males was 2.2. The majority had seven years of education and were unemployed or underemployed. Four-fifths of attempts were triggered by acute social conflicts, psychiatric and physical illnesses in socio-economic deprivations partly aggravated by alcohol intake. Two-thirds of parasuicides ingested overdoses of medicaments of which chloroquine constituted 65% of all drugs. Nearly a third of all the attempters had neuropsychiatric illnesses, while 4.3% had physical disorders. Nearly one-fifth or 18.3% of the parasuicides had a history of mental illness in their families, and 12% had individual or family history of previous suicidal attempts. Forty percent of the attempts were categorized as demonstrative, 31% as genuine, 10.3% were equivocal and 18.3% were not clarified.

Spiritual and religious beliefs in acute illness--is this a feasible area for study?

In this paper we discuss the measurement of spiritual, religious and philosophical beliefs in patients admitted to hospital with acute physical illness. The discussion is based on the results of a preliminary study of the beliefs of 300 patients studied by face-to-face interview and questionnaire. Principal outcome measures at 6 months were self reported psychological and belief scores and physical state as reported in the medical records. Two thirds of patients reported a religious and/or spiritual belief system. Strength of belief was not associated with social, psychological or diagnostic factors. However, those patients with a religious and/or spiritual life view who expressed strong beliefs were likely to fare less well clinically. We conclude that empirical study of patients' beliefs is possible, though care must be exercised over the measures used. Beliefs were at least as predictive of outcome as other social and psychological factors. This area is of considerable importance to patients and should not be neglected by carers or researchers.

A Survey of Researchers Using a Consent Policy for Cognitively Impaired Human Research Subjects

Illnesses leading to some degree of cognitive impairment are a considerable health problem in the United States. These include Huntington’s disease, cerebrovascular disease, psychiatric disorders, chronic alcoholism, and AIDS dementia complex. For many years, investigators at the Warren G. Magnuson Clinical Center (CC) of the National Institutes of Health have conducted research involving cognitively impaired subjects in order to investigate the etiology and treatment of these disorders. However, dementing and mental disorders may limit or destroy research subjects’ abilities to give informed consent. Therefore, a challenge to all institutions and investigators conducting such research is balancing the scientific mandate to advance knowledge with the ethical requirement to protect the rights and safeguard the welfare of human subjects. The Belmont Report interprets the relevant principle of respect for persons as incorporating two ethical convictions: that individuals should be treated as autonomous agents, and that persons with diminished autonomy are entitled to protection. Also, protecting human subjects with diminished autonomy is addressed broadly in Department of Health and Human Services regulations: “where some or all of the subjects are likely to be vulnerable to coercion or undue influence, such as persons with acute or severe physical or mental illness, . . . appropriate additional safeguards have been included to protect the rights and welfare of these subjects . . . .” In 1987, the CC adopted an informed consent policy that provides additional safeguards for research subjects who, because of their underlying diseases, are or are likely to become cognitively impaired during the course of the research. We report the results of a survey conducted in 1990 to address practices and attitudes concerning this policy. It is our intent that by presenting the experience with the CC policy, other IRBs and researchers will be encouraged to evaluate and formulate practical safeguards for cognitively impaired research subjects.

A Measure of Positive Health-Related Quality of Life: The Satisfaction with Illness Scale

The Satisfaction with Illness Scale measures the extent to which chronic or acute physical illness has had positive consequences for patients. In a sample of 52 persons with chronic bronchitis, the scale was shown to have good internal consistency and to correlate .42 with another scale of positive life satisfaction.

Quantification of physical illness in psychiatric research in the elderly

AbstractThis article outlines a simple coding matrix for recording physical illness in a compact form suitable for computerization in research. It allows the recording of physical illness in a number of different ways: the particular organ system(s) involved; whether the illness is acute or chronic; the severity of illness; and the severity of interference with daily living. The application of the scheme is shown in a cohort of depressed elderly patients in hospital. Also included were three self‐assessment scales of physical illness and an OARS Physical Health Rating. It was concluded that the simplest and most parsimonious approach to assessing global physical illness for psychiatric research purposes on the elderly would be to (a) measure the number of body system affected by acute and chronic physical illness, and (b) ask each patient to assess his/her own physical health by one appropriate question.

Physical illness and depression: the effects of acute physical illness on the mental state of psychiatric inpatients

A patient is described with a severe agitated depression who made a dramatic recovery following an acute myocardial infarction. A retrospective case notes study was conducted to investigate the effects of a sudden physical illness on the mental state of a group of psychiatric inpatients. Seven patients were identified with agitated depression who improved considerably following an acute life-threatening physical event. Patients with other forms of depression, schizophrenia and schizoaffective disorder showed either no change or underwent a deterioration in mental state.

Who are the Frail Elderly?

To even the most casual observer, the elderly are a very heterogeneous population. Some individuals remain fit and active into their ninth or tenth decades, whilst others show evidence of infirmity during their early sixties in the absence of an acute physical illness. This dissociation of biological and chronological age represents a continuum bounded by, in the parlance of contemporary gerontology, the terms 'fit' and 'frail' [1]. The lack of an agreed operational definition, however, has resulted in conflict and confusion in the gerontological literature. We propose a definition which, we believe, describes these extremes.

Why adolescents do not attend school: The views of students and parents

Despite the magnitude and importance of the problem, little is known about why many students are absent from school. This study assessed what a sample of excessively absent students and their parents believed were the reasons for the students' absences. In response to an openended question about their main reason for absence, almost half of the students reported a health-related reason. When asked whether any of 15 potential problems contributed to their absence, many reported common and acute physical illnesses, headaches or stomachaches, and other aches or pains. Half mentioned factors relating to low motivation or a concern about the school environment. The parents' responses were remarkably similar except they were more likely to cite emotional problems of the student, school violence, and racial problems. When individual student's responses were compared with those of his or her parents, agreement on individual items were little better than would be expected by chance.

Self-Disclosure and Physical Health: In Support of Curvilinearity

Present evidence suggests that an individual's willingness to self-disclose personal information to others may be related to his physical health status. For 62 undergraduate students, significant correlations were found between self-disclosure and measures of acute (—.39) and chronic (—.21) physical illness. These relationships seem to be more curvilinear than linear, supporting the idea that deviations from linearity may often go undetected in studies of self-disclosure.

Self-concept and body-image of children during physical illness

The authors explored children's understanding of their physical illnesses and their effects on body-image and self-concept. A majority of 19 hospitalized boys of latency age realistically understood the nature of their illness and their treatment when health care personnel provided them with adequate information. Interviews and psychological tests showed that acute physical illness did not have a significant impact on general self-concept but did alter body-image in 37% of the children during the period of acute illness.

Stress and Physical and Verbal Aggression in Families and the Incidence of Acute Physical Illness in Pre‐School Children

Stress and Physical and Verbal Aggression in Families and the Incidence of Acute Physical Illness in Pre‐School Children

The domiciliary assessment visit in hospital geriatric practice: pressures and dicisions on needs for admission.

In a sample of 230 cases, requests for admission to a hospital geriatric unit were assessed, in the patients' homes, by a physician and his associate. The physician recorded his opinion of the strength of 14 factors influencing his decisions and also of total admission pressure. Each case was affected by an average of five different factors. Medical factors were most commonly noted: chronic physical illness in 94% of patients, chronic mental illness in 70%; but acute physical illness in only 34%. Difficult nursing was recorded in 76% of cases: other social factors were noted less frequently and related mainly to problems of support. The analysis suggested the importance of the chronic physical illness, difficult nursing, an short-term advantage factors in their contribution to a decision on the need for admission. The chronic mental factor appeared to affect the decision independently of the other factors. It was considered that half the patients were very strongly in need of admission; but a third gave no, or weak, admission pressure, were too ill to be moved, or refused to leave home.

Management Problems of Mentally Retarded Children and Their Families

Pediatricians faced with the difficult task of providing management services to mentally retarded children and their families are confronted with a number of difficult problems. These range all the way from deciding how to inform parents that their child is retarded to dealing with grandparents who are a source of stress. Successful handling of these problems requires a recognition that management is central to the care of the mentally retarded child. The needs of mentally retarded children and their families will not be met by interacting with families only around issues of acute physical illness. Attention must be directed toward psychosocial as well as medical variables and the emphasis must be on the total family system.

Social class gradient in schizophrenia.

Introduction An understanding of the intricate relationship between an illness and the socio-economic complex of urban society is essential for its prevention. Are social, economic, occupational, or family circum stances associated with the illness? If so, are they causally connected or are they the results of the illness itself? Are unfavourable or economic factors connected with contracting the illness (inception), or do they operate only against the recovery of affected persons (prevalence)? Is the association between the inception of illness and environmental factors directly proportional, or do the latter enter into effect only beyond some thres hold of tolerance? Does the relationship between illness and environmental factors affect both sexes and all age groups similarly? Do or occupational factors operate in the same way in different cities or in different communities within the same city? These are only a few of the questions to which and preventive medicine needs answers. Some of these problems have been investigated in respect of acute physical illnesses such as infectious diseases, which become conspicuous fairly quickly after inception and for which the identification of the illness is relatively straightforward; but the identifi cation and separation of socio-economic and family factors is by no means straightforward. In mental illness, however, there are additional difficulties, as for example the unknown interval between the inception of illness and its manifestation, and between the latter and the demand for medical care; and there are further problems of precise diagnostic criteria and identification of mental illness outside hospital. It is not surprising, therefore, that as yet there are few conclusive findings on the relationship between mental illness and specific socio-economic factors; opinions on the possible reasons for?and even on the existence of?such relationships diverge considerably. Investigations into the hospital-treated prevalence of total psychiatric illness have agreed on the social gradient?the increase in prevalence with decrease in socio-economic status; but for individual diagnoses the findings have by no means agreed. Faris and Dunham (1939) found correlations between specific diagnoses and indices of isolation, and for schizophrenia in particular they showed that prevalence was highest in the central areas of Chicago and decreased progressively towards the periphery; however, studies of incidence in some cities of different types, as for example Kansas City (Schroeder, 1942) or in Austin, Texas (Belknap and Jaco, 1953), did not find such a regular pattern. Again, the findings in Bristol of Hare (1956) agreed with the Chicago findings in regard to male schizophrenics but differed somewhat for female schizophrenics; moreover, Hare found no association between the organization of the city and either manic depressive psychosis or the psychoses of old age. The class gradient in schizophrenia, observed in all studies in which a definite socio-occupational index has been used, has led to widely divergent hypotheses. Some investigators have construed the class gradient as resulting from downward occupa tional mobility?drift?of schizophrenics before reaching medical attention, while others have postu lated other factors connected with job-selection; for example Clark (1948) suggested that certain occupa tions and also low pay aggravated pre-schizophrenic problems, and Odegaard (1956) that schizophrenic persons tend to go into, and remain in, stationary or decreasing occupations rather than expanding occupations. Other investigators have considered that occupational mobility features are not relevant; Hollingshead and 'Redlich (1955), in a small 181