Demented Inpatients Research Articles

Factors Affecting Falls of Demented Inpatients

Factors Affecting Falls of Demented Inpatients

Early markers of prolonged hospital stay in demented inpatients: a multicentre and prospective study.

Dementia is a serious, chronic, and costly public health problem. Prior studies have described dementia as increasing length of hospital stay, but so far no explanations have been proposed. To identify early markers for prolonged hospital stay in demented elderly inpatients, 178 community-dwelling or institutionalized subjects aged 75+, hospitalized through an emergency department in 9 teaching hospitals in France, were analyzed. Prolonged hospital stays were defined according a limit adjusted for Diagnosis Related Group. All patients underwent a comprehensive geriatric assessment at admission. Logistic regression multifactorial mixed model was performed. Center effect was considered as a random effect. Of the 178 stays, 52 were prolonged. Most concerned community-dwelling patients (86%). Multifactor analysis demonstrated that demographic variables had no influence on the length of stay, while diagnosis of delirium (OR 2.31; 95% CI 1.77 - 2.91), walking difficulties (OR 1.94; 95% CI 1.62 - 2.43) and report by the informal caregiver of moderate or severe burden (OR 1.52; 95% CI 1.19 - 1.86) or low social quality-of-life score (OR 1.25; 95% CI 1.03 - 1.40), according to the Zarit's Burden Inventory short scale (12 items) and the Duke's Health Profile respectively, were identified as early markers for prolonged hospital stays. At the time of the rising incidence of cognitive disorders, these results suggest that preventive approaches might be possible. In a hospital setting as well as in a community-dwelling population, more specific, specialized and coordinated care, using the expertise of multiple disciplines appears as a probable effective measure to limit prolonged hospital stay. Such approaches require (i) clear patient-oriented goal definition, (ii) understanding and appreciation of roles among various health care and social disciplines and, (iii) cooperation between partners in patient's management. However, the cost- and health-effectiveness of such approaches should be evaluated.

Assessment of clinical outcome in patients with moderate dementia and concomitant depression

Background and aims: Reliable assessment of depression in demented patients remains a challenging task in the absence of validated clinical tools. A French version of the HoNOS65+ was used to assess the clinical changes in moderately demented inpatients. Methods: Thirty elderly inpatients with both major depression (major depressive episode or recurrent depressive disorder) and dementia (Alzheimer's disease 57%, mixed dementia 43%) according to ICD-10 criteria, were assessed at hospital admission and release. Clinical changes were measured using the HoNOS65+F as well as six widely used rating scales. Results: There was a significant decrease in both mean HoNOS65+F (p=0.000) and BPRS (p=0.000) total scores at the end of the hospitalization in the present series. In contrast, GAF scores increased from 50.66 points at admission to 63.33 points at release (p=0.000). Although significant differences between the first and last day of hospitalization were also observed for CDR (p=0.01) and ADL (p=0.038) scores, they did not persist after Bonferroni correction. Total HoNOS65+F scores were significantly associated with both total BPRS (p=0.008) and GAF (p=0.026) scores. Changes in four HoNOS65+F items (behavioral disturbance, depressive symptoms, activities of daily life, drug management) were associated with BPRS item changes as well as GAF improvement. Conclusions: Our data should be interpreted in line with recent evidences supporting the utility of HoNOS65+ in the detection of mental health problems in the elderly. Our results reveal that the HoNOS65+F may be one of the rare available scales to reliably assess the evolution of depression in patients with moderate dementia.

Chinese demented inpatients admitted following a suicide attempt: a case series

Suicide attempt is rarely reported in dementia. This study explores the clinical and phenomenological aspects as well as the treatment of Chinese demented patients who have attempted suicide. During a 1-year period, demented patients admitted to a geropsychiatric unit as a result of suicide attempt were investigated for factors related to suicide attempt, such as motives and method. In this 1-year survey, seven demented patients (11.7% of all demented patients) were admitted immediately following a suicide attempt. All seven patients had mild or moderate dementia. Three had significant clinical depression symptoms on admission. In all patients, delusions were the primary cause of suicide attempt. Their suicidal ideations were improved with antipsychotic and antidepressant treatment. These cases, taken together, suggest that suicide attempt can occur in patients with dementia. It is important for clinicians to be aware of the risk of suicide in patients with dementia, especially those associated with delusions, even if they have no major depression or suicide attempt history. Antidepressants and antipsychotics may play a critical role in the treatment of suicide attempt in dementia.

P1-139 Risk factors for delirium in demented and not demented elderly inpatients

P1-139 Risk factors for delirium in demented and not demented elderly inpatients

Pacing Rhythms of “Wanderers” with Dementia

Background: As wandering in the demented is difficult to define qualitatively, we tride to define it quantitatively. We investigated the relationship between wandering and rhythm abnormalities. Methods: In order to study the pacing rhythms of wanderers observed in a subgroup of demented inpatients (dementia due to Alzheimer's disease and vascular dementia), we assessed 115 inpatients in terms of steps during four parts of a day and total daily steps using a pedometer.As the mean+2 S.D. of total daily steps in the nondemented was 9,979, we defined 10,000 steps in a day as the cut off for defining demented wanderers versus nonwanderers. Then, the pacing rhythms (nadir part and amplitude) were compared among demented wanderers, demented nonwanderers and nondemented subjects. Results: That there were no statistically significant differences among the three groups. But wandering groups defined by pedometer exhibited many of the same characteristics in wanderers observed in other studies. Conclusion: The quantification of steps might provide a good hallmark of wandering behaviors in the demented, and these results might indicate hyperpacing rather than rhythm dysfunctions to be essential to wandering behavior.

Hyperactivity in the hypothalamic-pituitary-adrenal axis in demented patients with delirium.

Occurrence of delirium is known to be related to, among other things, organic brain disorder, somatic disease and old age. It has been hypothesized that delirium is also associated with stress. Disturbances of the hypothalamic-pituitary-adrenal (HPA) system have been found in delirious patients in various studies. The aim of the present study was to determine the activity in the HPA axis in demented patients to ascertain whether the stress regulating system was more disturbed in patients with delirium than in those without delirium. Demented inpatients with no acute medical illness were included in the study. Basal cortisol levels in serum were measured and dexamethasone suppression test (DST) was performed. The most important finding of the study was a strong relationship between delirium and DST pathology irrespective of age and severity of dementia. It is suggested that certain demented individuals have an impaired HPA system and a low delirium threshold and respond to stress with delirium.

Repeated pulmonary aspiration in the aged demented patients

We investigated the aged demented inpatients who had repeated aspiration in our hospital during a period of 21 months from July 1997. Subjects are 60 patients aged from 65 to 94. We investigated the clinical background of the subjects, dividing them into the group with pneumonia and the group without pneumonia, and compared their type of dementia, grade of dementia, underlying diseases, laboratory data, diet, and outcome. We further compared the effect of mucoid diet for pneumonia. The most common underlying diseases were hypertension, cerebrovascular disease, diseases of the digestive system, and malignant tumor. There was no statistically significant difference in the outcome of the two groups. Within the subjects, death due to pneumonia was statistically significantly less in patients who had a mucoid diet. These findings suggested that a mucoid diet is useful for the protection against death caused by aspiration pneumonia.

Neuropsychological Assessment of Psychogeriatric Patients with Limited Education

Traditional published norms for neuropsychological tests that do not consider demographic effects can lead to spuriously high false positive rates among low-educated elderly individuals. This problem may be compounded when trying to identify dementia in psychogeriatric patients whose cognitive functioning is also compromised by psychiatric illness. This study investigated the clinical utility of low education neuropsychological test norms to discriminate amongst demented and nondemented psychogeriatric inpatients and healthy community elderly with limited education. Results indicated that the Mattis Dementia Rating Scale (MDRS), the Fuld Object Memory Evaluation (FOME), the Mini-Mental State Examination (MMSE), and a Clock drawing task had high discriminability in differentiating the three groups. Application of demographically corrected norms has important implications for diagnosis and treatment planning, especially when neuropsychological status is complicated by psychiatric illness.

METHODOLOGICAL ISSUES IN CHARACTERIZING TREATMENT RESPONSE IN DEMENTED PATIENTS WITH BEHAVIORAL DISTURBANCES

Despite the proliferation of instruments developed to rate behavioral disturbances associated with dementia, systematic studies of how ratings on these instruments should be analyzed to measure change in disruptive behaviors or distressing symptoms (ie treatment response) are noticeably absent. Using one of these scales, we compared three methods to characterize treatment response in 52 elderly demented inpatients who participated in a standardized neuroleptic trial. While all three analyses identified a statistically significant improvement, they conveyed differently the clinical improvement experienced by the patients. Categorical outcomes communicated the clinical meaning of improvement better than changes in total score; changes in factor scores best revealed the differential impact of treatment on specific behavioral and symptomatic domains. Given the heterogeneity of the problematic behaviors and symptoms exhibited by demented patients included in treatment trials, regardless of the intervention being tested or of the instrument being used to rate behaviors, a focused approach to characterizing treatment response is needed. © 1997 John Wiley & Sons, Ltd.

METHODOLOGICAL ISSUES IN CHARACTERIZING TREATMENT RESPONSE IN DEMENTED PATIENTS WITH BEHAVIORAL DISTURBANCES

Despite the proliferation of instruments developed to rate behavioral disturbances associated with dementia, systematic studies of how ratings on these instruments should be analyzed to measure change in disruptive behaviors or distressing symptoms (ie treatment response) are noticeably absent. Using one of these scales, we compared three methods to characterize treatment response in 52 elderly demented inpatients who participated in a standardized neuroleptic trial. While all three analyses identified a statistically significant improvement, they conveyed differently the clinical improvement experienced by the patients. Categorical outcomes communicated the clinical meaning of improvement better than changes in total score; changes in factor scores best revealed the differential impact of treatment on specific behavioral and symptomatic domains. Given the heterogeneity of the problematic behaviors and symptoms exhibited by demented patients included in treatment trials, regardless of the intervention being tested or of the instrument being used to rate behaviors, a focused approach to characterizing treatment response is needed.

Effects of age and education on neuropsychological test performance: A comparison of normal versus cognitively impaired geriatric medical patients

The effects of age and education on neuropsychological test performance were examined in samples of cognitively intact (n = 51) and demented (n = 99) geriatric inpatients. Using Fisher's r to z procedure, no between sample differences for correlations were found, except for the relationship between Wechsler Memory Scale-Revised Logical Memory II performance and age (z = 1.68; p <. 05). These results are discrepant with those of previous studies that question the validity of demographically based score corrections for younger patients with neurological disease (e.g., Reitan & Wolfson, 1995). the authors advocate the consideration of demographic influences on neuropsychological test performance, particularly when evaluating older, less educated persons.

HIGH PROPORTION OF DEMENTIA WITH LEWY BODIES IN THE POSTMORTEMS OF A MENTAL HOSPITAL IN GERMANY

Dementia with Lewy bodies (DLB) is under-recognized in Germany. No data on the number of patients suffering from this condition in Germany are available at present. We were interested in the proportion of DLB in the postmortems of demented inpatients in the care of a psychogeriatric service. In a retrospective study we examined consecutive postmortems of inpatients who died in one mental hospital. A suburban and rural old age psychiatry service in Germany. 103 consecutive postmortems had been performed from 9/1987 to 6/1995. Fifty-nine (57.3%) of all cases warranted the clinical diagnosis of dementia (DSM-III-R). The causes of dementia were examined histologically. Lewy bodies (LBs) were detected with ubiquitin immunohistochemistry. DLB was the third most frequent cause of dementia (13.6% of demented), after dementia of Alzheimer's type (DAT) (35.6%) and mixed DAT and vascular dementia (15.3%), but ahead of 'pure' vascular dementia (MID). The DLB group showed a male preponderance compared with the DAT, MID and mixed group of our series. The DLB patients died younger than the DAT patients. The differences, however, were not statistically significant. All DLB cases showed neurofibrillary and amyloid pathology sufficient to warrant an additional diagnosis of DAT. Cases with 'pure' LB pathology had not been detected in our series. Our results indicate that by using appropriate methods, ie ubiquitin immunohistochemistry, a considerable number of DLB cases can be detected in postmortems of demented patients from German mental hospitals.

Stepwise comparative status analysis (STEP): a tool for identification of regional brain syndromes in dementia.

A method for clinical examination of patients with dementia, stepwise comparative status analysis (STEP), is presented. It combines psychiatric and neurologic status examination methods to identify certain common dementia symptoms by which the patient's regional brain symptom profile can be determined. Fifty status variables (items) are estimated with respect to occurrence and severity. The analysis is performed in three steps. The scores on the 'primary' variables reflect observations of single dementia symptoms. These scores form the basis for the assessment of the 'compound' variables, which in turn form the basis for evaluation of the 'complex' variables, one of which describes the patient's regional (predominant) brain syndrome (subcortical, frontosubcortical, frontal, frontoparietal, parietal, or global). In 96 mildly and moderately demented inpatients, the global (42%) and frontosubcortical (31%) were the most common. Ninety-one percent of the patients with vascular dementia had a predominant frontal and/or subcortical symptomatology.

TYPES AND PHENOMENOLOGIC SUBTYPES OF DEMENTIA IN TAIWAN: A PSYCHIATRIC INPATIENT STUDY

An investigation of 91 consecutive psychiatric inpatients with suspected dementia was designed to evaluate the relative frequency of different types and phenomenologic subtypes of dementia in Taiwan. The type of dementia was reviewed to determine different aetiologies. Phenomenologic subtypes of dementia were investigated according to the classifications of theDiagnostic and Statistical Manual of Mental Disorders. In contrast to previous studies in Taiwan, dementia of the Alzheimer's type (59.3%) was more frequent than vascular dementia (26.4%). The relative frequencies of phenomenologic subtypes were as follows; uncomplicated, 43%; with delusion, 38%; with delirium, 14%; with depression, 5%. This is the first report regarding the clinical subtypes of psychiatric demented inpatients in Taiwan. In spite of correct aetiological diagnosis of dementia, this report highlights the non-cognitive problems of dementia.

TYPES AND PHENOMENOLOGIC SUBTYPES OF DEMENTIA IN TAIWAN: A PSYCHIATRIC INPATIENT STUDY

An investigation of 91 consecutive psychiatric inpatients with suspected dementia was designed to evaluate the relative frequency of different types and phenomenologic subtypes of dementia in Taiwan. The type of dementia was reviewed to determine different aetiologies. Phenomenologic subtypes of dementia were investigated according to the classifications of the Diagnostic and Statistical Manual of Mental Disorders. In contrast to previous studies in Taiwan, dementia of the Alzheimer's type (59.3%) was more frequent than vascular dementia (26.4%). The relative frequencies of phenomenologic subtypes were as follows; uncomplicated, 43%; with delusion, 38%; with delirium, 14%; with depression, 5%. This is the first report regarding the clinical subtypes of psychiatric demented inpatients in Taiwan. In spite of correct aetiological diagnosis of dementia, this report highlights the non-cognitive problems of dementia.

Physical Aggression and Associated Factors in Probable Alzheimer Disease

Aggressive behavior is thought to be pervasive among and devastating to demented patients and their caregivers. This study investigated the prevalence of physical aggression in demented inpatients with Alzheimer disease (AD). Additionally, the characteristics and psychiatric symptoms that may be associated with aggression were tested. Forty-seven patients with probable AD were included in this study. Physical aggression was reported in 27 (57.4%) of the patients. These patients were older, had a later onset of dementia, and had a higher prevalence of misidentification, activity disturbances, and day/night disturbance. The relationship between these factors and physical aggression needs further clarification, which may help provide effective predictors and treatment of the aggressive behavior.

Survival in institutionalized patients. Influence of dementia and loss of functional capacities.

Several studies have shown a negative correlation between dementia and survival. To our knowledge, the simultaneous effect of other factors has not been systematically studied in institutionalized patients. To determine survival in demented inpatients compared with that in a matched population of nondemented patients institutionalized for other chronic debilitating diseases. The sample consisted of 213 patients with dementia and 157 patients without dementia. We studied the effect on survival of gender, age, loss of functional capacities, and cognitive functions with the method of Kaplan and Meier and with the model of Cox. Demented patients had significantly shorter survival when other factors were kept constant in the multivariate analysis. There was a strong correlation between survival and the degree of autonomy as measured by ability to walk, continence, and preserved activities of daily living. Survival was significantly shorter for men. No correlation was found with neuropsychological measures of severity of dementia or with age on admission. Survival of demented patients is shorter than that of patients institutionalized for other invalidating conditions. The lack of correlation between neuropsychological test results and survival indicates that in the population we studied, the severity of dementia did not predict length of survival. The data show that the combination of dementia and loss of functional capacities is the most important factor in predicting survival.

Effects of piracetam on the dexamethasone suppression test in Alzheimer's and multi-infarct dementias

SummaryResults of the dexamethasone suppression test (DST) in demented nondepressed patients have varied considerably, and there is evidence that these depend on the type of dementia, ie, Alzheimer’s disease (AD) or multi-infarct dementia (MID). AD is characterized by decreased central acetylcholine (Ach) activity, while MID is thought to be vascular in etiology. Pirecetam normalizes cerebral blood flow, along with other positive hemorheological properties. It may also increase central Ach levels. We performed the DST twice, 1 week apart, on 96 stable, demented geriatric inpatients. In 33 (21 AD, 11 MID), piracetam was started at an oral dose of 4.8 g/d 4-6 months before the first DST. The remaining 64 (39 AD, 25 MID) were untreated. Among untreated patients, those with MID were less suppressible (P &lt; 0.001 and P= 0.01) and had more week-to-week variability (P = 0.0006) in the DST than AD patients. This is consistent with our previous findings. However, treated patients showed no difference in either postdexamethasone cortisol levels or reproducibility of DST results. We interpret these findings to mean that piracetam, by increasing central Ach, makes AD patients less suppressible on the DST, and by maintaining more constant limbic blood flow, makes MID patients more DST stable.

The effect of prompting and reinforcement of activity in elderly demented inpatients

On a ward for 24 psychogeriatric patients, 18 were randomly assigned to three groups with different experimental conditions. The first group was prompted and reinforced for different activities; the second was only prompted; and the third served as a control group. Activities, both the trained ones and others, were continuously monitored throughout the five week study. The results showed a clear increase in the trained activities after training. The prompting condition was effective, and the addition of reinforcement did not add any to the effects. There was no generalization to untrained activities, and the effects did not last at the 1 hr or 21 hr assessments, but was clearly visible at 5 min after training. Time seemed to be more important than place, i.e. the effect ceased with elapsed time, not because of changes in the situation.