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Neuropsychological characteristics of mild vascular cognitive impairment and dementia after stroke
- Authors:
- STEPHENS S., et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 19(11), November 2004, pp.1053-1057.
- Publisher:
- Wiley
Post-stroke cognitive impairment is frequent, with characteristic impairments of attentional and executive performance. The study aims to determine whether the profile and severity of impairment in vascular Cognitive Impairment No Dementia (vascular CIND) is intermediate between that seen in stroke patients without significant cognitive impairment and patients with post-stroke dementia and thus to establish if the potential value of vascular CIND is a useful concept for predicting further cognitive decline and dementia in stroke patients. Stroke patients (n = 381) > 75 were recruited from representative hospital-based stroke registers in Tyneside and Wearside, UK. Sixty six age matched controls were also recruited. A detailed battery of neuropsychological assessments was completed 3 months post stroke. Deficits of attention (z = 5.7; p < 0.0001) and executive function (z = 5.9; p < 0.0001) were seen even in stroke patients without vascular CIND, compared to controls. However, stroke patients with CIND were significantly more impaired again on tests of executive function (z = 10.3; p < 0.0001) compared to those not meeting CIND criteria; and also had greater impairments of memory (z = 10.4; p < 0.0001) and language expression (z = 10.1; p < 0.0001). A similar overall profile of deficits was evident in the CIND and the dementia group, but specific deficits were significantly more pronounced in those with dementia, particularly in orientation (z = 7.2; p < 0.0001) and memory (z = 5.8; p < 0.0001). The current study indicates that attentional and executive impairments are frequent in stroke patients, but deficits of memory, orientation and language are more indicative of CIND and dementia. Further longitudinal studies are required to clarify the relationship between specific lesions and the progression of specific cognitive deficits in post-stroke patients.
Psychiatric issues in retrospective challenges of testamentary capacity
- Authors:
- SHULMAN Kenneth I., COHEN Carole A., HULL Ian
- Journal article citation:
- International Journal of Geriatric Psychiatry, 20(1), January 2005, pp.63-69.
- Publisher:
- Wiley
Challenges to Wills on the basis of lack of testamentary capacity are likely to increase due to a combination of economic factors, high prevalence of mental disorders in old age and the complexity of many modern families. Geriatric psychiatrists and other experts will be asked to provide expert assessment of the testamentary capacity of individuals whose Wills are being challenged retrospectively. The traditional criteria described in the Banks vs Goodfellow case have been held as the standard for testamentary capacity. However, these criteria may not be comprehensive enough for the coming generation of expert assessors. The literature and selected international case law relevant to testamentary capacity were reviewed. Particular focus is placed on the conceptual and empirical approaches to the assessment of complex capacities that may inform the development of specific legal standards. In addition, 25 consecutive medico-legal reports on retrospective testamentary capacity were analyzed according to co-morbid medical and psychiatric disorders as well as psychosocial and behavioural variables. Illustrative case vignettes are included. The typical profile for retrospective challenges to testamentary capacity included a radical change from a previous Will (72%), where undue influence was alleged (56%), in a testator with no biological children (52%), who executed the Will less than a year prior to death (48%). Co-morbid conditions were dementia (40%), alcohol abuse (28%) and other neurological/psychiatric conditions (28%). While Banks vs Goodfellow continues to provide a sound basis for assessing testamentary (task-specific) capacity, the complexity and subtlety of the issues reflected in these cases highlight the need to go beyond the traditional criteria and assess situation-specific factors. Expert assessors need to determine whether the testator appreciated the consequences of executing or changing a Will, especially when there has been a radical change in the context of a complex or conflictual family environment. Empirical studies addressing the cognitive functions relevant to testamentary capacity and the development of legal standards based on a competency construct may also help to inform retrospective capacity assessments.
A randomized, controlled, clinical trial of activity therapy for apathy in patients with dementia residing in long-term care
- Authors:
- POLITIS Antonios M., et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 19(11), November 2004, pp.1087-1094.
- Publisher:
- Wiley
Apathy is a common symptom in patients with dementia and has adverse consequences for patients and caregivers. Most treatments for apathy, particularly non-pharmacologic interventions, have not been evaluated in controlled trials. This study evaluated the efficacy of a kit-based activity intervention, compared to a time and attention control (one-on-one meetings with an activity therapist) in reducing apathy and improving quality of life in 37 patients with dementia. The design was a randomized, controlled, partially masked clinical trial. All outcome measures were administered at baseline and follow-up. The primary outcome measure was the apathy score of the Neuropsychiatric Inventory (NPI). Other outcome measures were the NPI total score, the Alzheimer Disease Related Quality of Life scale(ADQRL), and the Copper Ridge Activity Index (CRAI). There was a significant reduction in NPI apathy scores in both treatment groups. The only significant difference between the two treatment groups was a modest advantage for the control intervention on the CRAI cueing subscale (p = 0.027), but not on the other CRAI subscales. There was also a greater within group improvement in quality of life ratings in the control intervention (p = 0.03). Despite the substantial improvement in apathy scores during the course of the study, there was no clear advantage to the reminiscence-based intervention over the time and attention, one-on-one control intervention. More research is needed to develop specific behavioral interventions for apathy in patients with dementia.
Executive functioning in psychogeriatric patients: scalability and construct validity of the Behavioral Dyscontrol Scale (BDS)
- Author:
- DIESFELDT Han F, A.
- Journal article citation:
- International Journal of Geriatric Psychiatry, 19(11), November 2004, pp.1065-1073.
- Publisher:
- Wiley
Item response theory was used to test the scalability of the Behavioral Dyscontrol Scale (BDS). The BDS assesses the control of voluntary movement, working memory and self-monitoring. Construct validity of the BDS was examined with confirmatory factor analysis. The BDS was administered to 693 consecutive, community-dwelling visitors of a psychogeriatric day unit (424 women and 269 men between the ages of 50 and 94). Unidimensionality of the BDS was determined using Mokken's scalogram analysis. The BDS total score was correlated with other measures of executive function (Expanded Mental Control Test, category fluency, and alternating graphical sequences) and with episodic memory tests of orientation and delayed picture recognition in order to test a model of distinct latent constructs of executive functioning and episodic memory. Loevinger's scalability coefficient H was 0.58 for the complete item set of the BDS. Subjects can be ordered on the latent dimension of executive ability. The first eight items of the BDS (deleting the insight rating) satisfy the assumption of non-intersecting item characteristic curves (double monotonicity) which means that they comprise a Guttman-ordered scale (H = 0.60). The BDS and three independent measures of executive control strongly correlated with a latent construct of executive functioning (convergent validity). However, discriminant relations with a nonexecutive construct (recognition memory and orientation) could not be demonstrated. The BDS satisfies criteria for scalability according to item response theory. Its construct validity as an executive-specific measure is as yet unclear. Copyright
Competence to consent to treatment of geriatric patients: judgements of physicians, family members and the vignette method
- Authors:
- VELLINGA A., et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 19(7), July 2004, pp.645-654.
- Publisher:
- Wiley
In absence of a gold standard of methods to assess competence, three judgements of competency of geriatric patients are evaluated: the judgements of a physician, the judgement of a family member, and the judgement of an instrument. Competence of 80 geriatric patients was judged both by a physician and a family member. Decision making capacity was assessed with a vignette. A vignette describes a treatment choice, after which the following abilities are evaluated: evidencing a choice, understanding, reasoning and appreciating a situation. Cognitive functioning was measured with the Mini-Mental State Examination. Most of the geriatric patients were judged competent by all three methods. Disagreement between the three judgements was found for 25 patients. Agreement about incompetence was only reached for one patient. Physicians appeared to be most lenient in their incompetency judgement: only three patients were judged incompetent. These patients scored significantly lower than competent patients on cognitive functioning, the decisional ability of understanding, and the total vignette score. Family members appeared to be most stringent in their judgement: they considered 22 patients incompetent. Incompetent patients scored significantly lower than competent patients on cognitive functioning, reasoning and the total vignette score. The disagreement between the judgements suggests a difference in factors given emphasis by the three methods. The finding that both the judgement of physicians and family members are associated with the assessment of the vignette, suggests that the vignette method has more than a legal theoretical base and is associated with daily life experience and knowledge as well. Physicians can be helped to assess competence by the vignette method to evaluate decisional abilities and by family members who can provide more information about patients' values.
A longitudinal study of neuropsychological change in individuals with Parkinson's disease
- Authors:
- AZUMA Tamiko, et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 18(12), December 2003, pp.1115-1120.
- Publisher:
- Wiley
Neuropsychological changes in individuals with Parkinson's disease (PD) were studied longitudinally. Sixty-nine idiopathic PD patients, with Mini-Mental State Examination (MMSE) scores falling within normal range, and 37 elderly control participants were given neuropsychological tests twice approximately two years apart. The PD group performed poorer than the control group on Semantic Fluency, Letter Fluency, Modified Wisconsin Card Sorting Task, and Block Design at test time 1. Two years later, the PD group showed significant decline in Semantic and Letter Fluency. A subset of 12 PD patients declined in mental status by second testing (>4 MMSE points). Cox proportional-hazards models were used to see if any baseline measures were associated with relative risk of decline in mental status. In the final model, Repetition performance and Age were significantly associated with cognitive decline. Consistent with previous studies, executive function tasks were those most susceptible to disease progression.
The meaning of acute confusional state from the perspective of elderly patients
- Authors:
- ANDERSSON Edith M., et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 17(7), July 2002, pp.652-663.
- Publisher:
- Wiley
The meaning of the patients' lived experiences of being and having been confused was interpreted as Being trapped in incomprehensible experiences and a turmoil of past and present and here and there, comprising the themes trying to get a grip on the experience of the confusion, encountering past, present and the realm of the imagination as reality during the period of confusion and confronting the idea of having been confused. Contradictory to earlier research the patients remembered and could tell in great detail about their Acute Confusional State. While confused, the confusional state means that impressions of all kinds invade the mind of the person and are experienced as reality, making him/her a victim of these impressions rather than the one who controls what comes into his/her mind. While in the middle of these experiences the person simultaneously senses that the impressions are unreal, thus indicating that he/she is in some sort of borderland between understanding and not understanding. The things that come into the mind of the person can either be frightening or neutral or enjoyable scenarios that seem to be mainly familiar but can also be unknown. These scenarios seem to be a mixture of past and present, of events and people while they seem to float from location to location. The findings indicates that what takes place during the Acute Confusional State is not nonsense but probably a mix of the patient's life history, their present situation and above all a form of communication concerning their emotional state and inner experiences in this new situation
The attitudes of carers and old age psychiatrists towards the treatment of potentially fatal events in end-stage dementia
- Authors:
- COETZEE S. J., LEASK S. J., JONES R.G.
- Journal article citation:
- International Journal of Geriatric Psychiatry, 18(2), February 2003, pp.169-173.
- Publisher:
- Wiley
Deciding how to treat patients with end-stage dementia developing potentially fatal events has long been contentious. Under expected new legislation the role of carers is likely to increase. Old age psychiatrists frequently have to decide between active or palliative approaches to such patients. Little is known concerning the comparative attitudes of carers and old age psychiatrists. This research examined how their attitudes differed. Clinicians favoured active treatment of potentially fatal events in end-stage dementia less than carers who more significantly valued patient-centred issues such as dying with dignity, the patient's best interests and the patient's wishes.