자연주의적 탐구조사(Naturalistic Inquiry)

Death is the new sex, last great taboo in Western society and Western medicine, as Richard Smith discusses in his editorial (p 129). In the trinity of births, marriages, and deaths, only death does not have glossy magazines devoted to stylish consumption at the attendant ceremonies. On the web, of course, …

Death and dying

The discovery of effective interventions to prevent or delay disability in older persons is a public health priority. Most likely to benefit from such interventions are frail individuals who are not yet disabled and those with early disability who are at high risk of progression. In spite of this frail older persons have often been excluded from research on the assumption that they would not tolerate testing or benefit from treatment. The Interventions on Frailty Working Group developed recommendations to screen, recruit, evaluate, and retain frail older persons in clinical trials. Specific recommendations are: Eligibility screening should include a multistage process, to quickly exclude those who are too well and those who are too sick. Inclusion criteria should target those most likely to benefit, be meaningful to clinicians, and reflect advancements in the frailty research area. Disability outcome measures should include self-reported, objective, and proxy measures. Strategies to improve retention and compliance and to monitor their effectiveness should be an integral part of the study design. Estimation of cost and sample size should contemplate high dropout rates and interference by competing outcomes. Additional research is needed to refine criteria for screening frail older persons, identify objective measures of disability that are reliable and valid in frail older persons, and improve the informed consent process for high-risk participants, recognizing that research in this subgroup is essential to improving their health outcomes.

Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report.

Anxiety and related disorders are among the most common mental disorders, with lifetime prevalence reportedly as high as 31%. Unfortunately, anxiety disorders are under-diagnosed and under-treated. These guidelines were developed by Canadian experts in anxiety and related disorders through a consensus process. Data on the epidemiology, diagnosis, and treatment (psychological and pharmacological) were obtained through MEDLINE, PsycINFO, and manual searches (1980–2012). Treatment strategies were rated on strength of evidence, and a clinical recommendation for each intervention was made, based on global impression of efficacy, effectiveness, and side effects, using a modified version of the periodic health examination guidelines. These guidelines are presented in 10 sections, including an introduction, principles of diagnosis and management, six sections (Sections 3 through 8) on the specific anxiety-related disorders (panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder), and two additional sections on special populations (children/adolescents, pregnant/lactating women, and the elderly) and clinical issues in patients with comorbid conditions. Anxiety and related disorders are very common in clinical practice, and frequently comorbid with other psychiatric and medical conditions. Optimal management requires a good understanding of the efficacy and side effect profiles of pharmacological and psychological treatments.

/pdf/canadian-clinical-practice-guidelines-for-the-management-of-3kjxn44j0v.pdf

Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders

Summary No single outcome measure can describe or predict all dimensions of recovery and disability after acute stroke. Several scales have proven reliability and validity in stroke trials, including the National Institutes of Health stroke scale (NIHSS), the modified Rankin scale (mRS), the Barthel index (BI), the Glasgow outcome scale (GOS), and the stroke impact scale (SIS). Several scales have been combined in stroke trials to derive a global statistic to better define the effect of acute interventions, although this composite statistic is not clinically tenable. In practice, the NIHSS is useful for early prognostication and serial assessment, whereas the BI is useful for planning rehabilitative strategies. The mRS and GOS provide summary measures of outcome and might be most relevant to clinicians and patients considering early intervention. The SIS was designed to measure the patient's perspective on the effect of stroke. Familiarity with these scales could improve clinicians' interpretation of stroke research and their clinical decision-making.

https://www.thelancet.com/pdfs/journals/laneur/PIIS1474442206704951.pdf

Clinical interpretation and use of stroke scales

OBJECTIVES: To examine the association between mobility levels of older hospitalized adults and functional outcomes.

DESIGN: Prospective cohort study.

SETTING: A 900-bed teaching hospital in Israel.

PARTICIPANTS: Five hundred twenty-five older (≥70) acute medical patients hospitalized for a nondisabling condition.

MEASUREMENTS: In-hospital mobility was assessed using a previously validated scale. The main outcomes were decline from premorbid baseline functional status at discharge (activities of daily living (ADLs)) and at 1-month follow-up (ADLs and instrumental ADLs (IADLs)). Hospital mobility levels and functional outcomes were assessed according to prehospitalization functional trajectories. Logistic regressions were modeled for each outcome, controlling for functional status, morbidity, and demographic characteristics.

RESULTS: Forty-six percent of participants had declined in ADLs at discharge and 49% at follow-up; 57% had declined in IADLs at follow-up. Mobility during hospitalization was twice as high in participants with no preadmission functional decline. Low versus high in-hospital mobility was associated with worse basic functional status at discharge (adjusted odds ratio (AOR)=18.03, 95% confidence interval (CI)=7.68–42.28) and at follow-up (AOR=4.72, 95% CI=1.98–11.28) and worse IADLs at follow-up (AOR=2.00, 95% CI=1.05–3.78). The association with poorer discharge functional outcomes was present in participants with preadmission functional decline (AOR for low vs high mobility=15.26, 95% CI=4.80–48.42) and in those who were functionally stable (AOR for low vs high mobility=10.12, 95% CI=2.28–44.92).

CONCLUSION: In-hospital mobility is an important modifiable factor related to functional decline in older adults in immediate and short-term (1-month follow-up) functional outcomes.

Low Mobility During Hospitalization and Functional Decline in Older Adults

Objectives
To investigate the combined contribution of processes of hospitalization and preadmission individual risk factors in explaining functional decline at discharge and at 1-month follow-up in older adults with nondisabling conditions.

Design
Prospective cohort study.

Setting
Internal medicine wards in two Israeli medical centers.

Participants
Six hundred eighty-four individuals aged 70 and older admitted for a nondisabling problem.

Measurements
Functional decline was measured according to change in modified Barthel Index from premorbid to discharge and from premorbid to 1 month after discharge. In-hospital mobility, continence care, sleep medication consumption, satisfaction with hospital environment, and nutrition intake were assessed using previously tested self-report instruments.

Results
Two hundred eighty-two participants (41.2%) reported functional decline at discharge and 317 (46.3%) at 1 month after discharge. Path analysis indicated that in-hospital mobility (standardized maximum likelihood estimate (SMLE) = −0.48, P < .001), continence care (SMLE = −0.12, P < .001), and length of stay (LOS) (SMLE = 0.06, P < .001) were directly related to functional decline at discharge and, together with personal risk factors, explained 64% of variance. In-hospital mobility, continence care, and LOS were indirectly related to functional decline at 1 month after discharge through functional decline at discharge (SMLE = 0.45, P < .001). Nutrition consumption (SMLE = −0.07, P < .001) was significantly related to functional decline at 1 month after discharge, explaining, together with other risk factors, 32% of variance.

Conclusion
In-hospital low mobility, suboptimal continence care, and poor nutrition account for immediate and 1-month posthospitalization functional decline. These are potentially modifiable hospitalization risk factors for which practice and policy should be targeted in efforts to curb the posthospitalization functional decline trajectory.

https://www.smgg.es/images/articulos/hospitalizaciondecline.pdf

Hospital-associated functional decline: the role of hospitalization processes beyond individual risk factors.

Objective
The aim of the study was to empirically investigate the hypothesis that anxiety in the elderly, secondary to loss of memory, predicts future cognitive decline.

Method
The participants were 137 elderly subjects with no depression or cognitive impairment from a community geriatric assessment unit, 45% with anxiety. In addition to demographic characteristics, cognitive status was assessed using the Mini Mental State Examination; depression was assessed by Tucker's short Interviewer-Assisted Depression Rating Scale; anxiety by Sinoff's Short Anxiety Screening Test and Activities of Daily Living function by Shah's modified Barthel's Index.

Results
At follow-up 37 persons had dropped out, leaving 100 participants for final analysis. Mean re-examination time was 3.2 years with no group differences. The mean MMSE and modified Barthel scores decreased significantly more in those with anxiety. A relative risk of 3.96 for developing future cognitive impairment was found. Regression analysis showed that only anxiety was a significant predictor of cognitive decline. By path analysis, a more parsimonious model showed anxiety to have both a direct and an indirect effect on predicting future cognitive decline, and that the effect of loss of memory on cognitive decline was via anxiety.

Conclusions
Anxiety is inter-related and inseparable with loss of memory and its presence is a strong predictor for future cognitive decline, directly or indirectly via depression. It appears that loss of memory is the initial problem with consequent development of anxiety. Therefore, anxiety, like depression, is probably an early predictor of future cognitive decline and even possible future cognitive impairment. Copyright © 2003 John Wiley & Sons, Ltd.

Anxiety disorder and accompanying subjective memory loss in the elderly as a predictor of future cognitive decline.

BACKGROUND AND PURPOSE: The Barthel Index for assessing activities of daily living (ADL) was developed particularly for young stroke patients, but it now has a wider application in the geriatric assessment profile. This study tests the validity of the Barthel Index by self-report in the old-old (≥ 75 years). If more than 10% of the studied population assessed themselves incorrectly (≥ 15-point discrepancy), the test may have limitations. We set out to try to quantify and explain this discrepancy.

METHODS: During a 3-month period, we tested 126 old-old patients, both geriatric medical inpatients and subjects from the community, in a cross-sectional study. Using the Barthel Index, their functional status was assessed by self-report and by observation of performance. A measure of the magnitude of discrepancy between the two methods (discrepancy score) was calculated as the difference between the self-report and performance total scores.

RESULTS: Comparing the self-report with actual ADL performance scores, the mean score for self-report was higher (90 vs 88). There was a low Kappa score in all areas of the scale (range 0.103–0.398). Twenty of the 126 patients (15.9%) scored 15 or more points in the discrepancy score. By running a multiple linear regression, we were able to explain only 21% of the variance in the discrepancy score (R2 = .21). Significant explanatory variables were the presence of cognitive impairment, source of patients from acute geriatric ward, and age (very old ≥ 85 years).

CONCLUSION: For the purpose of this study, use of the Barthel Index by self-reporting was found to have its limitations in the old-old (≥ 75 years), particularly with regard to the very old (≥ 85 years) medical geriatric inpatients. Therefore, we suggest that the older people may have to be assessed by the rehabilatation services using a performance-based measure or a different self-report test for documenting their activities of daily living, bearing in mind that self-reported and performance-based measures capture physical abilities differently.

The Barthel Activities of Daily Living Index: Self-Reporting Versus Actual Performance in the Old-Old (≥ 75 years)

Introduction
The Short Anxiety Screening Test (SAST), an easily administered rating scale, was developed to standardize the detection of anxiety disorder in the elderly, even, and especially, in the presence of depression. The instrument also included somatic complaints, often the manifestation of anxiety in the elderly. Failure to relate to the anxiety component in depression may result in the initial failure of antidepressant therapy.

Objective
To validate the SAST in the elderly, especially in the presence of depression.

Design
The SAST was validated against a psychiatric evaluation in consecutive patients attending a geriatric service, both inpatient and outpatient. The initial validity of the SAST was tested in all the sample and subsequently in the subgroups of depressed and non-depressed.

Setting
An urban geriatric service in Israel.

Patients
One hundred and fifty medical inpatients and outpatients, 95 females, aged 70 years and older.

Measures
Psychiatric evaluation of modified Anxiety Disorders Interview Schedule for DSM-IV as criterion standard for anxiety and depression, SAST for anxiety and short Zung Interview-Assisted Depression Rating Scale for depression.

Results
By the psychiatrist's evaluation, 40.7% suffered from anxiety. Mean SAST scores in the presence and absence of anxiety were significantly different (25.3 and 20.1; p<0.0005). The overall validity of the SAST was high (sensitivity 75.4%, specificity 78.7%). In the presence of depression, sensitivity was 83.3% and specificity 70.5%.

Conclusion
The SAST was valid in detecting anxiety in the elderly, as well as in depressed patients. The study proved the usefulness of the SAST in a geriatric assessment programme. Copyright © 1999 John Wiley & Sons, Ltd.

Gary Sinoff

Papers

Low Mobility During Hospitalization and Functional Decline in Older Adults

Hospital-associated functional decline: the role of hospitalization processes beyond individual risk factors.

Anxiety disorder and accompanying subjective memory loss in the elderly as a predictor of future cognitive decline.

The Barthel Activities of Daily Living Index: Self-Reporting Versus Actual Performance in the Old-Old (≥ 75 years)

Short Anxiety Screening Test--a brief instrument for detecting anxiety in the elderly.