Functional recovery after hip fracture: the combined effects of depressive symptoms, cognitive impairment, and delirium

OBJECTIVES: To measure the prevalence of depressive symptoms, cognitive impairment, and delirium in patients with hip fracture and to estimate their effect on functional recovery, institutionalization, and death after surgical repair.
DESIGN: Prospective cohort.
SETTING: Hospital, follow-up to community and nursing home.
PARTICIPANTS: One hundred twenty-six patients aged 65 and older admitted for hip fracture repair.
MEASUREMENTS: Baseline measurements: Mini-Mental State Examination, Blessed Dementia Rating Scale, Geriatric Depression Scale, prefracture activities of daily living (ADLs), ambulatory status. The Confusion Assessment Method was used to diagnose in-hospital delirium. One- and 6-month outcomes were ADL decline, loss of ambulation, and new nursing home placement or death.
RESULTS: Twenty-two percent of patients had one cognitive or mood disorder, 30% had two, and 7% had three. At 1 month, each cognitive or mood disorder was independently associated with one or more adverse outcome. Considered together, each additional cognitive or mood disorder was associated with greater odds of 1 month outcomes (ADL decline: odds ratio (OR)=1.8, 95% confidence interval (CI)=1.1–2.9; decline in ambulation: OR=1.8, 95% CI=1.1–3.0; nursing home placement or death: OR=3.9, 95% CI=1.9–8.1).
CONCLUSION: Cognitive and mood disorders were common in elderly hip fracture patients and were associated with greater risk of poor outcomes, both independently and in combination. Recognition and treatment of these conditions may reduce adverse outcomes in this vulnerable population.     

Metoclopramide-induced movement disorders. Clinical findings with a review of the literature

Metoclopramide, a dopamine-2 receptor antagonist used for various gastrointestinal disorders, may cause or exacerbate a variety of extrapyramidal movement disorders. To draw attention to the frequent occurrence of metoclopramide-induced movement disorders, we identified and studied 16 patients who had been exposed to this neuroleptic. The average age at onset was 63 years (range, 24 to 85 years), and women outnumbered men 3 to 1. Tardive dyskinesia was the most common movement disorder (n = 10 [63%]). Five patients had metoclopramide-induced parkinsonism, 1 patient had tardive dystonia, and 1 patient had akathisia. The average duration of exposure prior to onset of movement disorders was 12 months (range, 1 day to 4 years). Therapy was continued for an average of 6 months (range, 1 day to 2 years) after the onset of symptoms, reflecting clinical nonrecognition of the movement disorder and its relationship to metoclopramide. To prevent persistent and disabling movement disorders, long-term use of metoclopramide should be avoided, and patients should be carefully observed for potential neurologic reactions.     

Cocaine-induced mood disorder: prevalence rates and psychiatric symptoms in an outpatient cocaine-dependent sample.

This paper attempts to examine and compare prevalence rates and symptom patterns of DSM substance-induced and other mood disorders. 243 cocaine-dependent outpatients with cocaine-induced mood disorder (CIMD), other mood disorders, or no mood disorder were compared on measures of psychiatric symptoms. The prevalence rate for CIMD was 12% at baseline. Introduction of the DSM-IV diagnosis of CIMD did not substantially affect rates of the other depressive disorders. Patients with CIMD had symptom severity levels between those of patients with and without a mood disorder. These findings suggest some validity for the new DSM-IV diagnosis of CIMD, but also suggest that it requires further specification and replication.     

Screening for diabetes using HbA1c in elderly subjects

The objective of the study was to determine the prevalence of known diabetes among elderly subjects receiving nursing care in a north Norwegian population, to screen for new cases using HbA1c measurement and to evaluate the quality of care for those with diabetes. Men and women, with and without known diabetes, above 69 years and receiving nursing care either in an institution or in their own home in the municipality of Troms?, were included. A health questionnaire was administered and HbA1c measured. An oral glucose tolerance test (OGTT) was performed in those with HbA1c > 6.5% (upper reference limit). A total of 788 subjects were evaluated for participation and 228 completed the study. Forty-six subjects (20.2%) had a previous diagnosis of diabetes. Their age was 80.1+/-5.9 years (mean+/-SD) and HbA1c level 7.6+/-1.4%. Most patients had their blood glucose measured weekly and 65% used blood pressure medication; on average they were seen by their private doctor four times a year and annually by an ophthalmologist. Six subjects with undiagnosed diabetes had HbA1c > 6.5%. Diabetes was confirmed in one, excluded in two and further testing declined in three. None of these six subjects had HbA1c > 7.0%. In conclusion, there is a high prevalence of diabetes among elderly subjects needing nursing care. The prevalence of undiagnosed diabetes in need of treatment, as evaluated by the HbA1c level, was low, indicating that the focus on diabetes and quality of care for the elderly in our area is fairly good.     

Personality disorders in gay, lesbian, bisexual, and transgender chemically dependent patients

This study sought to examine personality disorders and their related clinical variables in a sample of gay, lesbian, bisexual, and transgender (GLBT) individuals with substance use disorders. Study participants were 145 GLBT patients who were admitted to a residential dual diagnosis chemical dependency treatment program. A total of 136 (93.8%) had at least one personality disorder. The most common personality disorders were borderline (n = 93; 64.1%), obsessive-compulsive (n = 82; 56.6%), and avoidant (n = 71; 49.0%) personality disorders. Preliminary data suggest that there is a high prevalence of personality disorders in the GLBT population undergoing chemical dependency treatment.     

Suspected collagen disorders in the bleeding disorder clinic: A case–control study

Disorders of collagen are associated with a mild bleeding tendency because of the potential abnormal interaction of collagen, von Willebrand factor (VWF) and platelets required during primary haemostasis and due to generalized soft tissue fragility. Abnormal collagen may contribute to bleeding in existing mucocutaneous bleeding disorders, but the prevalence in this setting is unknown. Generalized symptomatic joint hypermobility (SJH) is common in collagen disorders and may be objectively measured. To assess the association between symptomatic joint hypermobility and mucocutaneous bleeding disorders, we performed a case–control study in which case subjects were 55 consecutive individuals who had visited our bleeding disorder clinic with a diagnosis of von Willebrand disease, low von Willebrand factor levels, mild platelet function disorder or undefined bleeding disorder. Controls were 50 subjects without a bleeding disorder, and were age and gender matched to the cases. All subjects were assessed with: (i) Beighton score for joint hypermobility, (ii) revised Brighton criteria, (iii) Condensed MCMDM1‐VWD bleeding questionnaire, and (iv) haemostasis laboratory studies. The prevalence of SJH/suspected collagen disorder in the bleeding disorder clinic was 24% (13/55) compared with 2% (1/50) in the control population (OR 15, 95% CI 2–121). Seventy‐seven per cent of bleeding disorder clinic SJH subjects (10/13) had a prior personal or family history of Ehlers‐Danlos, Benign Joint Hypermobility Syndrome or Osteogenesis Imperfecta (OI). Symptomatic joint hypermobility was associated with increased odds of an underlying mucocutaneous bleeding disorder. These findings suggest that a collagen disorder is common and often unrecognized in the bleeding disorder clinic as a potential contributor to the bleeding symptoms.     

Surprisingly high prevalence of anxiety and depression in chronic breathing disorders

STUDY OBJECTIVES: The objectives of this study were to assess the prevalence, screening, and recognition of depression and anxiety in persons with chronic breathing disorders, including COPD. DESIGN: Cross-sectional study. SETTING: The Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC). PARTICIPANTS: A large sample of 1,334 persons with chronic breathing disorder diagnoses who received care at the MEDVAMC. MEASUREMENTS: The prevalence of anxiety and depression was measured in a large sample of persons with a chronic breathing disorder diagnosis who received care at the MEDVAMC, using the Primary Care Evaluation of Mental Disorders (PRIME-MD) screening questions. The positive predictive value of the PRIME-MD questions was then determined. The prevalence of anxiety and depressive diagnoses in patients determined to have COPD was then measured, using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). RESULTS: Of patients screened with the PRIME-MD, 80% screened positive for depression, anxiety, or both. The predictive value of a positive phone screen for either depression or anxiety was estimated to be 80%. In the subsample of patients who had COPD and received a diagnosis using the SCID, 65% received an anxiety and/or depressive disorder diagnosis. Of those patients, only 31% were receiving treatment for depression and/or anxiety. CONCLUSIONS: It is troubling that a mere 31% of COPD patients with depression or anxiety are being treated, particularly given their high prevalence in this population. Practical screening instruments may help increase the recognition of anxiety and depression in medical patients, as suggested by the excellent positive predictive value of the PRIME-MD in our study.     

Diagnosis and management of parkinsonism in the elderly

Of 123 patients with parkinsonism attending a department of medicine for the elderly who were assessed, 73% were thought to have idiopathic Parkinson's disease, and 91% of these cases and 52% of the remaining cases had a history of rest tremor; 34% of all cases were demented. The prevalence of dementia did not correlate with the duration of disease. Demented patients with presumed idiopathic Parkinson's disease were not distinguishable from non-demented by duration of disease, presence of a history of rest tremor or use of L-dopa. Eighty-eight per cent of non-demented patients but only 44% of demented patients were thought to have responded to L-dopa. Lower doses of L-dopa were used than are conventional with younger patients.     

Psychopathology in Chronic Cocaine Abusers

A group of 30 hospitalized cocaine abusers were studied, along with 124 hospitalized patients who were dependent upon opiates or central nervous system depressants. DSM-III diagnoses, family history data, demographic characteristics, and measures of current depressive symptomatology were compared in the two groups. Nineteen (63%) of the cocaine abusers met criteria for an Axis I diagnosis other than substance abuse; sixteen (53%) had affective disorder. These figures reflected a significantly higher prevalence rate of affective disorder among the cocaine abusers than among the opiate and depressant abusers. In addition, a significantly higher rate of affective disorder was found in the first degree relatives of the cocaine abusers when compared to the other group. Since these findings suggest that a substantial number of cocaine abusers may be suffering from other psychiatric disorders, careful diagnostic evaluation is indicated in this population.     

Descriptive Epidemiology of Chronic Obstructive Pulmonary Disease in US Nursing Home Residents With Heart Failure

Chronic obstructive pulmonary disease (COPD) is highly prevalent in older adults with heart failure and heart failure is highly prevalent in older adults with COPD. Information is presently lacking about the extent to which COPD and heart failure co-occur among nursing home residents. The objective of this study was to describe the epidemiology of, and factors associated with, COPD among nursing home residents with heart failure. This cross-sectional study included 97,495 long-term stay nursing home residents with heart failure in 2018. The Minimum Data Set 3.0 (MDS) provided information on sociodemographic characteristics, comorbid conditions, and activities of daily living. Heart failure and COPD were defined based on notes at admission, hospitalizations, progress notes, and through physical examination findings. The majority of the study population were ≥75 years old (74.1%), women (67.3%), and Non-Hispanic Whites (77.4%). Nearly 1 in 5 residents had reduced ejection fraction findings, 23.1% had a preserved ejection fraction, and 53.8% of nursing home residents with heart failure had COPD. This pulmonary condition was less frequently noted in women, residents of advanced age, and racial/ethnic minorities and more frequently diagnosed in residents with comorbid conditions such as pneumonia, anxiety, obesity, diabetes mellitus, and coronary artery disease. We found a high prevalence of COPD, and identified several factors associated with COPD, in nursing home residents with heart failure. Our findings highlight challenges in the clinical management of COPD in nursing home residents with heart failure and how best to meet the care needs of this understudied population.     

Psychopathology in chronic cocaine abusers

A group of 30 hospitalized cocaine abusers were studied, along with 124 hospitalized patients who were dependent upon opiates or central nervous system depressants. DSM-III diagnoses, family history data, demographic characteristics, and measures of current depressive symptomatology were compared in the two groups. Nineteen (63%) of the cocaine abusers met criteria for an Axis I diagnosis other than substance abuse; sixteen (53%) had affective disorder. These figures reflected a significantly higher prevalence rate of affective disorder among the cocaine abusers than among the opiate and depressant abusers. In addition, a significantly higher rate of affective disorder was found in the first degree relatives of the cocaine abusers when compared to the other group. Since these findings suggest that a substantial number of cocaine abusers may be suffering from other psychiatric disorders, careful diagnostic evaluation is indicated in this population.     

An autopsy case of pallido-nigro-luysian atrophy associated with OPLL

Clinical and neuropathological studies of a case of pallido-nigro-luysian atrophy with thalamic degeneration and ossification of the posterior longitudinal ligament (OPLL) is reported. The patient was a 72-year-old man, suffering from gait disturbance caused by OPLL for about 3 years. The clinical features were characterized by gradual development of disorientation in place, time and person, memory disturbance, vertical gaze palsy and rigidity of extremities. Dysarthria, dysphagia, bradykinesia, masked face and neck dystonia appeared at the advanced stage of his illness. There was no tremor or other involuntary movements. A clinical diagnosis of parkinsonism was suspected. The main neuropathological findings were neuronal loss and gliosis in globus pallidus, substantia nigra, subthalamic nucleus and thalamus. In addition, neuronal loss of the anterior horn of the cervical spinal cord due to compression by OPLL (C4-C7) was recognized. The neuropathological findings of the present case were consistent with systemic degenerative disorder of the nervous system affecting the pallido-nigro-luysian tract. This rare disorder should be considered in the differential diagnosis of parkinsonism in old people.     

Evaluation of glucose metabolism profile in coronary disease. Prospective study in hospitalized patients.

BACKGROUND: In 1995, it was estimated that 4% of the adult population had a diagnosis of diabetes mellitus. The trend is for growing prevalence, with a prediction of 300 million individuals with diabetes diagnosed in 2025. There seems to be a large number of asymptomatic individuals with undiagnosed disorders of glucose metabolism. These disorders, whether diabetes mellitus or conditions considered as prediabetic, including impaired glucose tolerance or impaired fasting glucose, represent an important risk factor for coronary disease and worsen the prognosis of established disease. The aim of this study was to evaluate the prevalence of glucose metabolism disorders in individuals admitted to hospital with coronary disease and to determine whether a significant number of these patients had previously undiagnosed diabetes or prediabetic conditions. METHODS: We conducted a prospective study of 44 consecutive patients admitted to the Cardiology Department with a diagnosis of coronary disease, whether previously established or established at the time of admission. We measured morning plasma glucose in all patients, after at least eight hours fasting, and all except those with a previous diagnosis of diabetes underwent an oral glucose tolerance test with 75 g of glucose before hospital discharge. For classification of glucometabolic state, we used the values defined by the World Health Organization (1999). RESULTS: The mean age of our cohort was 64.2+/-13.6 years. The most prevalent disorder was diabetes, with 19 patients (43.2%). Of these, 12 patients (27.3%) had a previous diagnosis of diabetes and 7 patients (15.9%) were unaware that they had the disease. We identified isolated impaired glucose tolerance in 11 patients (25%), isolated impaired fasting glucose in one patient (2.3%) and combined impaired glucose tolerance and impaired fasting glucose in another (2.3%). The remaining 12 patients (27.3%) revealed normal glycemia values. CONCLUSIONS: Glucose metabolism disorders including diabetes and impaired glucose tolerance have a high prevalence in coronary patients. This population includes a significant number of asymptomatic patients with undiagnosed diabetes or undetected prediabetic conditions. A systematic evaluation of the glucometabolic state of individuals with coronary disease during hospitalization, using an oral glucose tolerance test, may enable earlier identification of these disorders and implementation of measures to reduce their future impact.     

Prevalence and impact of arthritis among nursing home residents

OBJECTIVE: To determine the prevalence, characteristics, and impact of arthritis in the US nursing home population. METHODS: A national cross sectional sample of US nursing homes (8138 sampled residents in 1406 nursing homes) from the 1997 National Nursing Home Survey provided demographic and functional characteristics for residents with primary arthritis, any arthritis, or no arthritis diagnosis at admission. RESULTS: Of the estimated 1.6 million current nursing home residents in 1997, only 43,000 (3%) had a primary and 300,000 (19%) had any arthritis diagnosis at admission. People with a primary or any arthritis diagnosis received physical/occupational therapy, used wheelchairs and walking aids, and needed assistance with walking and transferring more often than those with no arthritis diagnosis. CONCLUSIONS: These national estimates suggest that arthritis is underreported in nursing home residents. Because arthritis contributes to an increased physical burden on staff and decreased functional capability of residents, both staff and residents can benefit from better diagnosis, intervention, and education.     

Characteristics of gouty arthritis in the guatemalan population

Summary The purpose of this study was to determine the characteristics of gouty arthritis in an urban Guatemalan population. We reviewed the medical records of 148 (145 males and 3 females) patients with a diagnosis of acute gouty attack seen at an urban rheumatology clinic in Guatemala City between 1982 and 1993. Mean age at diagnosis was 49 years (range 21–87), mean age of onset was 42 years, mean duration of disease 7.4 years, family history of gout 42 (28%), peak prevalence 5^th decade 39 (26%). Seventy-one (48%) had monarticular, 49 (33%) oligoarticular, and 22 (15%) polyarticular attacks, respectively. Podagra was seen in 34 (23%) patients; however, 108 (73%) developed it at any moment of their life. Tophaceous gout was seen in 33 (22%). Mean serum urate concentrations (enzymatic method) were higher than 7.0 mg % in 90 (60%) patients. At follow-up, 44 (30%) patients never returned to our clinic, and a large majority of them [66 (45%)] were seen only during acute attacks. Associated disorders included hypertension (43%), obesity (27%), nephrolithiasis (16%), ischaemic heart disease (7%), renal insufficiency (2%), stroke (0.6%), and diabetes mellitus (0.6%), and two died due to sepsis; high alcoholic intake was found in 58 (39%) patients. In conclusion, our findings indicate that gout is not an unusual disorder in the Guatemalan population. It presents with the same characteristics as those reported in Caucasians, with the possible exception of a lower frequency of diabetes mellitus as an associated disorder.     

Primary pulmonary hypertension in patients with classic hemophilia

Five patients with classic hemophilia were found to have primary pulmonary hypertension, a disorder not previously recognized in this population. All patients had had their coagulation disorder treated for 10 years or more with self-administered lyophilized concentrates of factor VIII, and all had antibodies to human immunodeficiency virus (HIV). Primary pulmonary hypertension was confirmed by histologic means at autopsy in one patient and by lung biopsy findings in another. In the other three patients, the findings are in agreement with this diagnosis. No patient had underlying cardiac or pulmonary disease, or clinical or pathologic evidence of collagen-vascular disease, vasculitis, parasitic disorders, hemoglobinopathy, or exposure to anorexigenic agents. Whether the primary pulmonary hypertension was related to treatment with lyophilized factor VIII, or to the presence of antibodies to HIV, or both, is unknown.     

Accuracy of Rapid Urine Screening Tests Among Incontinent Nursing Home Residents with Asymptomatic Bacteriuria

OBJECTIVE: To determine the accuracy of rapid urine screening tests in detecting bacteriuria among incontinent nursing home residents. SETTING: Six nursing homes. PARTICIPANTS: 214 chronically incontinent, but otherwise asymptomatic, nursing home residents who were enrolled in a clinical intervention trial for urinary incontinence. MEASUREMENTS: 684 urine specimens were collected, the majority (76%) by a clean catch technique and the remainder by in-and-out catheterization. Each specimen underwent dipstick testing for nitrite and leukocyte esterase, a rapid, enzyme-based screening test for bacteriuria, and a quantitative urine culture using standard laboratory techniques. RESULTS: No one screening test or combination of tests had adequate sensitivity and specificity for clinical purposes. However, using all three tests, the sensitivity increases to 97% in females and 92% in males when any one of the tests is positive, and the specificity increases to 95% in females and 97% in males when all three tests are negative. Among nursing home residents suspected of having a symptomatic urinary tract infection, the prevalence of bacteriuria is probably higher than in our study population (e.g., 60–70%, compared with 32%). At these prevalence rates, the positive predictive value of any of the three tests being positive is 93% and higher, and the negative predictive value of all three tests being negative is 80 to 90%. CONCLUSIONS: Our data must be interpreted cautiously because of the specimen collection methods, the definitions we used, and the fact that we studied a population who did not have symptoms of an acute urinary tract infection. In addition, we did not examine the absolute accuracy of the screening tests, but their accuracy as a clinician might use them in a nursing home. Despite these caveats, our data suggest that a combination of these screening tests could be useful in the initial assessment of nursing home residents for bacteriuria, and result in considerable cost savings. Studies are needed to replicate our findings among nursing home residents with symptomatic urinary tract infections.     

Antipsychotic medications and drug-induced movement disorders other than parkinsonism: a population-based cohort study in older adults

OBJECTIVES: To study the relationship between initiating therapy with an antipsychotic medication and a subsequent new diagnosis of a drug-induced movement disorder other than parkinsonism in older adults with dementia. DESIGN: Retrospective, population-based cohort study. SETTING: Ontario, Canada. PARTICIPANTS: Ontario residents aged 66 and older with a diagnosis of dementia newly started on treatment with typical or atypical antipsychotic therapy. MEASUREMENT: Estimated relative risk of developing a drug-induced movement other than parkinsonism in the 1-year follow-up period after starting therapy with an antipsychotic medication. RESULTS: From April 1, 1997, to March 31, 2001, 21, 835 older adults with dementia who were newly started on antipsychotic medications were identified. Nine thousand seven hundred ninety subjects were started on atypical antipsychotics and 12,045 subjects started on typical antipsychotics. Demographic characteristics were similar between the groups. There were 5.24 cases of tardive dyskinesia (TD) or other drug-induced movement disorder per 100 person-years on therapy with a typical antipsychotic and 5.19 cases per 100 person-years on therapy with an atypical antipsychotic. The risk of developing drug-induced movement disorder while being treated with an atypical agent was not statistically different from that with a typical antipsychotic (relative risk=0.99, 95% confidence interval=0.86-1.15; P<.93). CONCLUSION: Older adults with dementia who are treated with typical or atypical antipsychotic therapy are at risk for developing TD and other drug-induced movement disorders.     

Significance of comorbidity for the long-term course of opiate dependence

OBJECTIVE: Studies on drug dependence show a high prevalence of comorbidity with additional mental disorders. Comorbidity patients also show more poly-substance use and other psychosocial problems. This study analyzed the importance of comorbidity for the long-term course of opiate dependence. METHOD: 350 opiate-dependent patients were examined at yearly follow-ups over 4 years using the EuropASI for the assessment of drug-related problems and the CIDI for diagnostic of psychiatric disorders. 196 patients were reached at final follow up (56%). RESULTS: Of the patients reached at final follow-up, 30% had severe, 29% mild and 41% no clinically relevant disorders at baseline. However, the linear relationship at baseline--the more severe the disorder, the greater the impairment through drug-related problems--was not present at final follow-up. The results show that lifetime diagnosis of mental disorder had no prognostic relevance for the long-term course of drug dependency. CONCLUSION: The assumption that opiate users with an additional mental disorder are more vulnerable in their course of addiction could not be confirmed.     

Clinical identification of the simple sleep-related movement disorders

Simple sleep-related movement disorders must be distinguished from daytime movement disorders that persist during sleep, sleep-related epilepsy, and parasomnias, which are generally characterized by activity that appears to be simultaneously complex, goal-directed, and purposeful but is outside the conscious awareness of the patient and, therefore, inappropriate. Once it is determined that the patient has a simple sleep-related movement disorder, the part of the body affected by the movement and the age of the patient give clues as to which sleep-related movement disorder is present. In some cases, all-night polysomnography with accompanying video may be necessary to make the diagnosis. Hypnic jerks (ie, sleep starts), bruxism, rhythmic movement disorder (ie, head banging/body rocking), and nocturnal leg cramps are discussed in addition to less well-appreciated disorders such as benign sleep myoclonus of infancy, excessive fragmentary myoclonus, and hypnagogic foot tremor/alternating leg muscle activation.