THE INTRODUCTION OF A BEHAVIOURAL APPROACH INTO THE MANAGEMENT OF THE CONFUSED AND DISTURBED ELDERLY IN A NURSING HOME

A ‘Behavioural Approach’ was introduced into the care and management of four elderly nursing home residents as a pilot project to investigate the problems and effects of implementing such a system. Base line observations were followed by recommendations for intervention based on ‘Rules of Thumb’ guidelines. Although data was not considered reliable, conclusions were that the techniques were of value, should be practiced by all nurses and that more training was needed. Recommendations included simpler recording of behavioural events and the establishment of special areas for the care of wandering, severely demented patients.     

The Effects of Dementia and Long-Term Care Services on the Deterioration of Care-needs Levels of the Elderly in Japan

To investigate the associations between dementia, the use of long-term care (LTC) services, and the deterioration of care-needs levels of elderly persons in Japan.Using a retrospective cohort study, we analyzed 50,268 insurance beneficiaries aged 65 years and older who had utilized LTC services between 2010 and 2011 in Kyoto prefecture, Japan. Logistic regression analyses were used to identify predictors of care-needs level deterioration.Dementia, facility care services, the male sex, older age, and lower baseline care-needs levels were associated with care-needs level deterioration. The disparity between odds ratios of home care services, dementia diagnoses, and facility care services on care-needs level deterioration diminished with increasing baseline care-needs levels. The other risk factors of care-needs level deterioration showed stronger associations as care-needs levels and age increased.The effects of baseline care-needs levels and dementia should be considered when developing LTC policies.     

Use of environmental manipulation and modified informal reality orientation with institutionalized, confused elderly subjects: a replication

The effectiveness, for confused elderly subjects, of modified informal reality orientation and environmental manipulation without any 'classroom' reality orientation was investigated with 10 experimental subjects in one ward and 10 control subjects in another. All subjects were assessed prior to the start of the intervention and after 6 and 12 weeks of treatment on cognitive and behavioural measures. While the control group showed decline on all measures except one, the experimental group improved in ward orientation and cognitive status and showed no decline on the behavioural measures.     

Psychological side effects of MTX treatment in juvenile idiopathic arthritis: a pilot study

OBJECTIVE: To document the psychological side effects of methotrexate (MTX) treatment in children with juvenile idiopathic arthritis (JIA) and to explore the usefulness of psychological therapy to ameliorate these side effects. METHODS: The patients included in this study consisted of 29 patients with JIA using MTX. Of these, ten were referred to a pediatric psychologist because of MTX side effects, and had behavioural therapy to cope with these side effects with a strong behavioural component (anticipatory nausea, anxiety). The behavioural therapy was adapted to age and used systemic desensitization (distraction in a positive atmosphere) or cognitive behavioural therapy (relaxation and overruling negative thoughts by positive ones). The parents of the 29 children were interviewed about MTX treatment and the side effects their child had developed. Parents of children referred to the psychologist were also interviewed for their impression of the results of the behavioural therapy. RESULTS: Prior to the behavioural therapy, nine out of 10 children reported MTX related nausea. Six of these ten were nauseous even before the administration and developed anticipatory nausea. Nine out of ten patients also showed some sign of distress in anticipation of MTX treatment, either orally of via injections. The behavioural therapy they had fully abolished side effects in five children and decreased the severity of nausea and distress in two children. Of the remaining nineteen children, not referred to the pediatric psychologist, 11 reported nausea after MTX treatment and four of these developed anticipatory nausea. In addition, eight of these 18 developed behavioural distress in anticipation of the treatment. CONCLUSION: This study showed that children with JIA who receive MTX treatment frequently develop psychological side effects, such as anticipatory nausea and behavioural distress in anticipation of treatment. This is true for patients selected for reported MTX side effects, as well as for randomly chosen JIA patients using MTX. As MTX is still the first choice in the treatment of severe JIA, more attention should be given to the treatment and prevention of side effects. Psychological intervention can be of help, but further studies are needed on the nature of the side effects, as well as on the prerequisites and efficacy of behavioural therapy.     

Medical therapy for the overactive bladder in the elderly

The overactive bladder is the commonest underlying bladder disorder causing urinary incontinence in elderly people. Management of the condition relies upon a holistic assessment of the problem, lifestyle adjustment, behavioural management and drug therapy. The majority of currently available drugs rely on their anti-muscarinic properties for efficacy. Both behavioural techniques and drug therapy are effective in treatment of the elderly and each modality has a particular role to play in successful treatment and maintenance of this condition.     

Effectiveness of validation therapy (VT) in group: preliminary results

VT is one of the best known psychosocial treatment for elderly affected by dementia. Notwithstanding its wide use, its efficacy is still a controversial issue, especially in comparison with other approaches. This study of 30 elderly subjects in a nursing home compared the effects of VT, sensorial reminiscence (SR) and no treatment on cognitive, functional, and affective status of the participants. The results indicated an improvement in the global functioning of the two treatment groups, compared to the control group, but the differences did not reach statistical significance. Significant within-group effects could be observed, where the SR treatment was the most effective in improving cognitive, affective, and behavioral status; the VT-group showed a reduction of the behavioral disturbances; the participants at the control group demonstrated a slight deterioration at all the three levels. Considerations are made about the implication of VT for the caregivers, as possible mediator of its effect on elderly.     

The living arrangements of elderly people

"In order to assess possible future trends in the living arrangements of elderly people and their implications, we need to understand the causes of...relatively recent changes. Analysts have variously stressed demographic trends, economic factors and behavioural or cultural shifts as major influences on changing household patterns. These arguments are reviewed [in this article]." Aspects considered include the availability of spouse and children, coresidence between elderly parents and children, cultural factors, income, and health and health care. The primary geographical focus is on the United Kingdom, with some additional information for the United States and selected other developed countries.     

Renal risks of cardiac catheterization in the elderly

Age-related changes in renal structure and function and an increased prevalence of comorbid illnesses predispose the elderly patient to increase risk of contrast-induced nephropathy following cardiac catheterization and other procedures. This article briefly reviews the effects of aging on the kidney, then summarizes current literature on the risks of nephrotoxicity following cardiac catheterization in elderly patients. Finally, a series of therapeutic guidelines are proposed which should serve to minimize the risk of contrast nephropathy in elderly patients requiring cardiac catheterization. Based on available evidence, it is concluded that the risk of serious deterioration in renal function following contrast exposure is acceptably low and should not be considered a strong contraindication to performing cardiac catheterization in appropriately selected elderly patients.     

Benefits of normalizing plasma phenylalanine: Impact on behaviour and health. A case report

An elderly man with mental retardation who had never received dietary treatment for his phenylketonuria was placed on a phenylalanine-restricted diet. Social skills and walking gait improved and a new interest in the objects in his environment developed spontaneously. A 2-year analysis of diet, blood plasma phenylalanine levels and behavioural state indicated that small differences in phenylalanine intake impacted his well-being. Of significant note, leg tremor and spasm that precipitated severe self-injury were only reversible when plasma blood phenylalanine concentrations were titrated to near normal ranges and daily phenylalanine intake was strictly controlled. This case may offer a potential explanation for some of the late treatment failures that have been reported and suggest new avenues to explore in the late treatment of PKU.     

Age, inactivity and some physiological responses to exercise

The quality of life in old age is crucially dependent upon the ability to pursue a variety of physical activities. Factors which affect the capacity for physical activity in the elderly should therefore be of interest both to individuals and to institutions concerned for the elderly. This is a review of literature pertinent to the problem of maintaining an adequate capacity for physical exercise into old age. It includes information about the interrelations between age, physical condition and physical working capacity; and the effects of training and inactivity upon all these parameters. Reduction in levels of habitual activity with age seems likely to cause or exacerbate deterioration in both exercise capacity and physical condition, setting up a vicious circle which eventually jeopardises the capacity for independent living. If so, efforts should be directed towards maintaining effective levels of habitual activity.     

Screening for diabetic retinopathy is well received by patients and may improve self-management intentions.

AIMS: To investigate patients' views of screening for diabetic retinopathy and the effects of the screening process on health beliefs and behavioural intentions. SETTING: A retinal screening clinic at a GP surgery in SW England. METHODS: Questionnaires administered before and immediately after screening by retinal photography. RESULTS: One hundred patients attended (94% of those invited); 12 had Type 1 and 88 Type 2 diabetes. Over 90% found the information, and seeing their retinal photograph, helpful. Sixty-three were found to have no problem and 37 had some type of eye problem detected. Overall, patients rated the news given at screening as better than expected (P < 0.001) and even those found to have problems mostly rated the news as good (P < 0.001). Detection of problems led patients to rate their recent eye health more negatively, but to be less pessimistic about future deterioration (P < 0.01). Patients with diabetes-related eye problems were more likely (P < 0.05) to say that they both should and would make changes to their self-management, but only after controlling for duration of diabetes. Those who had had diabetes longest declared least intention to change. CONCLUSIONS: Screening by retinal photography is acceptable to patients. Results suggest that screening modified health beliefs but had limited effect on behavioural intentions, with patients of longer disease duration being more reluctant to change their self-management. Opportunities during retinal screening for advice on self-management could be more effectively exploited.     

Prevention and treatment of dementia: what should we do today?

Three studies were conducted on elderly patients with dementia. A case of control study on life styles before falling ill revealed that "intake of sweets" was significantly associated with clinically diagnosed dementia of the Alzheimer's type. Evaluation of treatments of outpatients suggests that proper care and some kinds of neuroleptics are useful for alleviation of abnormal behavior such as agitation, wandering, hallucination, insomnia and depression, but not for improvement of cognitive function and memory. A study on caregivers of elderly demented patients was undertaken to determine the relationship between the components of burden and symptoms of patients. Insomnia and abnormal behavior of patients correlated with physical and mental components of the burden of caregivers. Memory disturbance, psychological symptoms and deterioration in ADL correlated with physical burden. These studies indicate that symptoms accompanying dementia such as insomnia, wandering, hallucination and agitation should be the treated intensively for the purpose of improvement of the quality of the lives of patients and caregivers.     

不同月龄鼠急性心肌梗死后心室重构和心脏破裂的观察

目的 探讨老龄对小鼠急性心肌梗死(AMI)后心室重构心脏破裂的影响. 方法 老龄和低龄C57BL/6小鼠,随机分为假手术组、心肌梗死组.建立AMI模型后,观察心脏破裂发生率,并于AMI后第7天行超声和血流动力学检查;应用酶谱法、病理染色及免疫组化方法 ,分别于AMI后第3、7天检测基质金属蛋白酶-2、-9(MMP-2、MMP-9)活性表达,炎性细胞浸润程度,心肌间质胶原含量(CVF)和类型的变化. 结果 AMI后老龄组心脏破裂率高于低龄组(38.0%与16.0%,X2=6.139,P＜0.05);第7天时,较低龄组出现明显的梗死区扩张、左心室重构、心功能障碍及血流动力学变化(t=5.754,P＜0.05).与低龄组比较,老龄AMI组AMI后第3天炎性细胞浸润程度、MMP-9表达明显增加(P＜0.05).与低龄组比较,老龄组心肌间质胶原含量、Ⅲ型胶原表达增加(P＜0.05). 结论 老龄是小鼠AMI后心脏破裂的高危因素,其原因可能与AMI早期炎性细胞浸润程度增加、MMP-9、Ⅲ型胶原过度表达和早期左心室重构恶化有关.     

Reduction of functional deterioration during hospitalization in an acute geriatric unit

The purpose of this study was to compare the incidence of functional deterioration of elderly patients hospitalized in acute care geriatric units compared to that in a conventional care unit. We performed a prospective controlled study over 9 months of patients above 65 years old with acute medical pathology. Upon discharge, we compared the degree of functional deterioration using the Katz index compared to the basal level before admission of both groups. Of the 143 patients studied, 68 were admitted to the geriatric care unit and 75 to the conventional care unit. In the geriatric unit, the incidence of functional deterioration occurred in 13 patients (19.1%), while in the conventional care unit it occurred in 30 (40%) (p=0.01). In a multivariate analysis of logistical regression, the odds ratio of developing functional deterioration at discharge in the conventional care unit, compared to the geriatric unit was 4.24 (95% CI: 1.50-11.99). The length of stay was shorter in the geriatric unit (7.5 vs. 9.92, p=0.03). We conclude that the elderly patients admitted to a geriatric care unit showed less functional deterioration on discharge compared with those kept in another care unit of a conventional type.     

Word fluency in aging and dementia: principles of relatedness in the generative naming process

Nineteen elderly people, some healthy, some Alzheimer patients, were given the Word Fluency Test. Their responses were correlated with several personal variables such as age, years of education, Mini-Mental-State score, etc. The responses were also analyzed in terms of types and percentage of word relatedness. It was found that the total number of response words, new words and percentage of word relatedness, correlates with the Mini-Mental-State score only. However, the degree of significance of the various correlations indicates a differential deterioration slope for various principles of relatedness. Results are discussed within the framework of semantic memory and its organizational principles.     

Treatment of hypertension in the elderly: II. Cognitive and behavioral function. Results of a Department of Veterans Affairs Cooperative Study

This study was designed to determine whether blood pressure reduction, per se, causes adverse effects on cognitive and behavioral function in elderly hypertensive patients. Men with mild-to-moderate diastolic hypertension who had passed their 60th birthday were entered into the trial. After a placebo washout period, they were assigned in a randomized, double-blind manner to one of two groups receiving hydrochlorothiazide (either 25 mg once or twice daily or 50 mg once or twice daily). Responders entered a 1-year maintenance period. Nonresponders were randomly assigned to double-blind treatment with hydralazine, methyldopa, metoprolol, or reserpine added to the diuretic therapy. During the placebo and treatment periods, patients underwent a battery of psychometric tests designed to assess cognitive function, motor skills, memory, and affect. A separate questionnaire assessed the patient's ability to perform activities of daily living. A subset of patients blindly being treated with placebo received the same battery of tests as a control for practice effect. The results showed that there was similar improvement on the psychometric tests between those patients whose blood pressure was successfully reduced and the placebo-treated control group. Therefore, the practice effect did not obscure a true deterioration in function. There were no substantive differences between the lower and higher doses of diuretic or among the four drugs added to the diuretic, although there were qualitative differences in side effects. We conclude that blood pressure reduction, per se, does not adversely affect cognitive and behavioral function in elderly hypertensive patients and that antihypertensive treatment is safe and effective in these patients.     

Health decline,aging and mortality: how are they related?

The deterioration of human health with age is manifested in changes of thousands of physiological and biological variables. The contribution of some of such changes to the mortality risk may be small and cannot be reliably detected by existing statistical methods. A cumulative index of health/well-being disorders, which counts changes in observed variables on the way of losing health, may be an appropriate way to take the effects of such variables into account. In this paper we investigate regularities of the aging-related changes in human health/well-being/survival status described by such an index using the new version of the quadratic hazard model of human aging and mortality. We found that the shape and the location of the mortality risk, considered as a function of the introduced health-related index, changes with age reflecting the decline in stress resistance and the age-dependence of the “optimal” health/well-being status. Comparison of these results with findings from early studies using the Cox’s-like model of risk function indicates that the results are likely to describe regularities of deterioration in human health during the aging process.     

Outcomes of hospitalized elderly patients with geriatric syndrome: report of a community hospital reform plan in Taiwan

The purpose of this study was to evaluate the outcomes of elderly inpatients with geriatric syndromes. A prospective study involving patients aged 65 years and older in 12 community hospitals was performed. Baseline data, which included demographic characteristics, mini mental status exam, geriatric depression scale (GDS), mini nutritional assessment (MNA), activities of daily living (ADL), and instrumental activities of daily living (IADL), were collected in geriatric assessments. The primary outcome was functional deterioration; additional outcomes included mortality, re-hospitalization, and emergency department visits, as identified by telephone interview and chart review. A total of 1,008 patients were recruited: 31.2% of the participants were ADL intact, 21.3% were IADL-intact, 11.5% had depression, 29.3% had nutritional problems, and 60.3% had impaired cognition at baseline. During follow-up, 172 patients (19.3%) died, 43.8% reported ADL deterioration, and 45.9% reported IADL deterioration. On multivariate analysis, older age, low mini mental state examination (MMSE) score, and low MNA score were predictors of functional deterioration. Under the interdisciplinary team care of the Community Hospital Reform Plan (CHRP), most of the elderly patients maintained or increased their functional capacity; the one-year mortality rate was higher than that of the general population but lower than that of other studies targeting the frail elderly.     

Patient characteristics and their influence on therapy and its outcome in hypertension of the elderly

A retrospective study was undertaken to analyze the effects of various patient factors on therapy and its outcome in elderly hypertensive subjects. Two hundred and three male hypertensives with a mean age of 63.1 years at entry, were followed in a special hypertension clinic by nurse practitioners under physician supervision, for 2 years or more (mean 3.7 years). Good patient compliance (84%) and blood pressure (BP) reduction were achieved and these were enhanced by advancing age. Neither excessive weight, nor widespread atherosclerosis seemed to interfere with BP control. However, while diastolic BP was well controlled with antihypertensive therapy, systolic BP tended to remain higher than 160 mm Hg in many of the older and more atherosclerotic subjects. Pharmacological treatment did not prevent a gradual although modest deterioration of renal function, which was related to both age and hypertension, and represents a greater problem in black patients. Because of the limitations of such a retrospective study, its conclusions may not be extrapolated for treatment of hypertension in all the elderly.     

Acute and sub-chronic effects of purified cathinone from khat (Catha edulis) on behavioural profiles in vervet monkeys (Chlorocebus aethiops)

We investigated the cumulative effects of cathinone on behavioural alterations in single-caged vervet monkeys. Fourteen adult vervets were divided into tests (12 animals) and controls (2 animals), and exposed to escalating doses of cathinone at alternate days of each week for 4 months in presence and absence of cage enrichment. One month of pre-treatment phase served to establish baseline values. Composite behavioural scores of aggression, anxiety, abnormal responses, withdrawal and appetite loss were done. A series of repeated measures analysis of variances were conducted to examine the extent to which cathinone administration was associated with patterns of changes in behavioural data. Results indicate a dose-dependent effect of cathinone on increases of aggression, anxiety, abnormal responses, withdrawal, and appetite loss. The findings demonstrate that at high doses and long-term exposure, cathinone causes behavioural alterations probably via changes in presynaptic striatal dopamine system.