-
[show abstract]
[hide abstract]
ABSTRACT: The importance of somatization among older primary care attenders is unclear. We aimed to establish the prevalence, persistence and associations of somatization among older primary care attenders, and the associations of frequent attendance.
One hundred and forty primary care attenders over 65 years were rated twice, 10 months apart, on measures of somatization, psychiatric status, physical health and attendance.
The syndrome of GMS hypochondriacal neurosis had a prevalence of 5% but was transient. Somatized symptoms and attributions were persistent and associated with depression, physical illness and perceived poor social support. Frequent attenders (top third) had higher rates of depression, physical illness and somatic symptoms, and lower perceived support.
Somatization is common among older primary care attenders and has similar correlates to younger primary care somatizers. Psychological distress among older primary care attenders is associated with frequent attendance. Improved recognition should result in benefits to patients and services.
Psychological Medicine 08/2003; 33(5):867-77. · 6.16 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Previous studies have shown a positive relationship between disease severity and cost.
To explore the factors affecting time to institutionalisation and estimate the relationship between the costs of care and disease progression.
Retrospective analysis of a longitudinal data-set for a cohort of 100 patients diagnosed with Alzheimer's disease or vascular dementia.
Changes in both Mini-Mental State Examination (MMSE) and Barthel scores have independent and significant marginal effects on costs. Each one-point decline in the MMSE score is associated with a pound sterling 56 increase in the four-monthly costs, whereas each one-point fall in the Barthel index is associated with a pound sterling 586 increase in costs.
It may be inappropriate for economic models of disease progression in dementia to be based solely on measures of cognitive change. MMSE and the Barthel index are independent significant predictors of time to institutionalisation and cost of care, but changes in the Barthel index are particularly important in predicting costs outside institutional care.
The British Journal of Psychiatry 08/2002; 181:36-42. · 6.62 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Psychiatric disorders are purported to play a role in the aetiology of violent crime, but evidence for their role in sexual offending is less clear. The authors investigated the prevalence of psychiatric morbidity and personality disorders in elderly incarcerated sex offenders compared with elderly non-sex offenders.
One hundred and one sex offenders and 102 non-sex offenders aged over 59 years wereinterviewed using standardized semi-structured interviews for psychiatric illness (the Geriatric Mental State) and the personality disorder (Structured Clinical Interview for DSM-IV personality disorders). Data on demographic, offence and victim characteristics were collected.
Six per cent of the elderly sex offenders had a psychotic illness, 7% a DSM-IV major depressive episode and 33% a personality disorder; and 1% had dementia. These prevalence figures were not different from the elderly non-sex offenders interviewed in this study. Differences emerged at the level of personality traits with sex offenders having more schizoid, obsessive-compulsive, and avoidant traits, and fewer antisocial traits compared with non-sex offenders.
Elderly sex offenders and non-sex-offenders have similar prevalence rates of mental illness. However, elderly sex offenders have increased schizoid, obsessive-compulsive, and avoidant personality traits, supporting the view that sex offending in the elderly is associated more with personality factors than mental illness or organic brain disease.
Psychological Medicine 03/2002; 32(2):219-26. · 6.16 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The number of elderly prisoners has increased significantly in Western countries over the past decade. Little is known about the psychiatric morbidity of this population.
To determine the prevalence of psychiatric morbidity in elderly sentenced prisoners.
A stratified sample of 203 male sentenced prisoners aged over 59 years, from 15 prisons in England and Wales, representing one in five men in this age group, was interviewed using semistructured standardised instruments for psychiatric illness and personality disorder.
More than half of the elderly prisoners had a psychiatric diagnosis. The most common diagnoses were personality disorder and depressive illness.
The prevalence of depressive illness was five times greater than that found in other studies of younger adult prisoners and elderly people in the community. Underdetected, undertreated depressive illness in elderly prisoners is an increasing public health problem.
The British Journal of Psychiatry 01/2002; 179:535-9. · 6.62 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To investigate the last phase of dementia and the causes of death; comparing autopsy and death certificate diagnoses.
Prospective, 11-year, longitudinal study of behavioural and psychological changes in dementia, with autopsy follow-up.
Participants with dementia, living at home with a carer. All lived in Oxfordshire, UK.
Ninety-one people with dementia (Alzheimer's disease and/or vascular dementia) who died during the course of the study.
At four-monthly intervals, carers were interviewed about the participants' behaviour using the Present Behavioural Examination. Participants were also assessed cognitively. Causes of death were established from death certificates and, where possible, from post-mortem examination.
The main immediate cause of death recorded at autopsy was pneumonia (57%), followed by cardiovascular disease (16%) and pulmonary embolus (14%). This agreed with the immediate cause of death on 53% of death certificates. Pulmonary embolism and bronchopneumonia were under-reported on death certificates. Dementia was mentioned on 73% of death certificates. The dementing illness lasted for a mean of 8.5 years with 58% dying in a debilitated state associated with severe dementia. In the period before death, 35% were unable to walk, 58% were hypophagic, 73% were incontinent of urine, 21% incontinent of faeces and 76% entered an institution permanently for a mean period of 18 months.
Family and professional carers of people with dementia can be given some information about prognosis to help them plan for the likely outcome of dementia.
International Journal of Geriatric Psychiatry 11/2001; 16(10):969-74. · 2.42 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Assessment of the health of men aged 60 and over in English and Welsh prisons.
203 men were interviewed from 15 prisons, comprising one-fifth of all sentenced men in this age group in England and Wales. Assessment included semi-structured interviews covering chronic and acute health problems, and recording of major illnesses from the medical notes and prison reception health screen.
85% of the elderly prisoners had one or more major illnesses reported in their medical records, and 83% reported at least one chronic illness on interview. The most common illnesses were psychiatric, cardiovascular, musculoskeletal and respiratory.
The rates of illness in elderly prisoners are higher than those reported in other studies of younger prisoners and surveys of the general population of a similar age. The increasing number of elderly people in prison poses specific health challenges for prison health-care services.
Age and Ageing 10/2001; 30(5):403-7. · 3.09 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This article analyzes the natural history of wandering behavior throughout the course of dementia.
Prospective, 10-year, longitudinal study of wandering behavior in dementia, with autopsy follow-up.
Participants with dementia, living at home with a carer. All lived in Oxfordshire, UK.
Eighty-six people with dementia who were living at home with a carer and who were able to walk unaided at entry to study. Measures: At 4-monthly intervals, the carers were interviewed using the Present Behavioural Examination to assess wandering behavior in detail; participants with dementia were assessed cognitively. Nine types of "wandering" behavior were distinguished.
Changes in wandering behavior were not generally related to gender, age, or time since onset of dementia. Onset of different types of wandering behavior showed some relationship with cognitive state. Various forms of increased walking first appeared during moderate dementia, each type typically persisting for 1 to 2 years. Late dementia was characterized by decreased walking and immobility.
Wandering behavior in dementia can cause great problems for carers. There are different causes for such changes, some of which are related to cognitive ability, for example increased confusion results in ineffectual "pottering" and getting lost. Increased walking at night corresponds with disruption of diurnal rhythm.
International Psychogeriatrics 07/2001; 13(2):137-47. · 2.24 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To determine the rates of psychiatric disorder and personality variables in a sample of older people who had committed suicide and to compare the rates in a subgroup of this sample with those in a control group of people who died from natural causes.
Descriptive psychological autopsy study, including interviews with informants, of psychiatric and personality factors in 100 suicides in older people. Case-control study using subgroup of 54 cases and matched control group.
Four counties and one large urban area in central England, UK.
Individuals 60 years old and over at the time of death who had died between 1 January 1995 and 1 May 1998, and whose deaths had received a coroner's verdict of suicide (or an open or accidental verdict, where the circumstances of death indicated probable suicide). The control group was an age-and sex-matched sample of people dying through natural causes in the same time period.
ICD-10 psychiatric disorder, personality disorder and trait accentuation.
Seventy-seven per cent of the suicide sample had a psychiatric disorder at the time of death, most often depression (63%). Personality disorder or personality trait accentuation was present in 44%, with anankastic or anxious traits the most frequent. Depression, personality disorder, and personality trait accentuation emerged as predictors of suicide in the case-control analysis.
Personality factors, as well as depression, are important risk factors for suicide in older people.
International Journal of Geriatric Psychiatry 03/2001; 16(2):155-65. · 2.42 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To determine the demographic characteristics, mode of death, and nature and timing of medical contacts in the year before death in a sample of suicides in older people.
Descriptive study of a case series of 195 suicides in older people.
Four counties and one large urban area in central England, UK.
Individuals 60 years old and over at time of death, who had died between 1 January 1995 and 1 May 1998, and whose deaths has received a coroner's verdict of suicide, or an open or accidental verdict where the circumstances of death indicated probable suicide.
Demographic details and information on mode of death and medical contact prior to death derived from coroners' inquest notes, General Practitioners' (GP) case-notes and psychiatric records.
67.7% were male. A higher proportion of men than women were single or divorced. The commonest methods of suicide were hanging in men and drug overdose in women, 49.8% had seen their GP in the month before death, although over half these last consultations were for physical complaints. Only 15.4% were under psychiatric care at the time of death.
Older men are at higher risk of suicide than women. Given the high proportion of drug overdoses in the sample, effective strategies to prevent suicide in older people might include improving the prescribing of analgesics and antidepressants. Although older people at risk of suicide often consult their GP shortly before death, GPs may have difficulty identifying those at risk because of the high proportion of physical complaints.
International Journal of Geriatric Psychiatry 09/2000; 15(8):736-43. · 2.42 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This study examines the influence of cognitive impairment, premorbid intelligence, and decision-making capacity to complete advance directives on the treatment preferences for life-sustaining medical therapy in the elderly.
One hundred elderly individuals were recruited. Fifty were first referrals to specialist services with a DSM-IV diagnosis of dementia, and 50 were volunteers. Each person was asked about treatment preferences in three clinical vignettes.
Elderly individuals who had cognitive impairment and were incapable of completing advance directives were significantly more likely to opt for life-sustaining interventions. There was no association between premorbid intelligence and treatment preferences.
Cognitive impairment appears to influence treatment preferences for life-sustaining medical therapy. With increasing cognitive impairment, elderly individuals tend to opt for treatment interventions.
American Journal of Psychiatry 07/2000; 157(6):1009-11. · 12.54 Impact Factor
-
International Journal of Geriatric Psychiatry 04/2000; 15(3):201-2. · 2.42 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To determine whether elderly medical inpatients without dementia who score >3.31 on the short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) are at an increased risk of developing dementia.
Twenty-nine patients with an IQCODE score of >3.31 without dementia and 29 age- and sex-matched controls, from an original sample of 201 medical inpatients over 65, were examined 17-24 months after initial assessment.
Interviews took place in patients' homes, but all subjects had been recruited while medical inpatients in a general hospital 17-24 months previously.
The IQCODE and clinical interview to make DSM-III-R diagnosis of dementia.
Ten of the study group and one control had developed dementia since the original assessment.
Non-demented elderly medical inpatients with an admission IQCODE score of >3.31 are more likely to develop dementia than those with an IQCODE score of <3.31. The IQCODE is a sensitive tool for detecting early dementia.
International Journal of Geriatric Psychiatry 11/1999; 14(11):941-5. · 2.42 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This article analyses changes in aggressive behaviour throughout the course of dementia.
Prospective, 10 year, longitudinal study of aggressive behaviour in dementia, with autopsy follow-up.
Subjects with dementia, living at home with a carer, Oxfordshire, UK.
Ninety-nine people with dementia (Alzheimer's disease and/or vascular dementia) who were living at home with a carer.
At 4-monthly intervals, the carers were interviewed about the subjects and the subjects were assessed cognitively. Subjects' behaviour was assessed using the Present Behavioural Examination. This is an investigator-based, semi-structured interview consisting of eight main sections monitoring behavioural and psychological change. Eight different aspects of aggressive behaviour were assessed in detail and comparison made with other relevant factors.
Verbal aggression is the most common and longest lasting form of aggressive behaviour. Aggressive resistance and physical aggression are most likely to persist until death. Intimate care is the main factor precipitating aggressive behaviour. There are no correlations between any type of aggressive behaviour and age, gender or time since onset of dementia.
Aggressive behaviour creates problems for carers. In general, the physical types of aggressive behaviour are most prevalent in people with more severe dementia.
International Journal of Geriatric Psychiatry 08/1999; 14(7):541-8. · 2.42 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: At referral, a fifth of patients with dementia were competent to complete advance directives. Competence was significantly related to higher premorbid IQ estimated by the National Adult Reading Test.
The Lancet 08/1999; 354(9172):48. · 38.28 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To develop a patient centred approach for the assessment of competence to complete advance directives ("living wills") of elderly people with cognitive impairment.
Semistructured interviews.
Oxfordshire.
50 elderly volunteers living in the community, and 50 patients with dementia on first referral from primary care.
Psychometric properties of competence assessment.
This patient centred approach for assessing competence to complete advance directives can discriminate between elderly persons living in the community and elderly patients with dementia. The procedure has good interrater (r=0.95) and test-retest (r=0.97) reliability. Validity was examined by relating this approach with a global assessment of competence to complete an advance directive made by two of us (both specialising in old age psychiatry). The data were also used to determine the best threshold score for discriminating between those competent and those incompetent to complete an advance directive.
A patient centred approach to assess competence to complete advance directives can be reliably and validly used in routine clinical practice.
BMJ 03/1999; 318(7182):493-7. · 14.09 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Alzheimer's disease and other types of dementia are characterised by numerous psychiatric and behavioural changes. Little is known of their natural history.
To investigate the sequence and pattern of these changes throughout the course of dementia.
One hundred people, initially living at home with carers, entered a prospective, longitudinal study. At four-monthly intervals, behavioural and psychiatric symptoms were assessed using the Present Behavioural Examination and Mini-Mental State Examination. Follow-up continued for up to nine years (mean 3.3 years; s.d. 2.4). Patterns of onset and disappearance of these symptoms, their sequence and association with time of death and cognitive decline were analysed. Autopsy confirmed a diagnosis of pure Alzheimer's disease in 48 subjects. Data for this subgroup are presented.
Some changes tend to occur earlier than others but changes can occur at almost any time in the course of dementia.
The natural history of behaviour changes in Alzheimer's disease shows great individual variation although some changes tend to follow a recognisable sequence.
The British Journal of Psychiatry 02/1999; 174:39-44. · 6.62 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This article examines the relationships between behaviour, psychological functioning, the caring environment and subsequent institutionalization in patients with dementia living at home with a carer.
Longitudinal study of behaviour in dementia, with a nested case-control study to investigate predictors of institutionalization.
Subjects with dementia, known to service, living at home with a carer. All lived in Oxfordshire, UK.
100 people with dementia (Alzheimer's disease and/or vascular dementia) who were living at home with a carer at the start of the study.
At 4-monthly intervals, the carers were interviewed and the subjects with dementia were assessed cognitively. Subjects' behaviour and psychological functioning were assessed using the Present Behavioural Examination.
The characteristics which best predicted institutionalization 1 year later were: excessive night-time activity; immobility or difficulty in walking; incontinence; being away from a carer for more than 16 hours a week; and being cared for by a female. Aggressive behaviour was not associated with an increased chance of entry into an institution 1 year later, although it was more prevalent 4 months before entering an institution.
Both behaviour and psychological functioning and the caring environment can help in predicting which patients with dementia currently living at home will enter an institution 1 year later. These predictors are not the same as those which are the immediate cause of institutionalization.
International Journal of Geriatric Psychiatry 11/1998; 13(10):682-90. · 2.42 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Cross-sectional studies of non-cognitive symptoms in dementia show that patients with psychotic symptoms tend to have more disturbed behaviour. However, it is not known whether individuals who experience psychiatric symptoms early in dementia are more prone to develop behavioural problems later in the illness.
The behaviour of 86 community-dwelling subjects with dementia was intensively studied for 4 years or until death, using an informant interview which was administered every 4 months on a median of eight occasions. The extent to which psychiatric symptoms, age, sex and cognitive function predicted clinically significant physical aggression or motor hyperactivity was assessed.
Physical aggression was predicted by sad appearance and motor hyperactivity was predicted by persecutory ideas. These associations were robust, remaining significant over 2, 3 and 4 years of follow-up and were independent of cognitive function, age, sex and duration of illness.
There may be two distinct longitudinal syndromes of non-cognitive symptoms in dementia. This suggests that important aberrant behaviours in late dementia may share pathophysiological mechanisms with psychiatric symptoms in early dementia.
Psychological Medicine 10/1998; 28(5):1119-27. · 6.16 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The occurrence of episodes of getting lost was examined in 104 subjects with dementia who were assessed every 4 months over 5 years. All subjects were initially living at home with a caregiver who could give good information. Forty-three subjects needed to be brought back home at least once. Five subjects repeatedly got lost. Forty-six subjects were kept behind locked doors at some point. Subjects who got lost were more likely to become permanently resident in institutions (odds ratio = 7.3; 95% confidence interval: 3.0 to 17.8). Patients who performed better on a behavioral test of topographical memory were less likely to get lost over the subsequent 5 years (negative predictive value: 90%). The risk of patients with dementia getting lost is substantial and requires frequent intervention by caregivers. This risk is a major reason for institutionalization. A simple test may help in assessing the risk of getting lost in patients with dementia.
International Psychogeriatrics 10/1998; 10(3):253-60. · 2.24 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Patients with dementia who go out unaccompanied are at risk of accidents or getting lost. It is not known whether they could benefit from electronic tracking devices or whether such devices are practically feasible.
The likely demand for an electronic tracking device was assessed by means of a telephone survey of a convenience sample of 99 carers. The practical feasibility of a tracking system was assessed in 24 patients with dementia.
The telephone survey suggested that 20% of patients were at continuing risk of traffic accidents and 45% were at continuing risk of getting lost. About 7% could have benefited from using the device at the time of survey and a further 11% could have benefited at an earlier point in their illness. In the feasibility study, only nine patients consistently used the device. In two patients, it was successfully used in a search. One patient was injured by a passing vehicle when he had got lost out of range of the device. A major barrier to using the device was recognizing the risk of getting lost before it happened.
Significant numbers of patients are at risk. Electronic tracking devices may occasionally be useful in carefully selected cases.
International Journal of Geriatric Psychiatry 09/1998; 13(8):556-63. · 2.42 Impact Factor
