Change "DNR" to "GPC".
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Advance Directives↗
Biomedical subjects
D W Molloy
Publications and source records attributed to D W Molloy.
Factors affecting physicians' decisions on caring for an incompetent elderly patient: an international study.
OBJECTIVES: To determine what treatment decisions physicians will make when faced with a hypothetical incompetent elderly patient with life-threatening gastrointestinal bleeding and to examine the relative importance of physician characteristics and factors (legal and ethical concerns, hospital costs, level of dementia, patient's age, physician's religion, patient's wishes and family's wishes) in making those decisions. DESIGN: Survey. SETTING: Family practice, medical and geriatrics rounds in academic medical centres and community hospitals in seven countries. PARTICIPANTS: Physicians who regularly cared for incompetent elderly patients. MAIN OUTCOME MEASURES: A self-administered questionnaire describing the elderly patient. Respondents were asked to choose one of four levels of care and to identify the level of importance factors had in making that decision. Older physicians, those less concerned about litigation, those for whom the level of dementia was important and those for whom the patient's age was important were expected to give less aggressive care than the other physicians. MAIN RESULTS: Supportive care was chosen by 8.1% of the respondents, limited therapeutic care by 41.5%, maximum therapeutic care without admission to the intensive care unit (ICU) by 32.2% and maximum care with admission to the ICU by 18.2%. The patient's wishes were reported by 91.0% as being extremely or very important in choosing the treatment. Stepwise logistic regression analysis revealed that the following variables independently predicted the level of treatment: level of dementia, country of residence, duration of practice, legal concerns, patient's age and ethical concerns. These factors were significantly correlated with the physicians' treatment choices (p less than 0.05). CONCLUSIONS: The importance that the physicians placed on the level of dementia was the strongest predictor of the level of care that would be provided. A societal consensus on the influence of cognitive function on the appropriate level of care as well as training of physicians in ethical issues are required.
Adult↗
A comprehensive health care directive in a home for the aged.
OBJECTIVES: To examine the use of and compliance with a new comprehensive health care directive by residents of a home for the aged and to determine the effect of the directive on the use of health care services. DESIGN: Descriptive study with a before-after design. SETTING: A home for the aged providing residential care to women. PARTICIPANTS: All 119 residents (ages 71 to 103 years, mean age 87.5 years). INTERVENTION: Introduction of a comprehensive health care directive and follow-up at 1 year. OUTCOME MEASURES: Residents' treatment choices, compliance with the directive, number of hospital admissions and length of hospital stay, number of deaths and places where deaths occurred. RESULTS: Ninety (76%) of the residents completed the directive. In the event of reversible life-threatening illness 34, 24, 11 and 21 residents requested supportive, limited, maximum and intensive care respectively. For irreversible illness the numbers were 75, 12, 3 and 0 respectively. In case of cardiac arrest 88% requested that cardiopulmonary resuscitation not be done. In the year before the introduction of the directive there were nine deaths, one in the home and eight in hospitals. In the year after there were 17 deaths, 11 in the home and 6 in hospitals. The mean length of hospital stay was significantly lower in that year than in the year before implementation (p less than 0.001). CONCLUSIONS: This innovative health care directive seems to be feasible, practical and well supported by residents, their families and health care professionals. Further studies are required to establish the generalizability and reproducibility of the data to other elderly people in institutions, to chronically ill patients and to the community at large.
Advance Directives↗
Variability in physicians' decisions on caring for chronically ill elderly patients: an international study.
OBJECTIVES: To determine what treatment decisions physicians will make when faced with an incompetent elderly patient with life-threatening gastrointestinal bleeding and to identify the factors that affect their decisions. DESIGN: Survey. SETTING: Family practice, medical and geriatrics rounds in academic medical centres and community hospitals in seven countries. PARTICIPANTS: Physicians who regularly cared for incompetent elderly patients. OUTCOME MEASURE: A self-administered questionnaire containing three case vignettes. Each provided the same details on an incompetent elderly patient; however, one gave no information about the wishes of the patient and his family (no directive), the second provided a do-not-resuscitate (DNR) request, and the third included a detailed therapeutic and resuscitative effort chart (DTREC) requesting maximum therapeutic care without admission to the intensive care unit (ICU). The four treatment options were supportive care only, limited therapeutic care, maximum therapeutic care without admission to the ICU and maximum care with admission to the ICU. MAIN RESULTS: Treatment decisions varied and were systematically related to age, level of training and country (p less than 0.001). The older physicians and those in family medicine were less likely than the others to choose aggressive treatment options. Brazilian and US physicians were the most aggressive; Australian physicians were the most conservative. The DNR request resulted in a significant decrease in the number of physicians choosing aggressive options (p less than 0.001). The DTREC resulted in a move toward more aggressive treatment, as outlined in the directive (p less than 0.001). Overall, however, about 40% of the physicians chose a level of care different from what had been requested. Furthermore, over 10% would have tried cardiopulmonary resuscitation despite the DNR request. CONCLUSION: Treatment of incompetent elderly patients with life-threatening illness varies widely within and between countries. Uniform standards should be developed on the basis of societal values and be communicated to physicians.
Advance Directives↗
Effect of tetrahydroaminoacridine on cognition, function and behaviour in Alzheimer's disease.
OBJECTIVE: To determine the efficacy of tetrahydroaminoacridine (THA) in Alzheimer's disease. DESIGN: Randomized, double-blind, multiple crossover trial with three treatment periods, each consisting of 3 weeks of active drug therapy and 3 weeks of placebo administration. SETTING: Referral-based geriatric practice in a community hospital. PATIENTS: Thirty-four patients with moderate to severe Alzheimer's disease. Subjects were included if they had stage 3 to 6 disease (as determined by the Reisberg scale) and had not been taking psychotropic drugs for at least 1 month and if informed consent had been obtained from the patients and their next of kin. INTERVENTIONS: Fifty to 100 mg of THA daily and matched placebo. RESULTS: Of the initial 34 patients 14 experienced liver toxicity and 3 gastrointestinal side effects during the study; however, all 22 who completed the study were able to tolerate at least the minimum dose. For the 22 patients there was no clinically or statistically significant effect of THA on cognition, functional status or behaviour. The results for individual patients showed no subgroup of THA-responsive patients. CONCLUSION: THA has no clinically important benefits in Alzheimer's disease and is associated with appreciable toxic effects.
Activities of Daily Living↗
Decision making in the incompetent elderly: "The Daughter from California syndrome".
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Advance Directives↗
Clinical significance of primitive reflexes in Alzheimer's disease.
STUDY OBJECTIVE: To establish the relationship between cognition, behavior, function, and clinical characteristics on the one hand, and the presence of primitive reflexes (PR) (pout, snout, palmomental and grasp) in patients with Alzheimer's disease (AD). DESIGN: Cross-sectional survey. SETTING: Secondary care geriatric practice specializing in the assessment of cognitive impairment. SUBJECTS: 136 consecutive patients presenting with AD. MEASUREMENTS: PR were assessed in standardized fashion by a single clinician. Cognitive function was measured using the Standardized Mini-Mental Status Examination, activities of daily living (ADL) and instrumental activities of daily living (IADL) were measured using the Lawton scale, and behavior was measured using the Behavioural Problem Checklist. RESULTS: There was no difference in age or duration of dementia in those with and without PR, nor was there any difference in cognitive function. Despite this, patients with PR showed a greater degree of functional limitation and dysfunctional behavior. There was also a higher incidence of rigidity, gait abnormalities, and apraxia in patients with PR. CONCLUSIONS: Patients with primitive reflexes had more severe impairment in ADL function and dysfunctional behavior for an equal level of cognitive function.
Activities of Daily Living↗
Validity and reliability of the Dysfunctional Behaviour Rating Instrument.
The objective of this study was to examine the reliability and validity of the Dysfunctional Behaviour Rating Instrument (DBRI) in cognitively impaired older adults living in the community. A total of 184 adults with suspected cognitive impairment received a standardized history, physical examination and work-up that included the Standardized Mini-Mental State Examination. Caregivers scored a DBRI Behaviour Problem Checklist (BPC) and Lawton Scale for each patient. The reliability of the DBRI, measured by an intraclass correlation coefficient, was 0.75. The correlation coefficient between the DBRI and the BPC total score was 0.71. The correlations between the DBRI and the cognitive, activities of daily living and self-care domain scores of the BPC were lower (0.66, 0.38 and 0.26 respectively). The DBRI is a specific, reliable and valid caregiver-reported measure of dysfunctional behaviour in cognitively impaired elderly living in the community.
Activities of Daily Living↗
Reliability of a Standardized Mini-Mental State Examination compared with the traditional Mini-Mental State Examination.
OBJECTIVE: The objective of this study was to compare the reliability of the Mini-Mental State Examination with that of a new Standardized Mini-Mental State Examination, which has expanded guidelines for administration and scoring. METHOD: The subjects were 32 stable elderly residents of a nursing home and 16 elderly residents of a chronic care hospital unit. Six raters administered the Folstein Mini-Mental State to 22 of these stable elderly subjects, and five raters administered the standardized version to 26 of these subjects. Each subject was tested on three different occasions 1 week apart. Each rater tested 4-6 subjects at the first and third weeks and 4-6 different subjects at the second week. The analytic technique used was one-way analysis of variance to estimate the interrater variance and the intrarater variance. RESULTS: The intrarater variance on all occasions was reduced by 86% and the interrater variance was reduced by 76% when the Standardized Mini-Mental State was used; the reductions in variance were significant (p less than 0.003). The intraclass correlation for the Mini-Mental State was 0.69; for the standardized version it was 0.90. It took less time to administer the Standardized Mini-Mental State than the Mini-Mental State. CONCLUSIONS: The Standardized Mini-Mental State had better reliability than the Mini-Mental State in this study group. Although the improved reliability of the Standardized Mini-Mental State was achieved by reducing measurement noise, this advantage would likely occur in a broad spectrum of patients.
Aged↗
The cardiopulmonary and renal hemodynamic effects of norepinephrine in canine pulmonary embolism.
Autologous blood clot was injected into six dogs to produce a graduated decrease in cardiac output (CO). The effects of an infusion of norepinephrine, titrated to specific end points, were recorded before embolization and at two levels of pulmonary hypertension. Simultaneous measurements of systemic and renal hemodynamics were made. Sequential blood clot injection increased (p less than .01) pulmonary vascular resistance (PVR) from 1.3 to 13 to 33 mm Hg.L-1.min and reduced CO 45 percent and 75 percent (p less than .01). Norepinephrine increased both stroke volume and CO (p less than .01) in each condition and did not increase PVR. Since the biventricular filling pressures remained constant or fell slightly with norepinephrine, the increase in CO is best explained by an improvement in pump performance. There was no deterioration in renal blood flow or creatinine clearance with norepinephrine. The data suggested that in this model of right ventricular dysfunction, norepinephrine consistently improved myocardial performance without provoking further vasoconstriction in either the pulmonary or renal circulations.
Animals↗
The effects of a three-month exercise programme on neuropsychological function in elderly institutionalized women: a randomized controlled trial.
This randomized controlled trial examined the effect of a 3-month exercise programme on neuropsychological function in a population of very elderly institutionalized women. Baseline neuropsychological testing was performed, and following 3 months of exercise or control intervention, subjects were retested 3-7 days after the completion of the study period. Apart from the Word Fluency Test, there was no significant improvement in any of the neuropsychological test scores. This study may not have shown any significant improvement in neuropsychological function because our exercise programme was too light to improve aerobic fitness, or because neuropsychological tests were repeated 3-7 days after exercise was completed and any acute effects of exercise may have disappeared by that time.
Age Factors↗
Acute effects of exercise on neuropsychological function in elderly subjects.
Fit elderly score higher on tests of fluid intelligence than aged-matched sedentary controls. Elderly patients who have taken part in exercise programs have shown improvement in mental function. We compared the effects of 45 minutes of exercise on memory, mood, and cognitive function in elderly subjects to a control intervention using a randomized control study design. Neuropsychological tests employed where the color slide test, digit symbol test, digit span test, logical memory test, word fluency test, and the Mini-Mental State Examination. We measured mood using a mood test and geriatric depression scale. Each subject was tested before, and immediately after, control and exercise sessions. Fifteen elderly subjects [ten men and five women; mean age, 66 years, (range, 60 to 85 years)] completed the study. There was a greater improvement in six of the eight scores of cognitive function following exercise, compared to control. These differences were significantly greater following exercise for the logical memory test score (P less than or equal to 0.02) and Mini-Mental State Examination (P less than or equal to 0.025) compared with the control intervention.
Affect↗
Acute chest pain in an elderly woman.
A 79-year-old woman was admitted to hospital complaining of chest pain, increasing weakness, anorexia, hoarseness, headache and discomfort in the throat and jaws while eating. Physical examination, chest x-rays, serial electrocardiograms and cardiac enzymes were unremarkable. After admission she developed weakness and numbness in the left leg with urinary retention, decreased sensation to touch, weakness, increased tone, absent deep tendon reflexes and a positive Babinski sign on the left. Zeta sedimentation rate was markedly elevated at 0.63. Computerized tomographic head scan, myelography, echocardiography, barium swallow and meal, immunoglobulins, electrophoresis and other laboratory investigations were unremarkable. Repeat sedimentation rate was still markedly elevated three weeks later. A temporal artery biopsy confirmed the diagnosis of temporal or giant cell arteritis. Prednisone, 60 mg daily, was started.
Acute Disease↗
Memory loss, confusion, and disorientation in an elderly woman taking meclizine.
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Aged↗
Hemodynamic management in clinical acute hypoxemic respiratory failure. Dopamine vs dobutamine.
We investigated short-term hemodynamic effects of dopamine and dobutamine in eight patients with acute hypoxemic respiratory failure. We tested the hypothesis that for a similar increase in cardiac output, left ventricular filling pressure (pulmonary capillary wedge pressure [PCWP]) would increase with dopamine and decrease with dobutamine. Dopamine increased cardiac output (p less than 0.05), stroke volume (p less than 0.05), and PCWP (p less than 0.01). Cardiac output increased almost 20 percent when PCWP increased 50 percent with dopamine. In contrast, despite a mean 30 percent increase in cardiac output with dobutamine (p less than 0.01), PCWP decreased. In six of these patients, left ventricular end-diastolic volumes and end-systolic volumes were measured using scintigraphic techniques. In all patients, end-diastolic volume increased with dopamine (p less than 0.05); and in four of six, end-systolic volume increased. In contrast, with dobutamine, in five of six patients, end-diastolic volume decreased; and in all six patients, end-systolic volume decreased. There was a small increase in intrapulmonary shunt with both drugs. We conclude that if an inotropic agent is required to increase cardiac output in patients with acute hypoxemic respiratory failure, dobutamine is probably preferred over dopamine.
Acute Disease↗
Effects of noradrenaline and isoproterenol on cardiopulmonary function in a canine model of acute pulmonary hypertension.
The authors investigated acute cardiopulmonary effects of noradrenaline and isoproterenol infusion in a canine model of increased pulmonary vascular resistance (PVR) and decreased cardiac output (CO). In six anesthetized, ventilated dogs, autologous blood clots were injected over approximately two hours to increase right ventricular (RV) afterload and decrease CO. After CO had decreased 40 percent dogs were treated with noradrenaline or isoproterenol in alternate sequence. Both drugs increased stroke volume but only isoproterenol affected CO. Flow increased from 1.3 to 3.0 L X min-1 (p less than .01) with isoproterenol infusion. Corresponding to the increase in CO, RV filling pressure and PVR decreased, from 9 to 5 mm Hg, and from 36 to 16 mm Hg X L-1 X min (p less than .01) respectively. When a moderate decrease in CO complicates an acute increase in PVR, isoproterenol may be an excellent drug to treat the decrease in flow.
Animals↗
Use of sodium bicarbonate to treat tricyclic antidepressant-induced arrhythmias in a patient with alkalosis.
Sodium bicarbonate has been recommended for the treatment of arrhythmias induced by tricyclic antidepressants. It is unclear, however, whether this therapy is effective only in the presence of acidosis. A case is presented in which there was an immediate response to sodium bicarbonate in three episodes of ventricular tachycardia despite the presence of alkalosis on two of the three occasions. Given the poor response to conventional therapy of arrhythmias induced by tricyclic antidepressants the use of sodium bicarbonate may be reasonable even in the presence of alkalosis. However, in the presence of pre-existing respiratory or metabolic alkalosis, such therapy is not without risk, and it is suggested that it be reserved for life-threatening situations when the arrhythmia has failed to respond to hyperventilation or antiarrhythmics or both.
Adult↗
Effects of hydralazine and nitroprusside on cardiopulmonary function when a decrease in cardiac output complicates a short-term increase in pulmonary vascular resistance.
We investigated the short-term cardiopulmonary effects of nitroprusside and hydralazine when cardiac output (CO) was reduced by a short-term increase in pulmonary vascular resistance (PVR). In six anesthetized, ventilated dogs, small autologous blood clots, injected over 1 to 2 hr, increased right ventricular afterload. When CO had fallen approximately 40%, dogs were treated with nitroprusside and subsequently with hydralazine. Both drugs reduced biventricular filling pressures (p less than .05), but only hydralazine increased CO and stroke volume (p less than .05). Although mean blood pressure and pulmonary artery pressure remained constant with hydralazine, systemic vascular resistance and PVR decreased (p less than .01). In contrast, although nitroprusside reduced blood pressure and systemic vascular resistance (p less than .01), it did not affect PVR and pulmonary artery pressure. When CO is significantly reduced because of a short-term increase in PVR, hydralazine may be superior to nitroprusside in improving cardiopulmonary function.
Animals↗