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Biomedical subjects

Greg A Sachs

Publications and source records attributed to Greg A Sachs.

At least 19 recordsLinked to original sources
PubMed2006

Evaluation of cognition in cancer patients: special focus on the elderly.

PURPOSE: The risks of both cognitive dysfunction and most cancers increase with age. A literature review was undertaken to identify how cognitive issues in older patients were being assessed in the oncology literature. METHODS: A systematic literature search was undertaken using a number of different search terms and databases to find all relevant articles in oncology and internal medicine journals. RESULTS: Eighty-eight articles were included in the review. Just over half of the articles studied a mixture of cancer types and had fewer than 100 patients. The vast majority of patients being studied were <65 years of age. While a little over half of the articles used >or=3 neuropsychological tests to assess cognition, more than 60 different tests were used to assess cognition. Forty-one percent of the studies were prospective trials, with most of the rest divided between cross-sectional and observational. One-fifth of the articles involved patients at end-of-life. CONCLUSION: The oncology literature contains little information about cognition in older cancer patients. More systematic and comprehensive studies of this important aspect of cancer care in the elderly are necessary.

Aged↗
PubMed2006

Implications of new geriatric diabetes care guidelines for the assessment of quality of care in older patients.

BACKGROUND: Current approaches to assessing quality of diabetes care do not account for the heterogeneity of older patients. OBJECTIVE: We sought to compare conclusions regarding adequacy of glucose and blood pressure control using current quality assessment approaches and a stratified approach based on geriatric care guidelines. DESIGN: This was a cross-sectional evaluation of diabetes care. SUBJECTS: We studied patients older than 65, living with diabetes (n = 554) attending clinics of an academic medical center. MEASUREMENTS: We measured the proportion of patients with and without markers of poor health (life expectancy < or = 5 years, age > or = 85, 4-6 activities of daily living dependencies, or Charlson Comorbidity Index Score > or = 5) achieving treatment goals. RESULTS: Under general population goals (glycosylated hemoglobin [HbA1C] < or = 6.5% or < 7%; systolic blood pressure [SBP] < 130 mm Hg), a small proportion of our subjects met glucose (24-36%) or SBP control (30%) targets. Under new guidelines, less-intense targets (HbA1C < or = 8%, SBP < 140 mm Hg) would be applied to patients with diminished health, with general population goals reserved for healthier patients. With this stratified approach, the proportion of sicker patients achieving their specified glucose (61-83%) and SBP goals (37-64%) generally was high, depending on the criteria for poor health, whereas the proportion of healthier patients achieving their goals remained low. CONCLUSIONS: A stratified approach to assessing the quality of diabetes care leads to distinct care conclusions for older patients with and without markers of diminished health. An approach to quality assessment and quality improvement that acknowledges patient heterogeneity could help ensure the clinical relevance of such efforts for older patients.

Aged↗
PubMed2006

High interest in screening and treatment for mild cognitive impairment in older adults: A pilot study.

OBJECTIVES: To assess interest of older adults in screening and treatment for mild cognitive impairment (MCI). DESIGN: Cross-sectional, in-person pilot survey with a convenience sample. SETTING: Two university-based geriatrics clinic waiting rooms in Chicago. PARTICIPANTS: Healthy adults aged 35 and older without cognitive impairment (n = 149). MEASUREMENTS: Following a description of MCI extracted from the Alzheimer's Association Website "Fact Sheet," questions concerning willingness to be screened and treated for MCI. RESULTS: Ninety-eight percent of respondents would be willing to be tested for MCI if a family member suggested they had memory problems, 99% were willing to take a medication if it would cut the risk of conversion from MCI to Alzheimer's disease (AD) in half, and 92% would take a medication to delay the conversion from MCI to AD by 1 year. If a family member suggested memory problems, African Americans were more willing than whites to be screened for MCI (75% vs 57%; P = .05). CONCLUSION: Older adults expressed high interest in screening and treatment for MCI. Interest in screening is even stronger in African Americans than in whites. Such high interest is potentially troubling, given the current state of knowledge about MCI.

Adult↗
PubMed2006

To what extent do geriatricians document the most bothersome symptoms of patients with advanced dementia?

OBJECTIVES: To assess whether geriatricians documented the bothersome symptoms of patients with advanced dementia, proxy reports of the most-bothersome symptoms affecting those patients (as elicited in research interviews) were compared with what geriatricians who had seen those patients in a proximate clinic visit documented in the medical record. DESIGN: Retrospective chart review. SETTING: Outpatient geriatrics clinic at the University of Chicago. PARTICIPANTS: Fifty-seven pairs of patients with dementia (Functional Assessment Staging Tool stage 6 or 7) and their proxies. MEASUREMENTS: Clinic notes were reviewed for documentation of patients' bothersome symptoms that proxies reported during research interviews. Proxy reports had been recorded in the previously established Palliative Excellence in Alzheimer Care Efforts database. RESULTS: The most-bothersome symptom was documented at least once in 84.2% (48/57) of clinic notes. The second-most-bothersome symptom was documented in 70.3% (26/37) of clinic notes. Most symptoms were documented in the Assessment and Plan section of the note. CONCLUSION: Geriatricians identified and documented the vast majority of bothersome symptoms, as reported by proxies, of patients with moderate to severe dementia.

Aged↗
PubMed2006

Management of noncancer pain in community-dwelling persons with dementia.

OBJECTIVES: To explore the pharmacological treatment of noncancer pain in persons with dementia and identify predictors associated with insufficient analgesia. DESIGN: Cross-sectional analysis of an observational cohort study. SETTING: Academic outpatient geriatric clinic in Chicago, Illinois. PARTICIPANTS: A total of 115 dyads, mostly African American, consisting of community-dwelling persons with dementia and their caregivers. MEASUREMENTS: Patient report of demographics, noncancer pain, function, cognition, and depression. Caregiver report of patient agitation and over-the-counter and prescription medications. RESULTS: Sixty-two of 115 (54%) patients reported pain "on an average day." The caregivers of more than half of persons with dementia who reported pain "on an average day" did not report analgesic use. The majority of caregivers who reported analgesic use reported that patients took a World Health Organization Class I medication. No patients had been prescribed a Class III (strong opioid) drug. Fifty-three of 115 (46%) patients had potentially insufficient analgesia. In the logistic regression, insufficient analgesia was associated with greater age, Mini-Mental State Examination score of less than 10, and impairment in daily functioning. Insufficient analgesia was 1.07 times as likely (95% confidence interval (CI) = 1.01-1.14) for each additional year of age, 3.0 times as likely (95% CI = 1.05-9.10) if the subject had advanced dementia, and 2.5 times as likely (95% CI = 1.01-6.25) if the patient had any impairment in activities of daily living. CONCLUSION: In this convenience sample from a geriatric clinic, many persons with dementia and noncancer pain were not receiving pharmacological treatment. Those at greatest risk for insufficient analgesia were older, had moderate to severe dementia, and experienced impairments in activities of daily living.

Activities of Daily Living↗
PubMed2005

A brief history and lessons learned from twin efforts to transform medicine.

In this article, we consider the intersection between the fields of geriatrics and palliative medicine in the United States. Although geriatrics and palliative medicine have sometimes used different strategies to address the same challenges, they have created opportunities where both fields can learn from the experiences of the other. One specialty may be able to learn from issues already dealt with by the other. Because the fields of geriatrics and palliative medicine have so much in common, including health professionals who bridge the two fields, it is the authors' goal to foster greater understanding and collaboration between the specialties and thus strengthen both.

Aged↗
PubMed2005

Factors associated with self- and caregiver report of pain among community-dwelling persons with dementia.

BACKGROUND: Among cognitively intact patients, self- and caregiver report of patient pain has been associated with worse psychological health for both the patient and caregiver. Little existing research examines factors associated with patient self-report of pain and caregiver report of patient pain among community-dwelling persons with dementia. OBJECTIVE: To identify patient and caregiver factors associated with self- and caregiver report of patient pain among community-dwelling persons with dementia. DESIGN: Cross-sectional analysis of a longitudinal study using structured interviews with dementia patients and their family caregivers. SETTING AND SUBJECTS: Urban outpatient geriatrics clinics affiliated with a university hospital. Dyads composed of dementia patients and their family caregivers were approached prior to routine clinic visits to participate in the study. MEASUREMENTS: Relevant patient measurements included self-report of pain; cognitive, functional, and comorbidity assessments; a screen for depression; and demographic information. Relevant caregiver measurements included their report of patient pain and agitation, screens for depression and strain, and demographic information. RESULTS: Of 115 dyads, 37 patients (32%) and 57 caregivers (53%) reported the patient to be in pain. No patient or caregiver factors were significantly associated with patient self-report of pain. In the univariate analysis, caregiver reports of patient pain were associated with the patient not being depressed (p = .036), caregiver reports of patient agitation (p = .038), higher level of education in the caregiver (p = .029), and caregiver depression (p = .019). In multivariate logistic regression analyses, caregiver depression and patient agitation remained significantly associated with caregiver report of patient pain. CONCLUSIONS: In community-dwelling persons with dementia, self-report of pain was not associated with any other variables measured, suggesting that pain should be assessed through direct self-report and treated accordingly. Caregiver report of patient pain was associated with both caregiver report of patient agitation and caregiver depression. These findings suggest that clinicians may need to routinely assess patient pain, patient agitation, and caregiver depression. More research is needed to understand the relationship between these conditions.

Aged↗
PubMed2004

Pain in community-dwelling persons with dementia: frequency, intensity, and congruence between patient and caregiver report.

To better understand the pain experience of persons with dementia and to describe what factors are related to congruence of pain reports within patient-caregiver dyads, a cohort study enrolled patient-caregiver dyads at a primary care geriatrics clinic. Thirty-two percent of persons with dementia self-report pain "right now." Of these, 65% report slight/mild pain, 27% moderate pain, and 8% severe pain or greater. Fifty-two percent of caregivers report their care recipients with dementia are in some pain "right now." Of these, 52% report slight/mild pain, 30% moderate, and 18% severe pain or greater. Fifty-nine percent of dyads agree on the presence or absence of patient pain. In multivariate analysis of dyadic congruence of pain reports by patient and caregiver factors, only patient factors predicted congruence. The odds of congruence of pain reports increase 3.7 (1.2-12.3) if the patient is male and decrease 0.938 (0.93-0.99) as the patient becomes more agitated. These findings suggest that community-dwelling persons with dementia report less pain than those in the nursing home and caregivers do a fair job of predicting patient pain.

Aged↗
PubMed2004

Strain experienced by caregivers of dementia patients receiving palliative care: findings from the Palliative Excellence in Alzheimer Care Efforts (PEACE) Program.

BACKGROUND: Programs that provide palliative care to individuals with dementia, which is a progressive terminal illness, are likely to encounter different issues (e.g., management of problem behaviors, caregiver strain extending over years) from those typically addressed by hospice programs. Little research is available on palliative care for individuals with dementia who live in the community. OBJECTIVE: This study examines predictors of types of strain experienced by caregivers of community-dwelling patients with dementia enrolled in a unique demonstration program titled Palliative Excellence in Alzheimer Care Efforts (PEACE), which moved palliative care "upstream," integrating palliative care into the primary care of patients with dementia. DESIGN: Data were collected through structured, face-to-face interviews with 150 community-dwelling, predominantly African American patient-caregiver dyads who were enrolled in the PEACE program. MEASUREMENTS: Established measures, including the Caregiver Strain Index, the Revised Memory and Behavior Problems Checklist, and the Katz Index of Activities of Daily Living, were used in addition to other measures assessing caregiver, patient, and situational characteristics. RESULTS: Factor analysis of the Caregiver Strain Index revealed three dimensions of strain (role, personal, and emotional) related to caregiving. Using a stress process model, regression analyses examined stressors and resources related to patient, caregiver, and support system characteristics in predicting these three dimensions of strain among caregivers. Patient problem behaviors predicted all types of caregiver strain. Perceived lack of support from the health care team predicted personal and emotional strain, whereas higher income, surprisingly, predicted role strain. Patient functional limitations predicted personal and role strain. CONCLUSIONS: Findings suggest that effective palliative care programs for patients with dementia need to understand and address the various sources and types of caregiver strain; provide adequate support to caregivers for the management of problem behaviors; provide counseling to help cope with the emotional reactions to the cognitive and behavioral changes associated with dementia progression; facilitate communication with the health care team; and broker access to community and other resources for assistance with functional limitations. Further research examining changes in strain over time will provide useful insights on the delivery of care and services for patients with dementia and their families in a palliative care framework.

Black or African American↗
PubMed2004

Barriers to excellent end-of-life care for patients with dementia.

While great strides have been made recently in improving end-of-life care in the United States, people with dementia often die with inadequate pain control, with feeding tubes in place, and without the benefits of hospice care. In this paper, we discuss the most important and persistent challenges to providing excellent end-of-life care for patients with dementia, including dementia not being viewed as a terminal illness; the nature of the course and treatment decisions in advanced dementia; assessment and management of symptoms; the caregiver experience and bereavement; and health systems issues. We suggest approaches for overcoming these barriers in the domains of education, clinical practice, and public policy. As the population ages, general internists increasingly will be called upon to provide primary care for a growing number of patients dying with dementia. There are great opportunities to improve end-of-life care for this vulnerable and underserved population.

Dementia↗
PubMed2004

Ethics reporting in publications about research with Alzheimer's disease patients.

Persons with impaired decision-making capacity require special ethical protections during recruitment for and participation in research. To assess how fully basic protections for these persons were reported in the literature, the first structured review of a sample of reports of trials including Alzheimer's subjects was performed in 62 journals between January 1992 and December 1998. Neither institutional review board review nor informed consent was mentioned in 28% of the studies. In 48% of the studies, there was no mention of subject involvement in the consent process or that any potential subjects refused or withdrew. Protections may have been offered and simply not reported in the journal articles. The critical importance of these protections would be demonstrated if editors required that authors provide full documentation of ethical protections when submitting an article for review. These might be briefly reported in the articles but be made available electronically to interested readers. Authors could then specify in detail how they conducted their research involving persons with diminished decision-making capacity.

Aged↗
PubMed2004

So I thought I wanted to be a chief.

In July 2000, Dr. William Hazzard published an article in the Journal of the American Geriatrics Society entitled "So you think you want to lead an academic geriatric program?" My answer to that question the same month was "Yes," as I agreed to become the chief of the newly established Section of Geriatrics at the University of Chicago. With about 3.5 years on the job now, I offer a more complete reply to Dr. Hazzard's query. Although his paper covered many important and practical issues to consider in looking at becoming a chief, this article provides a perspective on the academic geriatric leadership position based on a new chief's observations. Topics covered include pressures for and against becoming a chief, changing perspectives on goals and rewards, good help, mentoring, money problems/issues, support for the chief, and communication and relationships. It is hoped that these observations will be of use to geriatricians considering leading an academic geriatrics program and to other newly appointed chiefs.

Academic Medical Centers↗
PubMed2003

Are the rules for research with subjects with dementia changing?: views from the field.

Deliberative bodies have recommended additional protections for persons with dementia included in clinical trials. This survey of experienced dementia researchers revealed that 45 to 64% considered that specific ones of these recommendations would increase subject protection, and 40 to 86% considered they would make research less feasible. The real tradeoff between protection and difficulty in conducting research on devastating illnesses needs to be confronted when new regulations in this area are debated.

Alzheimer Disease↗