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Biomedical subjects

V Molinari

Publications and source records attributed to V Molinari.

At least 19 recordsLinked to original sources

Principles and practice of geriatric assent.

Geriatric assent involves health care professionals' active collaboration with cognitively impaired patients that takes account of their longstanding values in any major health care decisions. The main purpose of this paper is to assist geriatric health practitioners 'in the field' to understand how to apply geriatric assent in a variety of clinical situations to maximize incapacitated older adults' input into decision-making. A case example and algorithm are presented to illustrate the basic principles of implementing geriatric assent. Practice informed by the principles of geriatric assent will preserve respect for the current and future autonomy of patients across diverse cultural backgrounds.

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Psychological predictors of admission and discharge global assessment of functioning scale scores for geropsychiatric inpatients.

This study examined psychological predictors of Global Assessment of Functioning Scale scores (GAF) at intake and at discharge for geropsychiatric inpatients. A total of 301 predominantly male geropsychiatric inpatients were recruited from the Houston Veterans Affairs Medical Center. Path analysis was used to test a model proposing causal paths of psychological predictors (cognitive status, depression, agitation, general psychiatric status) to GAF scores on admission and discharge. At admission, all four psychological predictors had positive paths to the admission GAF scale scores but at discharge, only two (i.e., cognitive status and general psychiatric status) of the four psychological predictors had positive paths to the discharge GAF scale scores. The admission GAF scale scores also had a positive path to the discharge GAF scale scores. The overall functioning level of geropsychiatric inpatients may be predicted by measures which assess overall cognitive status and general psychiatric functioning during hospitalization. Results prompt consideration of a modified global scale specifically reflecting an older adult's activities during this period of life.

Activities of Daily Living↗

Measuring aggression in older adults: a latent variable modeling approach.

This cross-sectional measurement study demonstrates a technique for combining information from several aggression scales into one aggression score using latent variable modeling. Participants included male patients (n = 49) with a DSM-IV diagnosis of dementia at The Veterans Affairs Medical Center Outpatient Geriatric Psychiatry Clinic. Data from seven aggression scales were used to indicate the latent aggression variable. Results provided evidence that a unidimensional latent variable model of aggression adequately represented the data. Reliability of the aggression latent variable was estimated as 0.90, whereas reliability of the separate scales estimated with this sample were less than 0.84. Our findings suggest that combining multiple scales into one aggression score using latent variable modeling results in comprehensive and reliable aggression scores that offer researchers several advantages over current methods for measuring aggression.

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One session cognitive behavioural therapy for elderly patients with chronic obstructive pulmonary disease.

BACKGROUND: We hypothesized that compared to an educational intervention, a single 2 h session of cognitive behavioural therapy (CBT), with 6-week follow-up, would reduce anxiety and depression, improve physical and mental functioning, and lead to a better quality of life and greater satisfaction with treatment in older patients with chronic obstructive pulmonary disease (COPD). METHODS: Fifty-six subjects were recruited from a large, urban, academically affiliated Veterans Affairs (VA) Hospital, a non-profit private hospital, and a local newspaper, for a single blind randomized controlled clinical trial. One 2 h session of group CBT was designed to reduce symptoms of anxiety, with specific components including relaxation training, cognitive interventions, and graduated practice, followed by homework and weekly calls for 6 weeks. This was compared to a group that received 2 h of COPD education, followed by weekly calls. Pre- and post-intervention subjects in both groups were administered SF-36, Geriatric Depression Scale, Beck Anxiety Inventory, 6 min walk test, and the FEV-1. Following the intervention, both groups completed the Client Satisfaction Questionnaire. RESULTS: When compared with a group that received education about COPD, 2 h CBT group showed decreased depression and anxiety. Contrary to our hypothesis, despite the decrease in depression and anxiety, there was no change in the physical functioning of the patients. CONCLUSIONS: Twenty to 40% of patients with COPD have high levels of anxiety and depression. Our study finds that as little as 2 h of CBT administered in a group setting is able to reduce these anxious and depressive symptoms.

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Reminiscence and its relationship to attachment and personality in geropsychiatric patients.

The relationships between reminiscence functions and attachment styles; reminiscence and personality factors; and attachment and personality were examined in forty patients attending a geropsychiatric outpatient clinic. They were administered the Reminiscence Functions Scale, NEO-FFI, and the Relationship Questionnaire. Compared with insecurely attached older patients, securely attached older patients score higher on the teach/inform reminiscence function. Consistent with prior research, relationships were found between the extraversion personality factor and conversation reminiscence; and between the openness personality factor and both identity and problem-solving reminiscence functions.

Adaptation, Psychological↗

Informed consent and neuroanatomic correlates of intentionality and voluntariness among psychiatric patients.

The authors examine the less-studied components of patients' autonomous decision making, or decisional autonomy, in the light of current research in psychiatry and neuropsychology and developments in the construct of informed consent. The three components of decisional autonomy-understanding, intentionality, and noncontrol or voluntariness-are related to clinical constructs in psychiatry and neuropsychology, in particular to executive control functions. The authors review studies that examine deficits in prefrontal cerebral function in schizophrenia, depression, and some anxiety disorders that are related to intentionality and voluntariness. Assessment of decisional autonomy should encompass evaluation of impaired intentionality and voluntariness, not simply impaired understanding. The main response to finding such impairments should be to provide treatment to ameliorate them. New strategies for psychiatric care should be developed to address the clinical challenges of an increasingly complex view of decisional autonomy.

Anxiety Disorders↗

Clinical and ethical implications of impaired executive control functions for patient autonomy.

The authors identify the clinical and ethical implications of impaired executive control functions for patient autonomy. Executive control functions are processes that orchestrate relatively simple ideas, movements, or actions into complex goal-directed behavior, and impairments in these functions are becoming more common as the population ages. The authors examine difficulties that individuals with impaired executive control functions may have in making treatment decisions and describe a practical, ethically justified framework for making treatment decisions for patients with impairments in these functions. Three components of autonomy are identified-intentionality, understanding, and voluntariness. Intentionality and voluntariness are especially affected by impaired executive control functions. Impairments of these aspects of autonomy may often be overlooked when only traditional mental status examinations are employed, with adverse consequences for the health of patients wrongly thought to possess intact ability to make and carry out plans of care. Two case vignettes illustrate the complexities faced by clinicians intervening with patients who have deficits in decision-making capacity caused by impaired executive control functions.

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Guardianship applications for elderly patients: why do they fail?

Variables associated with successful completion of guardianship applications for elderly patients were identified. Thirteen patients for whom applications were approved were compared with 26 whose applications did not reach the court. Patients for whom the process was successful scored significantly higher on the anergia-depression subscale of the Brief Psychiatric Rating Scale and had significantly more medical conditions in the past year. A survey of next of kin revealed that the process had a much better chance of success when the unit social worker made the guardianship recommendation and when family members were given more information about the taxing and time-consuming process of obtaining guardianship.

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Cross-cultural differences in demented geropsychiatric inpatients with behavioral disturbances.

OBJECTIVE: Cross-cultural differences in treatment and diagnosis exist in several psychiatric disorders. This study examines phenomenological and treatment differences between Caucasian and African-American patients presenting to a geropsychiatric unit for treatment of behavioral disturbances associated with dementia. METHODS: One hundred and forty-one Caucasian patients were compared to 56 African-American patients consecutively admitted to a VA geropsychiatric inpatient unit. At admission, differences in behavior disturbances between the two groups were examined using the Mini-Mental State Examination (MMSE), Cohen-Mansfield Agitation Inventory (CMAI), Hamilton Rating Scale for Depression (HAM-D), Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale for Schizophrenia (PANSS). Differences in treatment were assessed by comparing medication types and doses between the two groups. RESULTS AND CONCLUSION: Results showed that Caucasian and African-American patients with dementia and behavioral disturbances presented and responded similarly to like treatment on an inpatient geropsychiatric unit. The similarity between the two groups may be explained by the multi-ethnic make-up of the interdisciplinary treatment team and by the use of standardized scales to measure symptomatology and response.

Black or African American↗

A multidisciplinary ethics teaching conference on a geropsychiatric service.

This article describes an ethics case conference on a multidisciplinary geropsychiatric service, and its unique clinical, training, and research benefits. We describe the structure of the conference, the major topics addressed, the perceived advantages, and the research implications. We conclude that the care of older patients, the education of students and trainees interested in aging issues, and cutting-edge geriatric research are all advanced by such a conference.

Bioethics↗

Rehospitalization of older psychiatric inpatients: an investigation of predictors.

The purpose of this study was to identify a combination of variables that could predict rehospitalization among a sample of 150 geropsychiatric inpatients. Logistic regression analyses testing a modified model identified risk factors for geropsychiatric rehospitalization and correctly classified approximately 80% of inpatients who were rehospitalized for subsequent treatment. Patients' psychiatric diagnosis (mood or schizophrenic disorder), poor general psychiatric functioning, depressive and agitated behavior at discharge, little or no supervision in living arrangements following discharge, limited social support, change in the social support system preceding hospitalization, and maladaptive family functioning could significantly predict geropsychiatric rehospitalization. The strongest independent predictor was maladaptive family functioning.

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The efficacy and tolerability of divalproex sodium in elderly demented patients with behavioral disturbances.

Behavioral disturbances are commonly encountered in elderly demented patients. The records of all patients admitted to a geropsychiatric inpatient unit within a 2-year period who had a primary diagnosis of dementia and an accompanying behavioral disturbance treated with divalproex sodium were reviewed. Of the 13 patients identified, all tolerated divalproex sodium without significant side-effects. General psychiatric symptoms, overall agitation, physical aggression and non-aggressive physical agitation decreased significantly, but verbal agitation did not. Divalproex sodium is well tolerated and may be effective in ameliorating certain behavioral disturbances in elderly demented patients with agitation.

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The contribution of cognitive impairment, medical burden, and psychopathology to the functional status of geriatric psychiatric inpatients.

In order to define the contributions of cognitive impairment, medical burden, and psychopathology to the functional status of geriatric psychiatric patients, a forward-looking, retrospective study of 106 consecutive admissions to a geriatric psychiatric unit at the Houston Veterans Affairs Medical Center Hospital was done. It was found that psychopathology and cognitive status, but not medical burden, contributed to the variance in functional status of geriatric psychiatric inpatients for both admission scores and for changes in scores during hospitalization. Improvements in cognitive state and psychopathology were associated with improvements in functional status during hospitalization.

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Standards for psychological services in long-term care facilities.

Psychologists in Long-Term Care (PLTC), a national network established in 1983, has developed, with input from colleagues and consumers, standards for psychological practice in long-term care facilities. These standards address provider characteristics, methods of referral, assessment practices, treatment, and ethical issues. This article describes the document's development and offers suggestions for its use.

Geriatric Assessment↗

Cognitive decline in patients on an acute geropsychiatric unit.

The authors compared patients in a geropsychiatric unit who showed marked cognitive decline during hospitalization with those who did not. Patients who declined in cognitive function were older, were more likely to have a diagnosis of dementia, and were more anergic on admission. These patients were also discharged to more restrictive living environments. The subgroup of demented patients who declined in cognitive function were also older and improved less on anxiety and depression.

Age Factors↗

The relationship between patient, informant, social worker, and consensus diagnoses of personality disorder in elderly depressed inpatients.

Two psychiatrists simultaneously administered the Personality Assessment Form (PAF) to 20 depressed geropsychiatric inpatients and to 20 of their relatives (informants). A social worker also completed PAF ratings, and a consensus conference independently assigned an Axis II diagnosis. For patient interviews, categorical and dimensional interrater reliability indices for cluster and total personality disorders (PDs) were generally marginal. For informant interviews, categorical interrater reliability indices for cluster and total PDs were also marginal, but dimensional reliability was high. Consistent with previous research, agreement between categorical scores yielded by the four assessment methods was poor, but agreement between dimensional scores was generally better. It appears that patients, family members, and staff maintain different perspectives on patients' personality that, if overlapping, may provide useful diagnostic data.

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Depression in male geropsychiatric inpatients with and without dementia: a naturalistic study.

The authors compared the presentation and course of major depression in male geriatric inpatients with and without a diagnosis of dementia. Of 326 consecutive admissions to an inpatient geropsychiatry unit, 22 (7%) had a diagnosis of major depression without dementia, 35 (11%) had major depression with dementia. Both groups presented with similar types and severity of depressive symptoms, which improved substantially with treatment in both groups, as measured by Hamilton Depression Rating Scale scores. In addition, agitation, psychiatric, and side-effects symptoms decreased significantly in both groups. Our naturalistic results suggest the clinical value of intensive treatment of depressive symptoms in elderly demented patients, whether or not they meet the criteria for major depressive episode.

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