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Geriatric care managers: a collaborative resource to the physician practice.

Strongly independent and/or socially isolated elders with multiple health problems are often a physician's most challenging patient. These patients typically require intensive follow-up including phone calls from concerned long distance relatives, frequent and urgent same day physician visits and recurrent hospitalizations. This article will describe the role of a professional geriatric care manager (GCM). This article will discuss how a GCM can greatly assist both frail elders and physicians through comprehensive and ongoing assessment of an elder's needs, implementation of an optimal plan of care and close monitoring and management of information and supportive services.

Aged↗
PubMed2004

Case-finding for depressive and exhausted mood in the general population: reliability and validity of a symptom-driven diagnostic scale. Results from the prospective MONICA/KORA Augsburg Study.

PURPOSE: Depressed and exhausted mood warrants epidemiological scrutiny as a cardiovascular risk factor. We evaluated the reliability and validity of a symptom-driven diagnostic scale. METHODS: To assess a depressed mood, items were derived from an extended battery of psychosocial questionnaires in a population-based study including 11,949 subjects aged 25 to 74 years. RESULTS: Eight items from the 24-item von Zerssen checklist were extracted by factor analysis resulting in an approximately normally distributed scale (range 0-24; mean=8.23, SD 4.76). Median for men was 8.00 and 10.00 for women. Its internal consistency was high (Cronbach's alpha 0.88). Test-retest reliability of a sub-sample was 0.83. Determining concurrent validity, correlation coefficients against a single depression questionnaire in 8237 subjects (p < 0.001) and SF-36 subscales (vitality and mental health) (both p < 0.0001) in 4226 subjects proved to be significant. Construct validity was confirmed by significant associations (all p < 0.001) with sleeping complaints, social isolation, and unhappiness. Test values for men above the 80th percentile exhibited significant hazard ratios for subsequent total mortality (80th percentile: HR 2.17, 95% CI: 1.31-13.55). CONCLUSION: The scale comprises eight items describing motivational depletion, decreased vitality, irritability, and an anxious mood with sufficient internal and external reliability, concurrent and construct validity. Its normal distribution allows a graduated analysis of different thresholds. The instrument may be particularly useful to identify exhausted and depressed mood of otherwise apparently healthy subjects in the general population.

Adult↗
PubMed2006

Supportive care needs of people with brain tumours and their carers.

GOALS OF WORK: The diagnosis and treatment of a brain tumour may result in long-term changes in a patient's functional and social abilities and/or in a greatly reduced life span. A qualitative investigation was conducted to examine the supportive care needs of patients with brain tumour and their carers. MATERIALS AND METHODS: Overall, 18 patients and 18 carers participated in focus groups or telephone interviews, following a structured interview guide to elicit supportive care services of importance to these patients and carers. MAIN RESULTS: Six major themes were identified using the framework analysis method, including needs for information and coping with uncertainty, practical support, support to return to pretreatment responsibilities or prepare for long-term care, support to deal with social isolation and organize respite care, support to overcome stigma/discrimination and support to discuss potentially reduced life expectancy. CONCLUSIONS: Five recommendations to improve service delivery include: assignment of a dedicated member of the care team or case manager; proactive dissemination of information, education and psychosocial support; access to objective assessment of neuropsychological functioning; facilitating easier access to welfare payments; and services facilitating communication about difficult illness-related topics. Provision of services along these recommendations could improve supportive care of brain tumour patients and their carers.

Adaptation, Psychological↗
PubMed2001

Chronicity reconsidered: improving person-environment fit through a consumer-run service.

In the past, the term "chronic" referred to people who had serious mental illness and who typically received long-term care in a state mental hospital. Although this term recently has fallen out of favor, we resurrect the term here, not to revive a demeaning euphemism, but rather to redefine it as the result of a poor person-environment fit between the complex and challenging needs of those with serious psychiatric disorders and a community-based service system that often is ill-equipped to treat them. Previous research indicates that recurrent acute hospitalizations and an inability to establish or maintain tenure in the community may be due to a disconnection from community-based services and supports, social isolation, and demoralization. One promising approach to addressing these issues is that of peer support. To illustrate the potential utility of peer support in improving person-environment fit and decreasing the chronicity of the subsample of people who continue to have difficulty in establishing viable footholds in the community, we describe a peer support-based program, the Welcome Basket, developed, staffed, and managed entirely by mental health consumers. Preliminary analyses that evaluate Welcome Basket's effectiveness are included, and we discuss the implications of these data for future research and program development in this area.

Adult↗
PubMed2006

Impact of eating disorders on family life: individual parents' stories.

AIMS AND OBJECTIVES: The aim of this study was to consider the impact that an eating disorder had on the family, particularly the parents. The objective was to give a voice to parents in order to develop new understandings of their experience leading to more appropriate clinical decision-making. BACKGROUND: The impact of an eating disorder on family life has not been well-documented in the published literature. There are numerous articles from the sufferer's perspective and treatment modalities. The following paper describes a component of a larger study that explored the parent's perspective of having a child with an eating disorder. DESIGN: Nineteen mothers and three fathers from Sydney, Australia, volunteered to be interviewed as the result of advertisements placed in parent support organization newsletters and by using the snowballing technique. METHODS: A qualitative approach using semi-structured interviews was used to explore parents' experiences of having a child/adult child with an eating disorder. Themes were identified through in depth analysis. RESULTS: Themes that were extrapolated from this research included, family unification or disintegration, parent's inability to cope, inconsiderate comments from significant others, social isolation and financial impacts. CONCLUSIONS: This study reports five overarching effects on family life. The authors conclude that one way in which the life of parents and families could be improved would be increased involvement and integration into the treatment process. For this to happen, health professionals would need to acknowledge the family as a resource. RELEVANCE TO CLINICAL PRACTICE: This research documents the family struggle and highlights the current omissions concerning the family's role. The need for changes to clinical practice is substantiated. It requires health professionals to scrutinize their own clinical practice and consider modification of the treatment process.

Adaptation, Psychological↗
PubMed2002

Psychosocial factors and their association with clinical outcomes in patients with heart failure: why clinicians do not seem to care.

Poor quality of life, social isolation, depression and anxiety all have been linked to increased risk of rehospitalization and mortality in patients with heart failure. Yet, despite evidence of their importance to outcomes in heart failure patients, psychosocial factors are assessed and treated infrequently in clinical practice. Potential reasons for this include: (1) inadequate dissemination of research about the link between psychosocial factors and outcomes; (2) insufficient training in heart-mind interactions that precludes clinicians from taking advantage of what is known; (3) perceived problems with interventions or with the science of heart-mind interactions that interfere with acceptance of what is known; (4) concerns about how to measure psychosocial factors in clinical practice; and (5) lack of curiosity from clinicians about the role of psychosocial factors in their patients. In this article, each of these possible explanations is explored and recommendations suggested.

Anxiety↗
PubMed1989

Deprived somatosensory-motor experience in stumptailed monkey neocortex: dendritic spine density and dendritic branching of layer IIIB pyramidal cells.

Infant macaque monkeys (Macaca arctoides) were individually raised to age 6 months in large clear cubes built into one wall of a control colony that allowed them visual access to it but not tactile contact. The two deprivation conditions (Cond 2 and Cond 3) were equal both in physical size and with respect to partial social isolation. They differed in the degree of somatosensory-motor opportunity available during development in that the Cond 2 chamber was empty, whereas Cond 3 contained ladders, a trapeze, and play objects. Four monkeys from each of these conditions were compared with four colony-reared (Cond CR) monkeys. Neuroanatomical changes were evaluated by using light microscopy in Golgi-Cox-stained neocortex. Dendritic spines on the apical shafts of layer IIIB pyramidal cells were counted in primary motor (MI), somatosensory (SI), and visual (area 17, V1) cortical regions. Layer IIIB pyramidal neurons with somas of medium size were selected from each cortical region and the density of apical dendritic spines determined. The basilar dendritic branches of these same neurons were traced, and the dendritic branching complexity was assessed in order to compare the sensitivity of the dendritic spine and branching measures consequent to deprived rearing. The number of apical dendritic spines was significantly reduced in Cond 2 when compared with either Cond 3 or Cond CR (which did not differ from each other). This occurred in both MI and SI cortex, but not in the visual cortex, the region used as a control for a global brain effect. Branching complexity measured on the same pyramidal neurons was reduced only in MI cortex of Cond 2. These results show spine density, a more direct measure of neuronal connectivity, to be the more sensitive measure of early environmental deprivation. Also, the enriched environment provided by Cond 3 relative to Cond 2 offset the effect of partial social isolation such that both morphometric measures had values comparable to Cond CR monkeys.

Animals↗
PubMed2002

Comorbidity of late life depression: an opportunity for research on mechanisms and treatment.

Late life depression principally affects individuals with other medical and psychosocial problems, including cognitive dysfunction, disability, medical illnesses, and social isolation. The clinical associations of late life depression have guided the development of hypotheses on mechanisms predisposing, initiating, and perpetuating specific mood syndromes. Comorbidity studies have demonstrated a relationship between frontostriatal impairment and late life depression. Further research has the potential to identify dysfunctions of specific frontostriatal systems critical for antidepressant response and to lead to novel pharmacological treatments and targeted psychosocial interventions. The reciprocal interactions of depression with disability, medical illnesses, treatment adherence, and other psychosocial factors complicate the care of depressed older adults. Growing knowledge of the clinical complexity introduced by the comorbidity of late life depression can guide the development of comprehensive treatment models. Targeting the interacting clinical characteristics associated with poor outcomes has the potential to interrupt the spiral of deterioration of depressed elderly patients. Treatment models can be most effective if they focus on amelioration of depressive symptoms, but also on treatment adherence, prevention of relapse and recurrence, reduction of medical burden and disability, and improvement of the quality of life of patients and their families.

Aged↗
PubMed2002

The effects of isolation rearing on glutamate receptor NMDAR1A mRNA expression determined by in situ hybridization in Fawn hooded and Wistar rats.

Rats reared in social isolation exhibit a syndrome of behavioral and biochemical effects indicative of enhanced mesolimbic dopamine (DA) function. The precise nature of the neurodevelopmental changes that produce this state are unknown but result in enhanced DA neurotransmission in the nucleus accumbens (NAC). It was hypothesized that this may be the indirect result of chronic changes in glutamate NMDA receptor function. The same prediction has been made for Fawn hooded (FH) rats that exhibit some of the characteristic effects of isolation-reared rats when compared to Wistar rats. Therefore, mRNA levels of the NMDAR1A receptor subunit were determined by in situ hybridization and were quantified in the striatum, hippocampus and prefrontal cortex of FH and Wistar rats. Isolation rearing alone was not found to have an effect on the expression of NMDAR1A, while FH rats had reduced levels across most brain regions examined. In some areas of the striatum and prefrontal cortex, this effect was greater in FH isolates than in FH socials, while in the hippocampus, the opposite was observed.

Animals↗
PubMed1999

Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy.

Recent studies provide clear and convincing evidence that psychosocial factors contribute significantly to the pathogenesis and expression of coronary artery disease (CAD). This evidence is composed largely of data relating CAD risk to 5 specific psychosocial domains: (1) depression, (2) anxiety, (3) personality factors and character traits, (4) social isolation, and (5) chronic life stress. Pathophysiological mechanisms underlying the relationship between these entities and CAD can be divided into behavioral mechanisms, whereby psychosocial conditions contribute to a higher frequency of adverse health behaviors, such as poor diet and smoking, and direct pathophysiological mechanisms, such as neuroendocrine and platelet activation. An extensive body of evidence from animal models (especially the cynomolgus monkey, Macaca fascicularis) reveals that chronic psychosocial stress can lead, probably via a mechanism involving excessive sympathetic nervous system activation, to exacerbation of coronary artery atherosclerosis as well as to transient endothelial dysfunction and even necrosis. Evidence from monkeys also indicates that psychosocial stress reliably induces ovarian dysfunction, hypercortisolemia, and excessive adrenergic activation in premenopausal females, leading to accelerated atherosclerosis. Also reviewed are data relating CAD to acute stress and individual differences in sympathetic nervous system responsivity. New technologies and research from animal models demonstrate that acute stress triggers myocardial ischemia, promotes arrhythmogenesis, stimulates platelet function, and increases blood viscosity through hemoconcentration. In the presence of underlying atherosclerosis (eg, in CAD patients), acute stress also causes coronary vasoconstriction. Recent data indicate that the foregoing effects result, at least in part, from the endothelial dysfunction and injury induced by acute stress. Hyperresponsivity of the sympathetic nervous system, manifested by exaggerated heart rate and blood pressure responses to psychological stimuli, is an intrinsic characteristic among some individuals. Current data link sympathetic nervous system hyperresponsivity to accelerated development of carotid atherosclerosis in human subjects and to exacerbated coronary and carotid atherosclerosis in monkeys. Thus far, intervention trials designed to reduce psychosocial stress have been limited in size and number. Specific suggestions to improve the assessment of behavioral interventions include more complete delineation of the physiological mechanisms by which such interventions might work; increased use of new, more convenient "alternative" end points for behavioral intervention trials; development of specifically targeted behavioral interventions (based on profiling of patient factors); and evaluation of previously developed models of predicting behavioral change. The importance of maximizing the efficacy of behavioral interventions is underscored by the recognition that psychosocial stresses tend to cluster together. When they do so, the resultant risk for cardiac events is often substantially elevated, equaling that associated with previously established risk factors for CAD, such as hypertension and hypercholesterolemia.

Animals↗
PubMed1987

Social support and child maltreatment: a review of the evidence.

Parents who maltreat their children have long been thought to lack support from informal and social networks. Recent writers have taken the position that this relationship is a proven, causal one, with social isolation seen as a necessary antecedent condition for the occurrence of child abuse. Concurrently, initial enthusiasm for social support as a powerful explanatory variable in other areas of psychological and health research is giving way to cautious reevaluation of the evidence. The present review was undertaken to bring into sharper focus what is now known regarding the relationship between child maltreatment and parental isolation from informal helping networks. Existing research is fraught with both conceptual and methodological problems. There is, at present, little research evidence that lack of social support plays a significant role in the etiology of physical abuse. Stronger evidence exists that neglectful parents are socially isolated, but the data are consistent with the hypothesis that this is one manifestation of the character problems of these parents. Future research must give closer attention to clearly defining social support and using reliable and valid instruments to measure it, while exploring multivariate models of child maltreatment.

Child↗
PubMed2002

Merging pathways: music therapy in neurosurgical rehabilitation.

Relatively few departments of Music Therapy are found within neurosurgical rehabilitation clinics. In institutions where these departments exist, music therapy has become an integral part of multi-professional treatment and research activities (Gilbertson 1999). The diverse intervention strategies in Music Therapy focus upon auditory, motor, visual, cognitive and affective processing which are all involved in receptive and expressive musical behaviour and which affect related non-musical behaviour. A clear differentiation is made between primary and adjunct therapy roles. The related fields of neuromusicology, neuroanatomy, neuropsychology, music psychology and humanistic psychology are primary sources in the development of models of clinical application (Hodges 1996). Our main interests are focussed on the following issues and areas of clinical application: The initialisation of contact with patients in vegetative status Communicative interaction with patients who can not (initially) use verbal communication (aphasic disorders) Temporal motor organisation with patients with sensomotor disorders Cognitive organisation and mnemonic framework with patients with neuropsychological functional disorders (concentration, memory, perception) Treatment of spatial perception disorders (neglect) Enhancing personal and social integration following individual isolation, social withdrawal. These topics will be discussed and highlighted with clinical examples.

Humans↗
PubMed2005

[Primary prevention-psychosocial aspects].

Psychosocial risk factors like low socio-economic status, social isolation and lack of social support, chronic work or family stress, depression, and hostility contribute significantly to the development and adverse outcome of coronary heart disease (CHD). The prevention of CHD should therefore include screening for psychosocial risk factors and adequate interventions. Methods to assess psychosocial risk factors are single item questions to be included in the cardiologist clinical interview and/or standardized questionnaires. Recommended interventions include an appropriate physician-patient interaction, multimodal, behavioral interventions with face to face or group counselling, and, in case of clinically significant depression, psychotherapy and medication.

Comorbidity↗
PubMed2005

Defining subjects at risk for psychosis: a comparison of two approaches.

The ability to detect individuals at high risk for developing schizophrenia before they express the disease will lead to targeted early intervention. It has been proposed that subjects at risk share a core deficit with people who already have schizophrenia. This includes cognitive impairment, affective symptoms, social isolation and decline in social functioning. In a sample of 104 help-seeking patients from a specialised outpatient clinic we investigated how well two different sets of criteria define the at-risk group and capture this core deficit. One set of criteria is the well-established ultra high-risk model of McGlashan et al. [McGlashan 2001 (SIPS) McGlashan, T. H., Miller, T. J., Woods, S. W., et al. (2001) Structured Interview for Prodromal Syndromes (Version 3.0, unpublished manuscript). New Haven, Connecticut: PRIME Research Clinic, Yale School of Medicine.]; the other criteria were those defined by Cornblatt et al. [Cornblatt, B., Lencz, T., Smith, C.W., Correll, C.U., Auther, A., Nakayama, E., 2003. The schizophrenia prodrome revisited: a neurodevelopmental perspective. Schizophr. Bull. 29, 633-651.]. There was considerable overlap in the two sets of criteria. However, when the basic symptoms of Klosterkötter [Klosterkötter, J., Hellmich, M., Steinmeyer, E.M., Schultze-Lutter, F., 2001a. Diagnosing schizophrenia in the initial prodromal phase. Arch. Gen. Psychiatry, 58, 158-164.] were included in the McGlashan et al. model, a more narrow and homogeneous group was defined.

Adolescent↗
PubMed2003

Eating habits and appetite control in the elderly: the anorexia of aging.

Although a high prevalence of overweight is present in elderly people, the main concern in the elderly is the reported decline in food intake and the loss of the motivation to eat. This suggests the presence of problems associated with the regulation of energy balance and the control of food intake. A reduced energy intake causing body weight loss may be caused by social or physiological factors, or a combination of both. Poverty, loneliness, and social isolation are the predominant social factors that contribute to decreased food intake in the elderly. Depression, often associated with loss or deterioration of social networks, is a common psychological problem in the elderly and a significant cause of loss of appetite. The reduction in food intake may be due to the reduced drive to eat (hunger) resulting from a lower need state, or it arises because of more rapidly acting or more potent inhibitory (satiety) signals. The early satiation appears to be predominantly due to a decrease in adaptive relaxation of the stomach fundus resulting in early antral filling, while increased levels and effectiveness of cholecystokinin play a role in the anorexia of aging. The central feeding drive (both the opioid and the neuropeptide Y effects) appears to decline with age. Physical factors such as poor dentition and ill-fitting dentures or age-associated changes in taste and smell may influence food choice and limit the type and quantity of food eaten in older people. Common medical conditions in the elderly such as gastrointestinal disease, malabsorption syndromes, acute and chronic infections, and hypermetabolism often cause anorexia, micronutrient deficiencies, and increased energy and protein requirements. Furthermore, the elderly are major users of prescription medications, a number of which can cause malabsorption of nutrients, gastrointestinal symptoms, and loss of appetite. There is now good evidence that, although age-related reduction in energy intake is largely a physiologic effect of healthy aging, it may predispose to the harmful anorectic effects of psychological, social, and physical problems that become increasingly frequent with aging. Poor nutritional status has been implicated in the development and progression of chronic diseases commonly affecting the elderly. Protein-energy malnutrition is associated with impaired muscle function, decreased bone mass, immune dysfunction, anemia, reduced cognitive function, poor wound healing, delayed recovery from surgery, and ultimately increased morbidity and mortality. An increasing understanding of the factors that contribute to poor nutrition in the elderly should enable the development of appropriate preventive and treatment strategies and improve the health of older people.

Aged↗
PubMed2004

Social group work: building a professional collective of hospital social workers.

Deconstruction of traditional social work departments can isolate social workers from their primary source of professional affiliation, leaving them without the support to take stands on controversial patient care issues. This paper describes an alternative: the building of a powerful social work collective based on social group work theory that potentiates professional practice while transcending management forms. The model includes group supervision, but moves beyond it to utilize the social work group as a central organizing principle. At the heart of the collective are the elements of professional accountability, support, autonomy, and collaborative decision- making within democratic peer group structures. The authors highlight current management theory, distinctions that create an authentic social work value-based practice, and outcomes for social workers, their clients, and colleagues.

Conflict, Psychological↗
PubMed2006

Risk factors for coronary heart disease in patients with schizophrenia.

Cardiovascular disease is the leading cause of death worldwide. As many as half of these death may be attributed to the unhealthy cholesterol and lipid levels. Elevated cholesterol levels could contribute to the increase in cardiovascular morbidity and mortality. Association between the coronary artery disease and mental disorder is less studied and documented, but several studies have demonstrated, that mental disorders increases the risk of developing cardiac disease, in particular coronary artery disease. Cholesterol and other lipids level were measured in 40 patients (n=40). Cholesterol and LDL levels in patients with schizophrenia were significantly higher and HDL was significantly decreased. Cholesterol level 180-200 mg/dl were determined in 35%, 200-235 mg/dl in 17,5%, >235 mg/dl 12,5%. HDL->35 mg/dl revealed in 37,5%. LDL 130-159 mg/dl were determined in 10%, >160 mg/dl - 20%. Triglycerides (Tg) from 150 mg/dl to 199 mg/dl were determined in 25%, from 200 mg/dl to 499 mg/dl in 12,5%. According to our study, patients with schizophrenia has some risk factors for cardiovascular heart disease such as, elevated levels of Tg and LDL-c, smoking, lack of exercise, psychosocial factors (depression, social isolation and lack of social support, low socioeconomic status) and so on. We can conclude that all these patients with schizophrenia may belong to the risk group of cardiovascular disease.

Adult↗