In the Clinic. Dementia.

This issue provides a clinical overview of dementia, focusing on prevention, diagnosis, treatment, practice improvement, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers.

Evaluating the clinical impact of involuntary admission to a specialized dual diagnosis ward.

Background: We aimed to identify characteristics and outcomes of involuntary and voluntary admissions of dual-diagnosis patients in a single, large mental health center in Israel.

Methods: Using a retrospective chart review methodology, 24 patient records were reviewed spanning a period of five years; clinical and demographic variables of voluntary and involuntary admissions were compared.

Results: No significant differences were found in sociodemographic characteristics, admission diagnosis and length of hospitalization between the two types of admission.

The role of environmental influences on schizophrenia admissions in Israel.

Objective: The role of environmental factors in hospitalization of patients with schizophrenia is incompletely understood. This study attempts to relate the pattern of hospital admissions to environmental variables such as season and to social factors such as nationally celebrated holidays.

Methods: Charts of all adults (n = 4,331) with a discharge diagnosis of schizophrenia admitted to the Abarbanel Mental Health Centre (Bat Yam, Israel) between 1 January 2001 and 31 December 2005 were reviewed.

Estimating severity of illness and disability in Frontotemporal Dementia: Preliminary analysis of the Dementia Disability Rating (DDR).

Background: Current measures of severity and disability do not stage or track the progression of disability in frontotemporal dementia (FTD) well. We investigated the reliability of the newly developed Dementia Disability Rating (DDR) in the measurement and staging of illness severity in FTD and dementia of the Alzheimer type (DAT).

Material/ Methods: We studied 48 consecutive patients of the Johns Hopkins FTD and Young-Onset Dementias Clinic, with diagnoses of DAT, FTD, vascular dementia and "other" cognitive disorder (CDNOS).

Quality of life in nursing home residents with advanced dementia.

Objectives: To examine quality of life (QOL) in nursing home (NH) residents with advanced dementia and identify correlates of QOL near the end of life.

Design: Cross-sectional data derived from NH records, interviews with residents' surrogate decision-makers, QOL ratings by NH caregivers, and assessment of residents' cognitive function.

Setting: Three NHs in Maryland.

Depression in frontotemporal dementia.

Objective: The authors describe mood abnormalities seen in a case series of patients with frontotemporal dementia (FTD).

Method: Authors provide a structured review of outpatient and inpatient charts of FTD patients.

Results: Three distinct depressive syndromes were identified: The first corresponds to DSM-IV major depression.

Surrogate decision makers' understanding of dementia patients' prior wishes for end-of-life care.

Objective: This study examines how surrogate decision makers for dementia patients developed an understanding of patient preferences about end-of-life (EOL) care and patient wishes.

Methods: Semistructured interviews were conducted with 34 surrogate decision makers for hospice-eligible nursing home patients with dementia. The data were content analyzed.

Prevalence and treatment of neuropsychiatric symptoms in advanced dementia.

Neuropsychiatric symptoms (NPS) are common in dementia, although little is known about their prevalence and treatment near the end of life. This study used a retrospective review of the medical records of 123 hospice-eligible nursing home residents with advanced dementia to investigate the prevalence of NPS and NPS-targeted pharmacological and non-pharmacological treatments. The most prevalent NPS were agitation or aggression (50.

Neuropsychiatric symptom patterns in hospice-eligible nursing home residents with advanced dementia.

Objective: The purpose of this study was to determine whether specific neuropsychiatric symptom patterns could be identified in a cohort of hospice-eligible nursing home residents with advanced dementia.

Methods: Surrogate decision makers gave informed consent to enroll 123 residents from 3 nursing homes. All participating residents met criteria for hospice eligibility and were determined by direct examination at the time of study enrollment to have advanced dementia.

The role of animal models in evaluating reasonable safety and efficacy for human trials of cell-based interventions for neurologic conditions.

Progress in regenerative medicine seems likely to produce new treatments for neurologic conditions that use human cells as therapeutic agents; at least one trial for such an intervention is already under way. The development of cell-based interventions for neurologic conditions (CBI-NCs) will likely include preclinical studies using animals as models for humans with conditions of interest. This paper explores predictive validity challenges and the proper role for animal models in developing CBI-NCs.

Medication use in nursing home residents with advanced dementia.

Objective: To describe medication usage in nursing home residents with advanced dementia, to identify how this usage changed as patients advanced towards death, and to identify correlates of increased medication usage.

Methods: Prospective cohort study (CareAD) during which data on medication prescription were extracted from medical records at regular intervals using standardized extraction procedures.

Results: Patients (n=125) were prescribed a mean of 14.

Treatment decisions regarding hospitalization and surgery for nursing home residents with advanced dementia: the CareAD Study.

Background: Dementia differs from other terminal illnesses both in its slow progression and the fact that patients and family members often do not perceive it as a cause of death. Furthermore, because decisional incapacity is almost universal in patients with advanced dementia, decisions must be made by surrogates. However, little is known about the factors that influence how surrogates make decisions for persons with late-stage dementia.

The physician-patient relationship in dementia care.

Medical care of patients with dementia often occurs within a physician-patient relationship whose features differ from relationships with patients without dementia. Many basic assumptions of the physician-patient relationship may not completely hold true, and certain aspects of the patient role may be shared by others besides the patient. For example, the entire premise of consent to the patient role may be inapplicable to patients who lack insight into their illness.

A pragmatic approach to teaching psychiatry residents the assessment and treatment of religious patients.

Objective: The authors describe a pragmatic and atheoretical frameword for teaching psychiatry residents how to assess and treat religious patients.

Results: The psychiatrist's goals in assessing the religious history are clarified. These goals differ between the assessment and treatment phases.

Ethical issues in mobile psychiatric treatment with homebound elderly patients: the Psychogeriatric Assessment and Treatment in City Housing experience.

Unique and challenging ethical difficulties arise during mobile psychiatric treatment of elderly patients. This article outlines and analyzes five of these challenges that have been encountered during nearly 20 years of experience with the Psychogeriatric Assessment and Treatment in City Housing Program in Baltimore, Maryland. The ethical challenges reviewed are: establishing the treatment contract versus the right to refuse treatment, protecting confidentiality versus patient protection, protecting autonomy versus asserting beneficence, treatment termination versus open-ended treatment, and cost versus benefit of care.