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Some observers have proposed that physicians may die differently compared with the average patient. Semi-structured interviews with family members of physicians who died offer an opportunity to better understand how patient preferences and wishes are perceived and acted on by family members at the end of life. The decision-making experiences of these family members for a loved one who was a physician may have implications for the lay person at end of life.
The Johns Hopkins Precursors Study includes individuals who matriculated into the graduating classes of 1948 to 1964 of the Johns Hopkins University School of Medicine. From this cohort, we interviewed 26 family members of physicians who died. Interviews were coded and analyzed using a comparative, iterative process.
We found that family members of physicians who died described the uncertainty at end of life. This overarching theme was organized into the following: (a) the certainty of uncertainty; (b) the preparation for uncertainty; and (c) brokering of decisions in the face of uncertainty. Despite careful end-of-life preparation by well-informed physicians, family members were still left to broker decisions as they navigated the wishes of the physician and what the family and medical care team believed to be in the best interest of the physician.
Significance of results
Our findings suggest that our family members were not immune to uncertainty. The clinical momentum at the end of life may contribute to challenges faced by patients and family members when brokering decisions. Normalizing uncertainty in medical training and for families may aid in addressing the stress of uncertainty at end of life.
Background: The Mini-mental State Examination (MMSE) is the most widely used cognitive test, both in clinical settings and in epidemiological studies. However, correcting its score for education may create ceiling effects when used for poorly educated people and floor effects for those with higher education.
Methods: MMSE and a recent cognitive test, the seven minute screen (7MS), were serially administered to a community sample of Mexican elderly. 7MS test scores were equated to MMSE scores. MMSE-equated 7MS differences indicated ceiling or floor effects. An ordinal logistic regression model was fitted to identify predictors of such effects.
Results: Poorly educated persons were more prevalent on the side of MMSE ceiling effects. Concentration (serial-sevens), orientation and memory were the three MMSE subscales showing the strongest relationship to MMSE ceiling effects in the multivariate model.
Conclusion: Even when MMSE scores are corrected for educational level they still have ceiling and floor effects. These effects should be considered when interpreting data from longitudinal studies of cognitive decline. When an education-adjusted MMSE test is used to screen for cognitive impairment, additional testing may be required to rule out the possibility of mild cognitive impairment.
Education is correlated with cognitive status assessment. Concern for test bias has led to questions of equivalent construct validity across education groups. Following the work of previous researchers, we submitted Mini-Mental State Examination (MMSE) responses to external validation analyses. Subjects were older participants in the Epidemiologic Catchment Area study (age 50-98). Little evidence for test bias against those with low education was found. The correlation of MMSE scores and age was equivalent across high-and low-education groups (−.29 vs. −.27, p = .48), as was the correlation of MMSE scores and activities of daily living (ADL) functioning (−.23 vs. −.27, p = .42). The MMSE displayed significantly higher internal consistency reliability in the low-education group (.75 vs .72, p = .04). The MMSE did not predict functional decline over 1 year or mortality over 13 years differently by level of educational attainment. Evidence for sex bias was found. The MMSE was more highly correlated with age among women than among men (−.28 vs. −.21, p < .001). The MMSE was more highly correlated with ADL impairment among women than among men (−.30 vs. −.17, p = .01). The MMSE predicted mortality differently according to participant sex (p = 0.53). The lack of evidence for bias provides little support to proposals to adjust MMSE scores according to level of education.
Background. Little work has been published on the internal structure of the Mini-Mental State
Examination (MMSE), one of the most widely used instruments for grading cognitive status in
clinical settings and field research.
Methods. MMSE responses from a sample of older adults (50–98 years) in five US sites (N = 8556)
Results. A five-factor solution was found to be most appropriate. The first factor (concentration)
had large loadings with serial sevens and spell world backwards items. The second factor (language
and praxis) had large loadings with naming, follow command and praxis items. The third factor
(orientation) had loadings with orientation to time and place items. The fourth factor (memory) had
large loadings with delayed recall items and the fifth (attention) had large loadings with immediate
Conclusions. We found that the MMSE is essentially unidimensional; nevertheless, evidence was
revealed suggesting that the MMSE is a multidimensional assessment instrument. Dimensions
revealed in this sample correspond directly to MMSE sections articulated by the developers of the
instrument. These findings have not been reported in previous factor analyses of the MMSE. The
findings support the construct validity of the MMSE as a measure of cognitive mental state among
community dwelling older adults.
The objective is to estimate parameters of the natural history of panic disorder, including its prodrome, incidence, recovery and recurrence.
In 1981 the Baltimore Epidemiologic Catchment Area Study interviewed 3481 individuals probabilistically selected from the household population. During 1993–1996, 1920 of these individuals (73% of survivors) were interviewed again. Baseline and follow-up interviews included the National Institute of Mental Health Diagnostic Interview Schedule. During the follow-up, a subsample was assessed by psychiatrists using the World Health Organization Schedules for Clinical Assessment in Neuropsychiatry (SCAN).
There were 35 new cases of panic disorder in 24 475 person years of exposure, yielding an annual incidence of 1.43 per 1000 per year. Data from the SCAN assessments suggest the incidence estimate is conservative. Incidence is greater in females and declines with age. About one-third of the new cases arise without agoraphobia, but about half have anxiety of some sort present for many years prior to meeting criteria for diagnosis. People with agoraphobia have less intense onsets but slower recoveries than those without agoraphobia.
Panic is heterogeneous in its pattern of onset and recovery. Some of the heterogeneity is associated with the presence of other anxiety over a long period of the life.
Background. Since depressive disorders are now eminently
treatable and early detection and
treatment could bring substantial benefits, it is critical to address
alternative presentations of depression in the general medical setting.
Concern regarding under-diagnosis of depression in
general medical settings has given rise to the question of whether the
clinical disorder of
depression differs qualitatively or only quantitatively across care settings.
Methods. Symptom profiles of depression were compared across
sectors to investigate how
the presentation of depression among general medical service users might
from speciality mental health service users. Data on depression symptoms
within 6 months of interview gathered in three community surveys that were
part of the NIMH Epidemiologic Catchment Area Program were analysed using
methods developed to assess item bias. The subjects
were 4931 and 363 persons who reported a visit to the general medical sector
or to speciality
mental health respectively, within 6 months of interview.
Results. Compared with speciality mental health service users,
general medical service users were
less likely to present dysphoria (adjusted Odds Ratio, aOR=0·57;
CI=0·38–0·84) and feeling worthless, sinful, or guilty
(aOR=0·63; 95% CI=0·40–0·98), but
were more likely to present fatigue (aOR=1·71; 95%
CI=1·09–2·69), even after holding
constant other characteristics that might influence reporting of symptoms
as well as level of depression.
Conclusions. These results suggest that there are qualitative
differences in depression presenting
in general medical care compared with speciality mental health care and
call for a reconceptualization of depression in the general medical setting.
In the course of a large twin study of Alzheimer's disease we used a two-stage telephone screening procedure. The modified Telephone Interview for Cognitive Status (TICS-m) served as an initial screen for dementia in 12709 individuals. The telephone Dementia Questionnaire (DQ) was then asked of collateral informants for subjects with TICS-m scores below 28, as well as for samples of persons with higher TICS-m scores. Based upon DQ responses, individuals with cognitive impairment not attributable to focal causes underwent assessment for the clinical diagnosis of Alzheimer's disease (‘Alzheimer's dementia’), as did their twins. Well-defined Alzheimer's dementia was apparent in 39 subjects. Employing a cut-off of 27 or lower as indicative of cognitive impairment, the sensitivity of the TICS-m in the detection of Alzheimer's dementia was estimated at >99% and specificity at 86%. Inclusion of the DQ increased the specificity at the 27/28 cut-point to 99%. The TICS-m score was associated with an area under the receiver operating characteristic (ROC) curve of 0·88 (95% confidence interval 0·81 to 0·94). The maximum number of cases of Alzheimer's dementia remaining undetected in the sample was estimated to be 34.
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