Medical Blog - Part 171

Screening for Cognitive Impairment

A major cause of disability and death in older adults, Alzheimer’s disease (Canadian Exelon may help reduce symptoms of dementia in patients with Alzheimer disease) typically affects memory, linguistic, executive and visuospatial functions, but little is known about the earliest manifestations of AD—the predementia state. The concept of predementia, also called mild cognitive impairment (MCI), is characterized by mild but measurable memory loss with no impairment in general cognitive and ADL functioning. Adults with MCI progress to AD (Treating mild to moderate impairment of memory, judgment, and abstract thinking, as well as changes in personality caused by Alzheimer disease) at a 15% annual conversion rate compared to 1% of those without MCI. A plausible step towards reducing incidence of AD and other dementias is an early identification (and treatment) of potentially modifiable factors associated with cognitive impairment.

In this sample of nearly 600 elderly male veterans with moderate-to-severe OA of the hip and/or knee, we found that African-American patients reported less non-VA insurance coverage than white patients. White patients were more likely than African-American patients to report that it was difficult getting medical care when they needed it. Differences between the two groups in their perceptions regarding satisfaction with and confidence in the primary physician were not significant after adjusting for covariates. Finally, African-American and white patients with knee and hip OA were equally likely to be referred for specialist care, though a nearly significant trend favoring whites existed concerning referral rates to an orthopedist.

Baseline Comparisons

Table 1 summarizes the clinical, demographic and psychosocial characteristics of the comparison groups. The two groups were similar with respect to age, Charlson Comorbidity Index score, Lequesne scores, WOMAC scores and GDS. However, African-American participants, when compared to white participants, reported lower annual household incomes (P<0.01) and were less likely to be employed (P=0.01), married (P<0.01) or educated beyond the high-school level (P<0.01). Radiographic evidence for OA severity measured by K/L score was similar between the two groups (P= 0.08).

Participants selected for this study were AfricanAmerican and white male patients who participated in a previous VA-funded study on ethnic/cultural variations in the management of OA. Participants were identified from a list of scheduled primary care visits at VA outpatient clinics. The study staff approached all the patients 50 years of age or older during their routine primary care clinic visit at the Louis Stokes Cleveland VA Medical Center in Cleveland, OH between May 1997 to March 2000. The Louis Stokes Cleveland VA Medical Center is a tertiary care VA medical hospital with primary affiliation with Case Western Reserve University School of Medicine, Cleveland. They were asked a series of questions pertaining to the presence, duration and severity of knee and hip pain, using questions similar to those included in the Arthritis Supplement National Health and Nutrition Examination Survey I (NHANES I).

Referrals to Specialists

By 2020, the estimated number of people in the United States suffering from arthritis in general will increase by 50%} By 2050, approximately 60 million Americans will suffer from arthritis at an estimated annual societal cost of $65 billion. The pain and dysfunction caused by osteoarthritis (OA) of the hip and knee is a leading cause of disability in the United States. As the U.S. population ages, the burden of clinically significant knee and hip OA will increase significantly. Knee and hip OA is one of the most common types of arthritis encountered in clinical practice, and the disability attributed to the pain of lower-extremity arthritis is disproportionately higher in older and minority populations.

Pattern of Emergency Neurologic Morbidities in Children DISCUSSION

Children with emergency neurologic morbidities accounted for 15.6% in this study, similar to previous reports from other parts of Nigeria. Those aged five years and under accounted for the majority (77.0%) of the children studied with the modal age group of 1-2 years. The predominance of children in this age is due to their vulnerability to febrile convulsion, which is caused by a variety of infections common in this age group, such as acute respiratory and urinary tract infections and malaria. Malaria is also more severe in this age group, especially in those under three years old, due in part to lack of partial immunity than older children and adults. About 90% of the neurologic morbidities in this study were of infectious origin. Malaria (febrile convulsion and cerebral malaria) and meningitis were the greatest culprits. These two morbidities were more frequently seen in the under-5s, whereas, meningitis—though encountered in all age groups— was the most frequent neurologic morbidity in children older than five years of age. This observed pattern in the older age group may be explained by the decline in the frequency and severity of malaria after the age of five years due to acquired partial immunity, and, secondly, febrile convulsion rarely occurs after the age of five years. The standard practice in our center is to commence treatment empirically for both cerebral malaria and meningitis for children five years of age or under presenting with fever and convulsion or alteration of consciousness until results of investigations are obtained. Culture-proven cases of meningitis are few in our center even in the presence of CSF biochemistry and pleo-cytosis suggestive of meningitis. This may be due to widespread and inappropriate use of antibiotics in the community before presentation to the hospital, and sometimes parents cannot afford the cost of investigations before the start of treatment. However, the organisms isolated in the few culture-proven cases include Neisseria meningitides and Streptococcus pneumoniae. In a previous study from this center, N meningitides was the commonest organism isolated in culture-proven cases of meningitis in children one month to 16 years of age.

Six-hundred-four patients were admitted with neurological morbidity consisting of 15.6% out a total of 3,868 patients admitted during the five-year period. One-hundred-ninety-eight patients (32.8%) had incomplete records with regards to outcome. A breakdown of the number of patients per year is shown in Table 1.