RESUMEN
In general, coma portends a very poor outcome in ICU patients except when a drug overdose is the cause. Interactions with concurrent diseases and the cause of the comatose state are important variables that modify mortality rates. Recent studies have made it possible to predict irreversibility with a high degree of specificity in many cases. Three approaches show promise for early prediction of poor outcome--multivariate analysis, neurologic findings, and technologic innovations. Multivariate analysis of combinations of clinical conditions common in ICUs appears to have defined some patients whose prognosis is nearly hopeless, empirically. It would seem reasonable to consider withholding or withdrawing life support from these patients so that mere prolongation of death is avoided. Additional studies are needed and are relatively easy to perform with computerized statistical analyses of a readily available database derived from large patient populations in multicenter studies. A second useful approach for predicting irreversibility has arisen from studies using neurologic findings at defined time points after brain injury. The studies of Levy and colleagues exemplify this approach; their data suggest that coma can be declared irreversible with a high degree of confidence in a large subset of patients, delineated by simple sequential neurologic observations. Finally, technologies are evolving that may lead to noninvasive measurements to provide quantitative evidence of irreversible brain damage. Additional clinical studies are needed to validate the predictive value of these approaches to identifying patients who are certain to have a poor ultimate outcome. It then may be possible to predict function and irreversibility of central nervous system injury in individual cases with a high degree of certainty early in the clinical course.
Asunto(s)
Lesiones Encefálicas/clasificación , Lesiones Encefálicas/mortalidad , Coma/clasificación , Coma/mortalidad , Cuidados Críticos , Resultado del Tratamiento , Lesiones Encefálicas/etiología , Lesiones Encefálicas/terapia , Coma/etiología , Coma/terapia , Toma de Decisiones en la Organización , Predicción , Humanos , Análisis Multivariante , Examen Neurológico , Pronóstico , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Tasa de Supervivencia , Factores de TiempoRESUMEN
Neuropsychological and psychiatric evaluations were made of 39 subjects with possible Alzheimer's disease and a history of excessive alcohol consumption (AD + ETOH), who had been abstinent or had drunk minimally for at least three months before evaluation, and 225 patients with probable Alzheimer's disease (PAD) of comparable age, years of education, and baseline global impairment. At baseline, there were no significant differences between the groups in terms of age of onset of dementia, neuropsychological test scores, or current behavioural or psychiatric symptoms. One year later, no differences in rates of decline between 20 abstinent AD + ETOH patients and 88 PAD subjects could be shown. Thus, past heavy alcohol consumption does not appear to modify the presentation of dementia of the Alzheimer's type, nor does it modify progression over a one-year interval.
Asunto(s)
Alcoholismo/complicaciones , Enfermedad de Alzheimer/diagnóstico , Pruebas Neuropsicológicas , Anciano , Alcoholismo/psicología , Alcoholismo/rehabilitación , Enfermedad de Alzheimer/psicología , Etanol/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Síndrome de Abstinencia a Sustancias/diagnóstico , Síndrome de Abstinencia a Sustancias/psicologíaRESUMEN
The aim of this paper is to assess the influence of selected psychosocial factors as predictors of stroke incidence in a probability sample of noninstitutionalized elderly. The main psychosocial factor of interest was depression. Marital status, social support, social networks, and religiousness were also assessed as potential antecedent or mediating factors. The data were obtained from a prospective longitudinal study based on 2,812 individuals aged 65 years and over living in New Haven, Connecticut. The incidence of stroke was monitored from the baseline interview in 1982 until December 1988. Depression, measured by the Center for Epidemiologic Studies Depression Scale (CES-D), was measured at baseline as were other predictor variables. Univariate Cox regression analyses revealed that higher CES-D scores were predictive of greater stroke incidence (p < 0.05). More frequent attendance at religious services was associated with lower incidence (p < 0.001). CES-D scores were also correlated with many measures of sociodemographic, health, and physical function factors in our multivariate analysis (p < 0.05). When combined with other significant predictor variables such as age, sex, hypertension, diabetes, physical function, and smoking, neither depression nor religious attendance retained its significance.
Asunto(s)
Trastornos Cerebrovasculares/psicología , Depresión/complicaciones , Apoyo Social , Anciano , Anciano de 80 o más Años , Trastornos Cerebrovasculares/epidemiología , Connecticut/epidemiología , Femenino , Humanos , Incidencia , Masculino , Análisis Multivariante , Pronóstico , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Análisis de Regresión , ReligiónRESUMEN
BACKGROUND AND PURPOSE: Our aim in this study was to assess physical function as a predictor of stroke incidence in a probability sample of noninstitutionalized elderly subjects with no previous history of stroke. SUMMARY OF REPORT: The data were obtained from a prospective longitudinal study of 2,812 individuals aged 65 years of age and older living in New Haven, Connecticut. Incidence of stroke was monitored from the baseline interview in 1982 until December 1988 (n = 167). Physical function was measured by the Katz scale of activities of daily living and a three-item scale measuring gross mobility function (Rosow scale). Both measures of impairment of function were independently associated with stroke incidence controlling for age, sex, diabetes, hypertension, and angina (p less than 0.001). CONCLUSIONS: Our findings suggest that in elderly persons, physical disability is a newly identified risk factor for stroke.