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Concern about the lack of human rights afforded to persons living with dementia has emerged in recent years. Although the literature addresses certain rights, it does not include a holistic framework of rights in terms of the lived experience of older persons with cognitive impairment. Inspired by the 20 rights advocated for children by physician-educator Janusz Korczak, this article analyzes his formulation of rights in the context of persons with dementia, linking them to the ethical principles of Beneficence, Autonomy, and Justice. The analysis thus provides a holistic framework for addressing the human rights of persons with dementia, and their meanings for the lived experiences of persons with dementia and their caregivers. It offers new insights into the philosophy and practice of care, with implications for dementia care research, public health policy, practice guidelines for health care professionals, and the instruction of family and other caregivers of persons with dementia., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Needle injection has been widely used in spinal therapeutic or diagnostic processes, such as discography. The use of needles has been suspected in causing mild disc degeneration which can lead to long-term back pain. However, the localised microscopic damage caused by needles has not been well studied. The local progressive damage on a microscopic level caused by needle punctures on the surface of bovine annulus fibrosus was investigated. Four different sizes of needle were used for the puncture and twenty-nine bovine intervertebral discs were studied. Polarization-resolved second harmonic generation and fluorescent microscopy were used to study the local microscopic structural changes in collagen and cell nuclei due to needle damage. Repeated 70 cyclic loadings at ±5% of axial strain were applied after the needle puncture in order to assess progressive damage caused by the needle. Puncture damage on annulus fibrosus were observed either collagen fibre bundles being pushed aside, being cut through or combination of both with part being lift or pushed in. The progressive damage was found less relevant to the needle size and more progressive damage was only observed using the larger needle. Two distinct populations of collagen, in which one was relatively more organised than the other population, were observed especially after the puncture from skewed distribution of polarization-SHG analysis. Cell shape was found rounder near the puncture site where collagen fibres were damaged., (Copyright © 2021. Published by Elsevier Ltd.)

Context: The experience of pain is aggravated among older persons with advanced dementia (OPAD). It is often undetected and therefore untreated because of their limited capacity to identify and report their symptoms. Therefore, it is crucial to improve the pain identification skills of those who know and live with them., Objectives: To compare the identification of pain among OPAD between family members and paid care workers and to compare the detection of pain through the use of two common assessment tools., Methods: This study is a cross-sectional comparison conducted between 82 dyads of informants: the family member of OPAD and the paid care worker, a total of 164 individuals., Measurements: The study used two previously validated pain assessment tools for persons suffering from dementia: the Pain Assessment in Noncommunicative Elderly persons tool (PAINE) and Pain Assessment in Advanced Dementia tool (PAINAD), and a general impression question., Results: Both family members and paid care workers were able to successfully use both tools. The correlation between family members' ratings and paid care workers' ratings was statistically significant for all the assessments. The correlations between raters were higher when family members lived with the OPAD. The correlations between PAINE and PAINAD scores were moderate and significant, both among family members and paid care workers., Conclusion: This study shows that it is feasible to improve the assessment and identification of pain among OPAD, through the use of validated tools by family members and paid care workers, suggesting the potential to improve quality of care and quality of life of OPAD., (Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Prevention of stillbirth remains one of the greatest challenges in modern maternity care. Despite this, public awareness is low and silence is common within families, the community and even healthcare professionals. Australian families and parent advocacy groups given a voice through the Senate Enquiry have made passionate and articulate calls for a national stillbirth awareness campaign. This fourth paper in the Stillbirth in Australia series outlines why stillbirth needs a national public awareness campaign; and provides an overview of good practice in the design, development and evaluation of public awareness campaigns. The cognitive and affective steps required to move from campaign awareness to action and eventually to stillbirth prevention are described. Using these best practice principles, learning from previous campaigns combined with close collaboration with aligned agencies and initiatives should assist a National Stillbirth Prevention Campaign to increase community awareness of stillbirth, help break the silence and contribute to stillbirth prevention across Australia., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: Recent advances in health monitoring technology have coincided with increases in the number of older adults with cancer, many of whom report difficulty using health information technology (HIT). Previous studies have identified lower electronic health (eHealth) literacy among older adults (≥65 years) compared to younger adults (<65), but studies in older adults with cancer are limited. The goal of this study was to examine age differences in eHealth literacy and use of technology devices/HIT in patients with cancer, and characterize receptivity towards using home-based HIT to communicate with the oncology care team., Materials and Methods: Patients (n = 198) in a Radiation Oncology clinic were offered an anonymous written questionnaire assessing demographics, eHealth literacy (eHealth Literacy Scale), current use of HIT, and interest in using home-based HIT., Results and Conclusion: Compared to younger patients, older patients had significantly lower eHealth literacy (p < .01), and were less likely to feel confident evaluating health resources on the Internet (p < .01) or knowing how to use the health information found on the Internet to help them (p < .01) or answer health questions (p = .01). Older patients were also less likely than younger patients to have an email address (p = .04), own a smartphone (p < .01), or use the online patient portal (p = .03). Regardless of age, most patients were not opposed to using home-based HIT to communicate with their oncology care team. Future studies on HIT use in older adults with cancer should further evaluate barriers to using HIT and ways to maximize implementation and accessibility., Competing Interests: Declaration of Competing Interest Heather Jim is a consultant for RedHill Biopharma, Janssen Scientific Affairs, and Merck. The authors declare no other conflicts of interest., (Copyright © 2019. Published by Elsevier Ltd.)

Our understanding of how, and the extent to which, phytopathogens reconfigure host metabolic pathways to enhance virulence is remarkably limited. Here we investigate the dynamics of the natural disaccharide nucleoside, 3'-O-β-D-ribofuranosyladenosine, in leaves of Arabidopsis thaliana infected with virulent Pseudomonas syringae pv. tomato strain DC3000. 3'-O-β-D-ribofuranosyladenosine is a plant derived molecule that rapidly accumulates following delivery of P. syringae type III effectors to represent a major component of the infected leaf metabolome. We report the first synthesis of 3'-O-β-D-ribofuranosyladenosine using a method involving the condensation of a small excess of 1-O-acetyl-2,3,5-three-O-benzoyl-β-ribofuranose activated with tin tetrachloride with 2',5'-di-O-tert-butyldimethylsilyladenosine in 1,2-dichloroethane with further removal of silyl and benzoyl protecting groups. Interestingly, application of synthetic 3'-O-β-D-ribofuranosyladenosine did not affect either bacterial multiplication or infection dynamics suggesting a major reconfiguration of metabolism during pathogenesis and a heavy metabolic burden on the infected plant., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Unlabelled: The intervertebral disc is a multicomposite structure, with an outer fibrous ring, the annulus fibrosus, retaining a gel-like core, the nucleus pulposus. The disc presents complex mechanical behaviour, and it is of high importance for spine biomechanics. Advances in multiscale modelling and disc repair raised a need for new quantitative data on the finest details of annulus fibrosus mechanics. In this work we explored inter-lamella and inter-bundle behaviour of the outer annulus using micromechanical testing and second harmonic generation microscopy. Twenty-one intervertebral discs were dissected from cow tails; the nucleus and inner annulus were excised to leave a ring of outer annulus, which was tested in circumferential loading while imaging the tissue's collagen fibres network with sub-micron resolution. Custom software was developed to determine local tissue strains through image analysis. Inter-bundle linear and shear strains were 5.5 and 2.8 times higher than intra-bundle strains. Bundles tended to remain parallel while rotating under loading, with large slipping between them. Inter-lamella linear strain was almost 3 times the intra-lamella one, but no slipping was observed at the junction between lamellae. This study confirms that outer annulus straining is mainly due to bundles slipping and rotating. Further development of disc multiscale modelling and repair techniques should take into account this modular behaviour of the lamella, rather than considering it as a homogeneous fibre-reinforced matrix., Statement of Significance: The intervertebral disc is an organ tucked between each couple of vertebrae in the spine. It is composed by an outer fibrous layer retaining a gel-like core. This organ undergoes severe and repeated loading during everyday life activities, since it is the compliant component that gives the spine its flexibility. Its properties are affected by pathologies such as disc degeneration, a major cause of back pain. In this article we explored the micromechanical behaviour of the disc's outer layer using second harmonic generation, a technique which allowed us to visualize, with unprecedented detail, how bundles of collagen fibres slide relative to each other when loaded. Our results will help further the development of new multiscale numerical models and repairing techniques., (Copyright © 2016 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

Objective: To portray the emotional and behavioral reactions of persons with dementia to the delusions and hallucinations they experience, according to the reports of their family caregivers. The article also explores the relationship between those reactions and background variables., Methods: Study participants were family caregivers of 74 older persons with a diagnosis of dementia (aged ≥ 65) residing in the community recruited from adult day centers and support groups for caregivers of persons with dementia and by advertising online. Assessments included the Behavioral Pathology in Alzheimer's Disease, the Neuropsychiatric Inventory, the Etiological Assessment of Psychotic Symptoms in Dementia, Activities of Daily Living questionnaire, and the Mini-Mental State Examination., Results: Findings concerning emotional reactions reveal that close to half of the delusions resulted in discomfort, whereas around 40% did not. We found significant differences in the discomfort associated with different types of delusions, with delusions of abandonment, danger, and infidelity associated with more discomfort than other delusions. Around half of the delusions were associated with a behavioral manifestation., Conclusion: The findings highlight the need to examine the emotional impact of delusions and hallucinations as part of their assessment and as a consideration in treatment decisions., (Copyright © 2016 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Crohn's disease and ulcerative colitis are the two major forms of inflammatory bowel disease; treatment strategies have historically been determined by this binary categorisation. Genetic studies have identified 163 susceptibility loci for inflammatory bowel disease, mostly shared between Crohn's disease and ulcerative colitis. We undertook the largest genotype association study, to date, in widely used clinical subphenotypes of inflammatory bowel disease with the goal of further understanding the biological relations between diseases., Methods: This study included patients from 49 centres in 16 countries in Europe, North America, and Australasia. We applied the Montreal classification system of inflammatory bowel disease subphenotypes to 34,819 patients (19,713 with Crohn's disease, 14,683 with ulcerative colitis) genotyped on the Immunochip array. We tested for genotype-phenotype associations across 156,154 genetic variants. We generated genetic risk scores by combining information from all known inflammatory bowel disease associations to summarise the total load of genetic risk for a particular phenotype. We used these risk scores to test the hypothesis that colonic Crohn's disease, ileal Crohn's disease, and ulcerative colitis are all genetically distinct from each other, and to attempt to identify patients with a mismatch between clinical diagnosis and genetic risk profile., Findings: After quality control, the primary analysis included 29,838 patients (16,902 with Crohn's disease, 12,597 with ulcerative colitis). Three loci (NOD2, MHC, and MST1 3p21) were associated with subphenotypes of inflammatory bowel disease, mainly disease location (essentially fixed over time; median follow-up of 10·5 years). Little or no genetic association with disease behaviour (which changed dramatically over time) remained after conditioning on disease location and age at onset. The genetic risk score representing all known risk alleles for inflammatory bowel disease showed strong association with disease subphenotype (p=1·65 × 10(-78)), even after exclusion of NOD2, MHC, and 3p21 (p=9·23 × 10(-18)). Predictive models based on the genetic risk score strongly distinguished colonic from ileal Crohn's disease. Our genetic risk score could also identify a small number of patients with discrepant genetic risk profiles who were significantly more likely to have a revised diagnosis after follow-up (p=6·8 × 10(-4))., Interpretation: Our data support a continuum of disorders within inflammatory bowel disease, much better explained by three groups (ileal Crohn's disease, colonic Crohn's disease, and ulcerative colitis) than by Crohn's disease and ulcerative colitis as currently defined. Disease location is an intrinsic aspect of a patient's disease, in part genetically determined, and the major driver to changes in disease behaviour over time., Funding: International Inflammatory Bowel Disease Genetics Consortium members funding sources (see Acknowledgments for full list)., (Copyright © 2016 Cleynen et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd.. All rights reserved.)

We have investigated the cause of the restricted multiplication of hrp mutant bacteria in leaves of Arabidopsis. Our focus was on early interactions leading to differentiation between virulent wild-type and non-pathogenic hrpA mutant strains of Pseudomonas syringae pv. tomato. An initial drop in recoverable bacteria detected 0-4 h after inoculation with either strain was dependent on a functional FLS2 receptor and H2O2 accumulation in challenged leaves. Wild-type bacteria subsequently multiplied rapidly whereas the hrpA mutant was restricted within 6 h. Despite the early restriction, the hrpA mutant was still viable several days after inoculation. Analysis of intercellular washing fluids (IWFs), showed that high levels of nutrients were readily available to bacteria in the apoplast and that no diffusible inhibitors were produced in response to bacterial challenge. Histochemical and immunocytochemical methods were used to detect changes in polysaccharides (callose, two forms of cellulose, and pectin), arabinogalactan proteins (AGPs), H2O2 and peroxidase. Quantitative analysis showed very similar changes in localisation of AGPs, cellulose epitopes and callose 2 and 4 h after inoculation with either strain. However from 6 to 12 h after inoculation papillae expanded only next to the hrp mutant. In contrast to the similar patterns of secretory activity recorded from mesophyll cells, accumulation of H2O2 and peroxidase was significantly greater around the hrpA mutant within the first 4h after inoculation. A striking differential accumulation of H2O2 was also found in chloroplasts in cells next to the mutant. Ascorbate levels were lower in the IWFs recovered from sites inoculated with the hrp mutant than with wild-type bacteria. The critical response, observed at the right time and place to explain the observed differential behaviour of wild-type and hrpA mutant bacteria was the accumulation of H2O2, probably generated through Type III peroxidase activity and in chloroplasts. It is proposed that H2O2 and apoplastic peroxidase cross-link secreted glycoproteins and polysaccharides to agglutinate the hrp mutant. Generation of H2O2 has been identified as a likely target for effector proteins injected into plant cells by the wild-type bacteria., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objective: This study compares different nonpharmacological interventions for persons with behavioral symptoms and dementia on frequency of use and perceived efficacy in terms of change in behavior and interest., Methods: Participants were 89 nursing home residents from six Maryland nursing homes with a mean age of 85.9 years (SD: 8.6 years). Research assistants presented interventions tailored to the participants' needs and preferences in a pre-intervention trial phase and in an intervention phase. The impact of each intervention on behavioral symptoms and on the person's interest was rated immediately after the intervention by a research assistant., Results: The most utilized interventions in both trial and treatment phases were the social intervention of one-on-one interaction, simulated social interventions such as a lifelike doll and respite video, the theme intervention of magazine, and the sensory stimulation intervention of music. In contrast, the least utilized interventions in both phases were sewing, fabric book, and flower arrangement. Interventions with the highest impact on behavioral symptoms included one-on-one social interaction, hand massage, music, video, care, and folding towels. Other high impact interventions included walking, going outside, flower arranging, food or drink, sewing, group activity, book presentation, ball toss, coloring or painting, walking, and family video., Conclusions: The results provide initial directions for choosing specific interventions for persons with dementia and also demonstrate a methodology for increasing knowledge through ongoing monitoring of practice., (Copyright © 2015 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objectives: Behavioral disturbances and pain are common in nursing home (NH) patients with dementia. An association between pain and increased agitation has been suggested, and recently a significant reduction of agitation has been demonstrated by pain treatment in patients with moderate to severe dementia. We now examined which specific agitated behaviors respond to individualized pain treatment., Design: Cluster randomized clinical trial., Setting: 60 clusters (i.e., clusters defined as single independent NH units) in 18 NHs within five municipalities of Western Norway., Participants: 352 patients with moderate to severe dementia and clinically significant behavioral disturbances., Intervention: The control group received usual treatment and care. According to a predefined scheme for 8 weeks, all patients in the intervention group received individual daily pain treatment with acetaminophen, extended release morphine, buprenorphine transdermal patch, and/or pregabaline., Measurements: Cohen-Mansfield Agitation Inventory subscales and items., Results: Analyses demonstrated that Factor 3 (Verbally agitated behaviors) showed the largest significant difference (DF = 1204.0, t = -4.308, p <0.001), followed by Factor 2 (Physically non-aggressive behaviors) (DF = 1198.0, t = -2.672, p = 0.008), and Factor 1 (Aggressive behaviors) (DF = 1196.0, t = -2.093, p = 0.037) after 8 weeks, by a linear random intercept mixed model in two-way repeated-measures configuration with adjustment for heteroscedasticity., Conclusion: We found that verbal agitation behaviors such as complaining, negativism, repetitious sentences and questions, constant request for attention, and cursing or verbal aggression responded to pain treatment. In addition, restlessness and pacing were sensible to analgesics. Such behaviors should therefore lead to an assessment of pain, and pain treatment. Further studies comparing how pain treatment should be balanced against other strategies including psychotropic drugs are needed., (Copyright © 2014 American Association for Geriatric Psychiatry. All rights reserved.)

Articular cartilage (AC) is a highly anisotropic biomaterial, and its complex mechanical properties have been a topic of intense investigation for over 60 years. Recent advances in the field of nonlinear optics allow the individual constituents of AC to be imaged in living tissue without the need for exogenous contrast agents. Combining mechanical testing with nonlinear microscopy provides a wealth of information about microscopic responses to load. This work investigates the inhomogeneous distribution of strain in loaded AC by tracking the movement and morphological changes of individual chondrocytes using point pattern matching and Bayesian modeling. This information can be used to inform models of mechanotransduction and pathogenesis, and is readily extendable to various other connective tissues., (Copyright © 2014 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

Objective: Behavioral symptoms are common in persons with dementia, and nonpharmacological interventions are recommended as the first line of therapy. We describe barriers to conducting nonpharmacological interventions for behavioral symptoms., Design: A descriptive study of barriers to intervention delivery in a controlled trial., Settings: The study was conducted in six nursing homes in Maryland., Participants: Participants were 89 agitated nursing home residents with dementia., Intervention: Personalized interventions were developed using the Treatment Routes for Exploring Agitation decision tree protocol. Trained research assistants prepared and delivered the interventions. Feasibility of the interventions was determined., Measurements: Barriers to Intervention Delivery Assessment, activities of daily living, cognitive functioning, depressed affect, pain, observed agitation, and observed affect., Results: Barriers were observed for the categories of resident barriers (specifically, unwillingness to participate; resident attributes, such as unresponsive), barriers related to resident unavailability (resident asleep or eating), and external barriers (staff-related barriers, family-related barriers, environmental barriers, and system process variables). Interventions pertaining to food/drink and to 1-on-1 socializing were found to have the fewest barriers, whereas higher numbers of barriers occurred with puzzles/board games and arts and crafts activities. Moreover, when successful interventions were presented to participants after the feasibility period, we noted fewer barriers, presumably because barrier identification had been used to better tailor interventions to each participant and to the environment., Conclusion: Knowledge of barriers provides a tool by which to tailor interventions so as to anticipate or circumvent barriers, thereby maximizing intervention delivery., (Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Engagement refers to the act of being occupied or involved with an external stimulus. In dementia, engagement is the antithesis of apathy., Objective: The Comprehensive Process Model of Engagement was examined, in which environmental, personal, and stimulus characteristics impact the level of engagement., Methods: : Participants were 193 residents of 7 Maryland nursing with a diagnosis of dementia. Stimulus engagement was assessed via the Observational Measure of Engagement, measuring duration, attention, and attitude to the stimulus. Twenty-five stimuli were presented, which were categorized as live human social stimuli, simulated social stimuli, inanimate social stimuli, a reading stimulus, manipulative stimuli, a music stimulus, task and work-related stimuli, and two different self-identity stimuli., Results: All stimuli elicited significantly greater engagement in comparison to the control stimulus. In the multivariate model, music significantly increased engagement duration, whereas all other stimuli significantly increased duration, attention, and attitude. Significant environmental variables in the multivariate model that increased engagement were: use of the long introduction with modeling (relative to minimal introduction), any level of sound (especially moderate sound), and the presence of between 2 and 24 people in the room. Significant personal attributes included Mini-Mental State Examination scores, activities of daily living performance and clarity of speech, which were positively associated with higher engagement scores., Conclusions: Results are consistent with the Comprehensive Process Model of Engagement. Personal attributes, environmental factors, and stimulus characteristics all contribute to the level and nature of engagement, with a secondary finding being that exposure to any stimulus elicits engagement in persons with dementia.

Objectives: To determine which stimuli are 1) most engaging 2) most often refused by nursing home residents with dementia, and 3) most appropriate for persons who are more difficult to engage with stimuli., Methods: Participants were 193 residents of seven Maryland nursing homes. All participants had a diagnosis of dementia. Stimulus engagement was assessed by the Observational Measure of Engagement., Results: The most engaging stimuli were one-on-one socializing with a research assistant, a real baby, personalized stimuli based on the person's self-identity, a lifelike doll, a respite video, and envelopes to stamp. Refusal of stimuli was higher among those with higher levels of cognitive function and related to the stimulus' social appropriateness. Women showed more attention and had more positive attitudes for live social stimuli, simulated social stimuli, and artistic tasks than did men. Persons with comparatively higher levels of cognitive functioning were more likely to be engaged in manipulative and work tasks, whereas those with low levels of cognitive functioning spent relatively more time responding to social stimuli. The most effective stimuli did not differ for those most likely to be engaged and those least likely to be engaged., Conclusion: Nursing homes should consider both having engagement stimuli readily available to residents with dementia, and implementing a socialization schedule so that residents receive one-on-one interaction. Understanding the relationship among type of stimulus, cognitive function, and acceptance, attention, and attitude toward the stimuli can enable caregivers to maximize the desired benefit for persons with dementia.

Purpose: The aim of this article is to delineate the underlying premises of the concept of engagement in persons with dementia and present a new theoretical framework of engagement., Setting/subjects: The sample included 193 residents of seven Maryland nursing homes. All participants had a diagnosis of dementia., Methodology: The authors describe a model of factors that affect engagement of persons with dementia. Moreover, the authors present the psychometric qualities of an assessment designed to capture the dimensions of engagement (Observational Measurement of Engagement). Finally, the authors detail plans for future research and data analyses that are currently underway., Discussion: This article lays the foundation for a new theoretical framework concerning the mechanisms of interactions between persons with cognitive impairment and environmental stimuli. Additionally, the study examines what factors are associated with interest and negative and positive feelings in engagement.

Objectives: This paper reports on a survey documenting physicians' assessment of current levels of care in the nursing home and of the importance and feasibility of strategies to improve care., Design: This is a descriptive study presenting responses to a Web-based questionnaire that asked about treatment of behavior problems in nursing homes as well as about perceptions of quality of care., Setting: Nursing home., Participants: Participants were 110 physicians who provide services in a nursing home environment., Measurements: Likert-type ratings of perceived levels of care in the facility and of the importance and feasibility of strategies to improve care., Results: These physicians perceived current levels of care in the nursing home to be acceptable, but not good or outstanding. Overall care in the facility and the level of staff care for residents were seen as better than the level of administration care for nursing assistants or for physicians. The importance of specific strategies to improve care was rated higher than the feasibility of these strategies actually being employed. The item rated the most important for improving care was having the administration show respect, support, and caring for front line staff; this item was also rated the most feasible. Other items rated as highly important concerned either front line staff or families. The feasibility of improving care, but not the importance of improvement, was associated with the perception of current levels of care., Conclusion: These findings can be used as guidelines for improving the culture of care in nursing home facilities.

Objectives: To describe physicians' perceptions of their role in treating the behavior problems associated with dementia that commonly occur in the nursing home, both the way it is currently and the way they think it should be., Design: This is a descriptive study presenting responses to a Web-based questionnaire., Participants: Participants were 110 physicians who provide services in nursing homes., Measurements: Likert-type ratings of items pertaining to the role of the physician in treating behavior problems in nursing homes, with respect to both current and ideal practices., Results: Physicians perceived the most characteristic part of both their current and ideal role to be determining if there is a treatable medical problem that is causing the behavior. They rated referral to a mental health specialist as the least important aspect of their current role, but rated prescribing psychotropic medication as the item they thought should be least important. Ideally, physicians believed that all aspects of their current role in treating behavior problems should increase except for prescribing psychotropic medication. Gender and for-profit/public/nonprofit status were the demographic and facility characteristics that were most likely to influence physicians' ratings on individual items., Conclusion: Physicians believe that most aspects of their involvement in treating behavior problems associated with dementia in nursing homes should increase, the exception being prescription of psychotropic medication.

Objectives: To describe the perceptions of physicians who care for nursing home residents regarding the etiology of behavior problems associated with dementia, their attitudes toward treatment, their knowledge of nonpharmacological interventions, and relationships among these issues and demographic variables and actual practice., Design: This is a descriptive study presenting responses to a Web-based questionnaire., Participants: Participants were 110 physicians providing services in a nursing home setting., Measurements: Likert-type ratings of statements related to the etiology of behavior problems, attitudes toward treatment, and knowledge of various nonpharmacological interventions., Results: These physicians rated medical/mental health issues and system/environment/staff/care problems to be as frequently involved as dementia in the etiology of behavior problems. Their attitudes concerning nonpharmacological treatment were more positive than those for the use of psychotropic medication. There was a broad range in knowledge of nonpharmacological interventions among the respondents. They were most likely to report previous use of physical interventions and were least likely to have used sensory interventions. Physicians with knowledge of a greater number of nonpharmacological methods were more likely to use these in actual practice. Staff requests for medication and insufficient resources were reported to be barriers to the use of nonpharmacological methods., Conclusion: The frequency with which behavior problems in dementia are attributed to environmental and psychosocial causes suggests there are a large number of cases in which nonpharmacological interventions could be employed. Physicians are generally in favor of the use of these methods, but their knowledge varies. Increasing physicians' knowledge of nonpharmacological techniques would increase the likelihood of their use.

Objectives: Behavior problems are common in dementia, yet little is known about how physicians deal with these problems in practice. This article reports on a survey asking physicians to describe, with respect to the last nursing home resident with dementia they treated for behavior problems, the behaviors observed, assessment methods used, suspected etiology of the problem, types of intervention, and their reaction to the intervention process., Design: This is a descriptive study presenting responses to a Web-based questionnaire., Participants: Participants were 110 physicians providing services to nursing home residents., Measurements: Physicians answered a close-ended questionnaire with open-ended "other" options concerning symptoms, methods of assessment, suspected etiological factors, and interventions to describe the last nursing home resident they treated for behavior problems associated with dementia., Results: Resisting care was the most frequently reported symptom (71%). Physicians were most likely to attribute the behavior problems to the indirect effects of dementia on the ability to remember, communicate, and comprehend (67%). Most (87%) reported using more than one method for treating these problems. Rate of reported use of psychotropic drugs (80%) was slightly higher than that for nonpharmacological methods (75%), with the majority (61%) reporting use of both of these methods. Standardized instruments were not used in assessment. Forty percent of the participants reported feeling satisfied or very satisfied with the intervention they provided, and close to a third (32%) reported feeling frustrated with the intervention process., Conclusion: The data underscore the complexity in the treatment of behavior problems. Despite federal regulations limiting their use, the potential for side effects, and ambivalence toward such treatment, psychotropic drugs are still used for the majority of nursing home residents with behavior problems associated with dementia. On the other hand, physicians report employing nonpharmacological methods to a closely similar extent, although their role in the implementation of these treatments is less clear. Further work is needed to clarify physicians' involvement in and decision to use nonpharmacological interventions.

Objective: To assess nursing home physicians' and social workers' perceptions of the new Maryland Patient Plan of Care Form (PPOC)., Design: Mailed survey., Setting: Nursing homes in Maryland., Participants: Thirty-seven physicians and 60 social workers., Measurements: Views of physicians and social workers were assessed through quantitative questions about the use of the PPOC form and qualitative questions about barriers in completing the form and recommendations to improve the form., Results: The majority (79.2%) of physicians and social workers reported that completing the PPOC is somewhat of a major burden. An overwhelming majority (85.6%) reported that social workers are completing the form, while close to half of the physicians and a quarter of the social work respondents say that physicians are involved in completing the form. Moreover, significantly more social workers (63.3%) than physicians (36.7%) believe the form would be more useful as a physician's order (X(2) = 5.287; d f = 1; P = .021). Both physicians and social workers identify barriers to completing the form and offer recommendations to improve the form., Conclusions: Despite legislation requiring physicians to sign the PPOC, it is not a physician's order, thus shifting the burden of completing the PPOC to social workers. We conclude that most physicians and social workers view the PPOC as burdensome and do not feel that it is useful, but whether it is having an effect on patient care preferences merits further investigation.

Objective: This study investigated the temporal pattern of agitated behaviors in nursing home residents with dementia and compared it with temporal patterns of pleasure, interest in the environment, and sleep., Methods: Trained research assistants recorded direct observations of agitation and affect by the Agitation Behavior Mapping Instrument and the Lawton's Modified Behavior Stream for 174 participants from 12 nursing homes., Results: The temporal pattern found for total agitation showed a gradual increase from the morning until approximately 4 pm with a decrease thereafter. Only 26% of the sample showed a clear increase of their agitation in the later hours in comparison to the morning hours based on our criterion. Pleasure did not show a consistent pattern, whereas levels of interest peaked during lunch and dinner times., Conclusions: The results fit with a hypothesis of fatigue of daytime nursing staff members and disruption during shift change and may also be partially accounted for by resident fatigue. Although the literature supports the notion that there is a peak in overall agitation around 4 pm, the term "sundowning" is not supported and should be replaced. The phenomenon of increased levels of agitation during later hours characterizes only a minority of agitated nursing home residents, albeit the most highly agitated.

Objective: Limited work has addressed the construct validity of the Cohen-Mansfield Agitation Inventory (CMAI) in nursing home patients. The authors tested the CMAI factor structure by use of data from three samples of nursing home patients categorized a priori as having at least mild behavioral and psychological symptoms of dementia., Methods: CMAI data were from the baseline assessment of three randomized, placebo-controlled trials of risperidone for treating elderly nursing home patients. Exploratory factor analyses were conducted on two trials (N = 304; N = 344), and the results of these exploratory factor analyses were then tested with confirmatory factor analysis by use of data from a third trial (N = 617)., Results: Principal-components analysis suggested the presence of four factors: 1) Aggressive Behavior (hitting, kicking, scratching, biting, pushing, grabbing, throwing things, cursing or verbal aggression, spitting, tearing things/destroying property, hurting self or others, screaming); 2) Physically Non-Aggressive Behavior (pacing, trying to get to a different place, general restlessness, inappropriate dressing or disrobing, handling things inappropriately, performing repetitious mannerisms); 3) Verbally Agitated Behavior (complaining, constant requests for attention, repetitive questions, negativism); and 4) Hiding and Hoarding. Confirmatory factor analysis indicated that the four-factor solution was a reasonable fit to the data., Conclusion: Four factors emerged on the CMAI in nursing home patients with behavioral and psychological symptoms of dementia. The results obtained converge reasonably with previous publications concerning the factor structure of the CMAI, which, taken together, suggest a fairly robust factor structure for the instrument.

The management of behavior problems is one of the most difficult challenges a clinician must face when treating patients with dementia. This article presents a qualitative analysis of the responses of 7 nursing home physicians and 1 nurse practitioner to open-ended questions regarding their experiences in treating behavior problems in dementia with an emphasis on nonpharmalogical methods. This study serves to highlight both the issues encountered by those commonly asked to treat behavior problems in the nursing home, and the thoughtfulness and insight developed by some clinicians to address the problems. Several themes emerged from clinicians' responses. Some of the clinicians developed algorithms for treating behavior problems. Some of the clinicians were frustrated with the expectation that behavior problems would be effectively treated pharmacologically. The treatment of behavior problems was described as complex and requiring more time than is allocated by reimbursement systems. They also expressed the need for multiple systemic changes in order to improve treatment, and provided many examples of inadequate resources, including reimbursement, staff, activities, staff training, and management issues needed to improve treatment of behavior problems in nursing home residents. On the positive side, they reported a high level of satisfaction when treating behavior nonpharmacologically. The clinicians felt that with appropriate systemic change many behavior problems can be either prevented or treated effectively by nonpharmacological means.

Objective: This study examined barriers to hearing aid use among persons who were reported to have a hearing aid and among those reported to have hearing difficulties but no hearing aids., Setting: Interviews were conducted at a large, mid-Atlantic nonprofit nursing home., Participants: Both nursing home residents (279) and nursing staff members (51) were interviewed., Design and Measurements: In a cross-sectional survey of nursing home residents, brief structured interviews were performed by trained research assistants with both residents and caregivers to obtain information regarding residents' hearing ability, hearing aid use and daily maintenance, and potential barriers to such use., Results: Among residents reported to have hearing problems but who did not use a hearing aid, the major problem was neglect of the issue; participants did not know why residents did not have a hearing aid, residents had not had hearing evaluations, and staff members were not aware of hearing problems in residents. Among residents who did use a hearing aid, the majority (69%) of those for whom information was available had problems with the devices. The most common problems reported were that the device was hard or inconvenient to use, it did not fit well or hurt, and the device was not functioning well. The vast majority (86%) needed help taking care of the hearing aids. Close to half of the staff members had not received any training in the use or maintenance of the devices. Lack of delegation of responsibility for the management of hearing was identified for 29%, and relatives were used for maintenance of hearing aids in 14% of residents with hearing aids., Conclusions: Barriers to hearing aid use are therefore complex and multifactorial, involving lack of system commitment to utilization of hearing aids, lack of knowledge by staff members, inappropriate delegation and care procedures, hearing aid design and fit issues, and difficulties for residents in handling the hearing aids. Addressing these issues requires change on multiple levels, including change at the institutional level, concerning policy and training; change at the unit level, regarding care procedures and follow up; change at the individual level, providing better checks of fit and function of the hearing aids; and finally, change at the societal level, addressing design and cost issues for hearing aids in this population.

Unlabelled: Although hearing impairment is among the most common chronic ailments of older persons, the problem is even greater among those in nursing homes. It is estimated that 70% to 90% of elderly residents in long-term care facilities have some degree of hearing impairment. Despite this high prevalence, significant underuse of hearing aids or other assistive devices exists, especially among those with dementia., Objectives: The current study assessed rates of hearing impairment and hearing aid use among residents in a large, mid-Atlantic nursing home., Setting and Design: In a cross-sectional survey, interviews were conducted at a large, mid-Atlantic nonprofit nursing home., Participants: Reports were obtained from 279 resident-caregiver dyads, as well as from the Minimum Data Set (MDS) and research assistants performing the structured interviews., Measurements: Measures included the MDS and the Barriers to Hearing Aid Use Questionnaire, which was developed for this study., Results: Results show an inconsistency in reports of both hearing impairment and hearing aid use by multiple sources, as well as the underuse of hearing aids. These inconsistencies suggest that gross hearing impairment is undetected in clinical practice in over half of the residents., Conclusion: The findings highlight the need for regular hearing assessments in the nursing home population. They also suggest the need for evaluation of institutional-level policies regarding screening and hearing aid management, as well as the need for further information regarding potential barriers to effective hearing aid use. These issues are addressed in part 2 of this study following this report.

Alterations in the proteome of Arabidopsis thaliana leaves during early responses to challenge by Pseudomonas syringae pv. tomato DC3000 (DC3000) were analysed using two-dimensional (2D) gel electrophoresis. Protein changes characteristic of the establishment of basal resistance and R-gene mediated resistance were examined by comparing responses to DC3000, a hrp mutant and DC3000 expressing avrRpm1 respectively. The abundance of selected transcripts was also analysed in GeneChip experiments. Here we present data from the soluble fraction of leaf protein, highlighting changes in two antioxidant enzyme groups; the glutathione S-transferases (GSTs F2, F6, F7 and F8) and peroxiredoxins (PrxA, B and IIE). Members of both enzyme groups showed signs of specific post-translational modifications, represented by multiple spots on gels. We suggest that oxidation of specific residues is responsible for some of the spot shifts. All forms of the GST proteins identified here increased following inoculation with bacteria. GSTF8 showed particularly dynamic responses to pathogen challenge, the corresponding transcript was significantly up-regulated by 2 h after inoculation, and the protein showed post-translational modifications specific to an incompatible interaction. Differential changes were observed with the peroxiredoxin proteins; PrxIIE and to a lesser extent PrxB, no change was observed with PrxA, but a truncated form PrxA-L was greatly reduced in abundance following bacterial challenges. Our data suggest that bacterial challenge generally induces Prxs and the antioxidants GSTs, however individual members of these families may be specifically modified dependent upon the virulence of the DC3000 strain and outcome of the interaction. Finally, proteomic and transcriptomic data derived from the same inoculation system are compared and the advantages offered by 2D gel analysis discussed in light of our results.

This paper examines the validity of the Minimum Data Set (MDS), a comprehensive functional assessment used in most United States nursing homes, for recognizing pain in cognitively impaired nursing home residents. Eighty nursing home residents participated in the study. They were initially divided into four groups, along two dimensions: severe vs. mild/moderate cognitive impairment, and pain-medicated vs. non-medicated for pain. Three indicators of pain were derived from the MDS: pain frequency, pain intensity, and number of sites with pain. Geriatricians from outside the nursing home assessed the medical condition of the residents and their associated pain levels. Residents were asked to report on their level of pain. The three MDS indicators were highly intercorrelated. According to these indicators, 34-39% of the residents suffered from pain. Some correlations between self-report of pain and MDS ratings were significant among those with mild/moderate impairment, but not for those with severe impairment. Similarly, some correlations between MDS ratings and the geriatricians' ratings were significant for those with mild/moderate impairment but not for those with severe impairment. Persons with mild/moderate cognitive impairment were rated by the MDS as having more pain than those with severe impairment. The findings reveal that the MDS underreports pain in cognitively impaired residents. Given the centrality of the MDS in the U.S. as a tool for clinical decision-making in long-term care, there seems to be an urgent need to improve either the MDS pain assessment tools or the procedures used for completing them.

Background: There is a paucity of controlled trials comparing the merits of different heart valve prostheses. In this prospective randomized trial we compared Starr Edwards and St. Jude prostheses in the aortic and mitral positions., Methods: Two hundred sixty-seven patients and 122 patients undergoing aortic and mitral valve replacement, respectively, were allocated by minimization to receive either St. Jude or Starr Edwards prostheses. Patients (2 patients were lost to follow-up) were followed up in a special clinic. Event definition, recording, and reporting were in accordance with published guidelines., Results: There were no demographic differences between patients receiving the two different valve models. With the exception of infective endocarditis, we found no differences in the rates of death or complication between patients receiving a Starr Edwards prosthesis or a St. Jude prosthesis in either position. Neither were there any differences between the two valve models in either position, in terms of symptomatic relief 5 years after surgery., Conclusions: We found no differences in rates of complication or of symptomatic improvement between the Starr Edwards and St. Jude valve prostheses in either aortic or mitral position. Left ventricular function had such a marked effect on long-term survival that it overwhelmed any differences that might exist between different prosthetic designs. This confirms that historical comparisons are of limited value in deciding the respective merits of heart valve prostheses. The most reliable method of assessing surgical procedures is through prospective controlled trials.

To assess the utility of relatives' assessments of pain in cognitively impaired nursing home residents, the internal consistency of these assessments, and their relationship to other assessments of pain, was examined in a correlational study of 79 residents of a large suburban nursing home. The cohort was 85% female and had an average age of 87 years. The sample included moderately and severely cognitively impaired residents, some of whom were taking pain medication. The results demonstrated that relatives were less likely to rate the pain of the resident when the resident's cognitive level was more impaired and when they had a longer stay in the nursing home. The internal consistency of the relatives' ratings were good and, when only relatives who visited at least once a week were included, correlated significantly with most Minimum Data Set (MDS), resident, physician, and nursing staff ratings. They also correlated significantly with frequency of visits, higher cognitive function, type of relationship with the resident, and with a shorter stay in the nursing home. Relatives' ratings of pain and of past sources of pain may prove useful in the detection of pain in cognitively impaired persons. However, relative's pain ratings are only useful when relatives visit regularly. Like other informants, relatives have more difficulty rating pain when the resident is severely cognitively impaired.

Many couples presenting for preimplantation genetic diagnosis (PGD) for a single gene disorder are of advanced reproductive age (>35 years) and have a greater chance of producing embryos with chromosomal aneuploidies. The most common chromosomal aneuploidy observed in newborns is trisomy 21, or Down's syndrome. Consequently, the availability of a highly reliable system that simultaneously detects the heritable gene disorder and trisomy 21 would be beneficial to couples at specific risk. A pentaplex chromosome 21 (Ch 21) single-cell DNA fingerprinting system was developed in a multiplex fluorescence polymerase chain reaction (FL-PCR) on single cells. High reliability and accuracy rates were observed, together with low allele dropout (ADO) and preferential amplification rates on diploid buccal cells, trisomy 21 buccal cells and blastomeres derived from Ch 21 aneuploid embryos. A combined multiplex FL-PCR format was optimized with the common cystic fibrosis delta F508 mutation and validated on single buccal cells from a carrier of the cystic fibrosis delta F508 mutation. This new test is a very powerful technique, which also allows confirmation of the embryo parentage and the identification of extraneous DNA contamination that could cause a misdiagnosis in PGD cases.

This study compared the utility of different health indicators in frail older people, as a component of a larger study of medical evaluations of 183 adult day care participants in five Maryland centers. Indices examined included: number of disease categories, number of active categories, number of severe categories, number of categories with worsening trajectory, and average severity score. In predicting survival, none of the medical indicators without dementia was a strong predictor of survival. When dementia was included, number of categories with worsening trajectory seemed to be the best indicator of survival, with average severity score being a close second. Among the diagnoses, dementia and its severity were the strongest predictors of survival. Prediction of continuous stay in the community (in contrast to death or entry into a nursing home) was significant for most indices and is easier to predict from medical indices than death. Different indicators provided best utility depending on the criterion applied.

Inappropriate behaviors are very common in dementia and impose an enormous toll both emotionally and financially. Three main psychosocial theoretical models have generally been utilized to explain inappropriate behaviors in dementia: the "unmet needs" model, a behavioral/learning model, and an environmental vulnerability/reduced stress-threshold model. A literature search yielded 83 nonpharmacological intervention studies, which utilized the following categories of interventions: sensory, social contact (real or simulated), behavior therapy, staff training, structured activities, environmental interventions, medical/nursing care interventions, and combination therapies. The majority are reported to have a positive, albeit not always significant, impact. Better matching of the available interventions to patients' needs and capabilities may result in greater benefits to patients and their caregivers.

A noninvasive tool for skin tumor diagnosis would be a useful clinical adjunct. The purpose of this study was to determine whether near-infrared spectroscopy can be used to noninvasively characterize skin lesions. In vivo visible- and near-infrared spectra (400--2500 nm) of skin neoplasms (actinic keratoses, basal cell carcinomas, banal common acquired melanocytic nevi, dysplastic melanocytic nevi, actinic lentigines, and seborrheic keratoses) were collected by placing a fiberoptic probe on the skin. Paired t tests, repeated measures analysis of variance and linear discriminant analysis were used to determine whether significant spectral differences existed and whether spectra could be classified according to lesion type. Paired t tests showed significant differences (p < 0.05) between normal skin and skin lesions in several areas of the near-infrared spectrum. In addition, significant differences were found between the lesion groups by analysis of variance. Linear discriminant analysis classified spectra from benign lesions compared with premalignant or malignant lesions with high accuracy. Near-infrared spectroscopy is a promising noninvasive technique for the screening of skin lesions.

The authors studied patients age 60 and over to assess the effect of elective surgery as a precipitating factor for cognitive decline over the postoperative year. They found an association between change in test performance and age, physical disability, and number of depressive symptoms. However, persistent decline in Mini-Mental State Exam scores was associated with identifiable factors related to the initial surgery in only 3/ 251 (1 percent of cases). Depression and new onset of acute illness were confounding factors in the assessment of cognitive decline.

A number of medical applications of near-infrared spectroscopy are growing closer to clinical acceptance, and new techniques involving both spectroscopy and imaging are evolving rapidly. In vivo spectroscopy and, more recently, imaging techniques are largely based upon optical electronic transitions involving the metal centers of hemoglobin (blood), myoglobin (muscle) and cytochrome aa3 (mitochondria). The wide variety of near-IR based applications includes heart and stroke research, monitoring cerebral oxygenation of premature babies, and 'functional activation' (response of brain to mental tasks). All of these applications are founded upon changes in hemoglobin O2 saturation; these changes are monitored by following trends in the near-infrared absorptions of deoxyhemoglobin (760 nm) and oxyhemoglobin (920 nm). The same absorptions provide a basis for imaging regional variations in blood oxygenation. This report presents and discusses examples, both from the literature and from our recent work, of near-infrared spectroscopy and imaging in medical applications.

A prospective cohort study was conducted to examine predictors of mortality in the nursing home. Participants were 399 long-term nursing home residents, who were followed up for 11 years at the end of which 380 had died, 16 were still alive, 2 were discharged with unknown status, and 1 was alive when discharged. The median duration from baseline to death was 2.75 years. For cognitively intact residents, male gender, larger number of medical diagnoses, and manifestations of physically nonaggressive agitated behaviors (e.g., restlessness, pacing) were significant predictors. For cognitively impaired residents, the significant predictors were older age, impaired activities of daily living, and screaming behavior at a high frequency. Cognitive impairment is important both in predicting death in this population and in understanding the impact of other predictors. The impact of agitated behaviors, quality of social relations, and appetite on mortality highlights issues of quality of life at the end of life.

Resistance to African trypanosomes is dependent on B cell and Th1 cell responses to the variant surface glycoprotein (VSG). While B cell responses to VSG control levels of parasitemia, the cytokine responses of Th1 cells to VSG appear to be linked to the control of parasites in extravascular tissues. We have recently shown that IFN-gamma knockout (IFN-gamma KO) mice are highly susceptible to infection and have reduced levels of macrophage activation compared to the wild-type C57BL/6 (WT) parent strain, even though parasitemias were controlled by VSG-specific antibody responses in both strains. In the present work, we examine the role of IFN-gamma in the induction of nitric oxide (NO) production and host resistance and in the development of suppressor macrophage activity in mice infected with Trypanosoma brucei rhodesiense. In contrast to WT mice, susceptible IFN-gamma KO mice did not produce NO during infection and did not develop suppressor macrophage activity, suggesting that NO might be linked to resistance but that suppressor cell activity was not associated with resistance or susceptibility to trypanosome infection. To further examine the consequence of inducible NO production in infection, we monitored survival, parasitemia, and Th cell cytokine production in iNOS KO mice. While survival times and parasitemia of iNOS KO mice did not differ significantly from WT mice, VSG-specific Th1 cells from iNOS KO mice produced higher levels of IFN-gamma and IL-2 than cells from WT mice. Together, these results show for the first time that inducible NO production is not the central defect associated with susceptibility of IFN-gamma KO mice to African trypanosomes, that IFNgamma-induced factors other than iNOS may be important for resistance to the trypanosomes, and that suppressor macrophage activity is not linked to either the resistance or the susceptibility phenotypes., (Copyright 1999 Academic Press.)

Infrared (IR) spectroscopy applied to tissue sections yields complex spectra that provide a molecular fingerprint of the tissue. We have studied a cohort of 77 breast tumors by IR spectroscopy to develop an objective method for the assignment of grade of breast tumors. Although the major variations between spectra from different tumors were in absorptions arising from triglycerides (adipose tissue) and collagen, subtle changes in spectra could be detected that were independent of cellularity and tissue composition. Using a specific multivariate pattern recognition strategy to associate these changes in spectra with different tumor grades, we then were able to accurately reclassify tumors by grade (87% accuracy; kappa = 0.835). A similar approach allowed classification of steroid receptor status (93% accuracy; kappa = 0.852). We conclude that IR spectroscopy may have clinical utility in the objective assignment of breast tumor grade.

The frequency of the manifestation of delusions and hallucinations (d/h) among participants of adult day care centers was examined, as was the relationship of d/h to demographic and medical variables, agitation, depressed affect, and dementia. Changes in d/h were also assessed over a 1-year period, and those changes were compared with changes in agitation, depressed affect, and dementia. Depressed affect and agitation were related both to delusions and to hallucinations. Dementia was also related to d/h, although a substantial percentage of individuals who were not diagnosed with dementia also experienced some type of d/h. Finally, delusions were more prevalent and generally tended to relate more strongly to agitation, depressed affect, and dementia than did hallucinations.

The aim of this study is to compare the assessment of pain in 200 elderly persons participating in five senior day care programs, as rated by family caregivers, day care staff members, and the participants themselves. Staff members and participants provided information in a face-to-face interview. Family members provided information about the participants and their demographic characteristics via a mailed questionnaire. Agreement rates among informants ranged between 63% and 69%, showing moderate agreement rates. Health status (as reflected in number of medications taken and the presence of a diagnosis of musculoskeletal disease) and depression were associated with ratings of pain by all the informants. The assessment of pain in the elderly population is very difficult and there is a need for reliable and valid pain assessments to be used by different raters. The relationship between pain, depression and other variables should be further explored.

The authors report on a sample of 108 subjects over 60 years old who underwent cataract surgery and were assessed for cognitive and affective changes before surgery and at 1 week, 6 weeks, 6 months, and 1 year postoperatively. Cataract surgery did not predispose to significant cognitive deterioration in the perioperative period nor during the first postoperative year. However, objective vision changes, the subjective measure of adjustment to the effects of surgery, and a high depression score before surgery were significant predictors of depression at the end of the study year., (Copyright © 1996 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

A prospective study of vision-related outcomes of cataract surgery as well as cognitive functioning, activities of daily living (ADL) functioning, and depressed affect was conducted with 19 nursing home residents scheduled for cataract surgery. Also studied were 22 candidates for cataract surgery who decided against it. Comparison of both groups at baseline revealed that residents who chose cataract surgery were less cognitively and ADL impaired. Analysis after cataract surgery showed that visual acuity improved significantly at 4 months and was maintained at 1 year after surgery.