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Importance of integrating culturally competent care by caregivers for older people from different ethnic backgrounds who suffer from dementia is discussed. Methods of implementing such measures are also suggested.

Objective: The authors sought to determine whether integrated mental health services or enhanced referral to specialty mental health clinics results in greater engagement in mental health/substance abuse services by older primary care patients. Method: This multisite randomized trial included 10 sites consisting of primary care and specialty mental health/substance abuse clinics. Primary care patients 65 years old or older (N=24,930) were screened. The final study group consisted of 2,022 patients (mean age=73.5 years; 26% female; 48% ethnic minority) with depression (N=1,390), anxiety (N= 70), at-risk alcohol use (N=414), or dual diagnosis (N=148) who were randomly assigned to integrated care (mental health and substance abuse providers co-located in primary care; N=999) or enhanced referral to specialty mental health/substance abuse clinics (i.e., facilitated scheduling, transportation, payment; N=1,023). Results: Seventy-one percent of patients engaged in treatment in the integrated model compared with 49% in the enhanced referral model. Integrated care was associated with more mental health and substance abuse visits per patient (mean=3.04) relative to enhanced referral (mean=1.91). Overall, greater engagement was predicted by integrated care and higher mental distress. For depression, greater engagement was predicted by integrated care and more severe depression. For at-risk alcohol users, greater engagement was predicted by integrated care and more severe problem drinking. For all conditions, greater engagement was associated with closer proximity of mental health/substance abuse services to primary care. Conclusions: Older primary care patients are more likely to accept collaborative mental health treatment within primary care than in mental health/substance abuse clinics. These results suggest that integrated service arrangements improve access to mental health and substance abuse services for older adults who underuse these services.

This article examines the challenges Japan faces with extreme population aging and lack of adequate social services. The author, focusing on family relations, health services, retirement, and the economic well-being of the aged, maintains there is an increased demand for social and health services for the aged, but a declining tax base to provide these services as a large portion of the population settles into retirement.

* We evaluated the occurrence and persistence of delirium in 325 elderly patients admitted to a teaching hospital from either a defined community or a long-term care facility. Of the study participants, 34 (10.5%) had Diagnostic and Statistical Manual of Mental Disorders, Third Edition-defined delirium at initial evaluation; of the remaining patients, 91 (31.3%) developed new-onset delirium. An additional 110 patients also experienced individual symptoms of delirium without meeting full criteria. Preexisting cognitive impairment and advanced age were associated with increased risk of incident delirium in the community sample but not the institutional one. Delirium was not associated with an increased risk of mortality, but it was associated with a prolonged hospital stay and an increased risk of institutional placement among community-dwelling elderly. Only five patients (4%) experienced resolution of all new symptoms of delirium before hospital discharge, and only 20.8% and 17.7%, respectively, had resolution of all new symptoms by 3 and 6 months after hospital discharge. These data suggest that delirium is a common disorder that may be substantially less transient than currently believed and that incomplete manifestations of the syndrome may be frequent. (Arch Intern Med. 1992;152:334-340)

* We studied the serum albumin level within 48 hours of hospitalization for acute illness to predict in-hospital death, length of stay, and readmission in 15 511 patients older than 40 years. Patients with low serum albumin levels (

Association of impaired neuropsychological performance and cognition with delirium after coronary artery bypass graft (CABG) surgery is examined.

The merits of combining qualitative and quantitative methods are well known. While used often in evaluation research, a combined methods approach is rarely used in health studies with minority elders. This approach can be particularly useful for overcoming theoretical and recruitment problems specific to health research with minority elders. A cross-cultural study of family caregiving for demented-affected elders is presented to show how issues of rigor, theory building, language, and cultural adaptation of diagnostic tools can be effectively dealt with using combined methods. Specifically, the authors found qualitative data valuable in ensuring the cultural appropriateness of quantitative measures and in confirming causal relationships to which quantitative data pointed. They also found applying quantitative data collection techniques to qualitative data collection to be useful in theory building and in overcoming some of the reliability problems associated with qualitative data.

Conflict between caregivers and their family members has been examined in relation to caregiver burden. However, specific theoretical models have not been applied to analyses of caregiver family conflicts. Nor has there been much research on the family conflicts of ethnic minority caregivers. Using Selman's1 interpersonal conflict strategies and their related levels of social perspective coordination as our framework, we content analyzed conflict reports of African-American and Chinese-American caregivers. Overall, there were more similarities in the strategies and social perspective coordination levels of the two groups than differences. In narratives where conflict was present (78 percent), about half of caregivers in both groups reported higherlevel conflict strategies, and half reported lower-level strategies. More advanced social perspective coordination seemed associated with greater satisfaction with family sharing of responsibilities in both groups. If these data patterns bear up under further testing, training in conflict resolution and social perspective coordination skills may prove an effective means of fostering better social relationships and sharing arrangements between caregivers and family members, and be a worthwhile complement to existing stress reduction interventions for caregivers.

The authors examined whether there are differences in the determinants of physician use between aged and middle-aged individuals. Data were obtained through interviews and medical records from a probability sample of 460 individuals aged 45-89 years old. Physical health measures were important predictors for both age groups, but there were differences in the relative importance of specific variables. The number of diagnoses was more important in predicting physician use for the middle-aged and bed days was more significant for the aged. Psychologic factors played a slightly greater role in predicting physician use for the aged, and enabling and predisposing variables were somewhat more important for the middle-aged. Utilization during the year before the interview was associated with subsequent physician use for both age groups, but the correlation was weaker among the aged. Age differences in the predictors of physician use are believed to result from the unique illness response elicited by chronic, as opposed to acute, illness.

A better understanding of the processes through which elderly individuals perceive, evaluate, and act on symptoms will enable physicians to respond more appropriately to the needs of older patients. This paper reviews existing evidence on how the experience of chronic disease and the atypical presentation of symptoms influence symptom recognition and reporting among elderly individuals. A discussion of research on health perceptions suggests that some elderly may inappropriately deny illness and delay seeking medical care, while others with overly negative health perceptions may make excessive physician visits. An overview is presented of the process by which elderly individuals come to seek care from their physicians, combining evidence from the diverse literatures on chronic illness, atypical presentation of disease, and health perceptions. We conclude by discussing the practical implications of this information for clinicians working with the elderly.

We analyzed factors associated with the discharge diagnosis of delirium among 1,285 patients admitted to a major teaching hospital during a 2‐year period, developed a model to classify the risk of developing delirium on the basis of clinical and diagnostic data, and tested the model on 471 patients admitted during the subsequent year. Using the multivariate technique of recursive partitioning, we identified four factors that distinguished 80% of all cases of delirium: 1) a urinary tract infection at any time during the hospital stay (odds ratio = 3.1; 95% confidence interval = 2.02–4.58); 2) no urinary tract infection, but low serum albumin on admission (odds ratio = 2.4; 95% confidence interval = 1.43–3.99); 3) neither urinary tract infection nor low serum albumin, but elevated white blood cell count on admission (odds ratio = 1.99; 95% confidence interval = 1.18‐3.37); 4) none of these risk factors, but proteinuria on admission (odds ratio = 1.82; 95% confidence interval = 2.25–2.66). Patients without any of these four risk factors had the lowest probability of developing delirium during their hospital stay. Among individuals with delirium, in‐hospital mortality and hospital charges were higher. The model developed accurately characterized the risk of delirium when it was tested on patients admitted to the same hospital during the subsequent year.

To study delirium in hospitalized elderly, a delirium symptom interview (DSI) was developed by an interdisciplinary group of investigators. This interview was administered in an acute care hospital to 50 patients who were over the age of 65 years. Results from the interview were compared to assessments of major symptoms of delirium made independently by a neurologist and a psychiatrist. This interview had good validity and reliability. The sensitivity of the DSI was .90 and the specificity was .80, when compared with the clinical judgment of a psychiatrist and neurologist. Interrater reliability, using lay interviewers, was .90 for the detection of major symptoms of delirium. These results indicate that the DSI could be used by lay interviewers to assess reliably the symptoms of delirium. (J Geriatr Psychiatry Neurol1992;5:14–21).

Antiretroviral therapy (ART) is the primary treatment for HIV, and adherence to it is crucial to addressing health disparities. Approximately half of individuals in the United States living with HIV are African Americans, and those over 45 years of age are more likely to die early from HIV/AIDS than their White counterparts. This mixed-method pilot study evaluated the feasibility of a text-based mobile phone intervention designed to improve ART adherence among older African Americans with HIV. Feasibility was assessed via implementation, participant adherence, acceptability, and satisfaction, as well as short-term impact on medication adherence, adherence-related self-efficacy, and positive affect. The intervention utilized pill reminder, motivational, and health educational texts. Participants (N= 21) ranged in age from 50 to 68 years. Outcomes were evaluated via quantitative results from self-report measures and qualitative data from four focus groups. There was no attrition in participation. After 8 weeks, participants reported statistically significant improvements in medication adherence, but not in self-efficacy or affect scores. Qualitative findings highlight the psychologically supportive potential of the intervention, challenges to adherence, as well as suggestions for improvement. The study demonstrates that a text messaging intervention may be feasible for older African Americans with HIV, and helpful in supporting ART adherence.

The value of different models for predicting treatment decisions of physicians, nurses, and social workers within acute and long term care settings was examined. Treatment choices were elicited to two case vignettes regarding decisions to allocate a scarce medical resource and to withhold treatment from a debilitated patient. Predictors of decisions varied between the vignettes. Primarily medical factors predicted the decision to allocate scarce resources, whereas a combination of medical, societal, and situational factors predicted the decision to withhold treatment.

To examine knowledge of geriatric health policies a 20-question true or false quiz was distributed to 541 physicians training in medicine, surgery, and psychiatry. Only 154 (28.5%) were returned, reflecting an unknown degree of disinterest in geriatrics. Among the respondents there was a widespread lack of knowledge that could interfere with physicians ability to use the health care system appropriately for patients benefit and to function effectively as a gatekeeper to health care utilization.