Revealing an Uncertain Diagnosis
Should patients be told when the diagnosis is possible Alzheimer's disease? The argument for not revealing the diagnosis relies on the fact that a certain diagnosis of Alzheimer's disease can be made only at autopsy; until it is confirmed, the diagnosis is "possible" or "probable." In addition, the diagnosis becomes more certain as the disease progresses and patients become less able to understand the diagnosis and its implications. Furthermore, unlike cancer, which may be slowed by radiation or chemotherapy, there is as yet no cure or treatment for Alzheimer's disease, and the clinical progress is unusually imprecise.
However, if patients are told the truth, they may become involved in medical decision-making. Although the actual diagnosis and disease progression are uncertain, information is important for patients to formulate appropriate advance directives. Most people fear "losing their minds" as the disease progresses and may wish to express their thoughts while they still have the capacity. If they are not informed of potential outcomes, they may lose that ability before they carry out their wishes.
As more is discovered about Alzheimer's disease, diagnoses will be made with more certainty and treatments will become available, thus supporting the practice of revealing the diagnosis to patients.
Ultimately, however, each decision must be made on a case-by-case basis [N Engl JMed. 1992; 326:947-951].
Predicting Delirium in Hospitalized Elders
Delirium is common in hospitalized elderly patients, but if there was a way to predict which patients are at greater risk, it may be prevented. A recent study set out to identify the factors that put elderly patients at greater risk for developing delirium.
Of 291 patients who were not delirious on admission, 91 (31.3%) developed DSM-IHdefined delirium during their hospital stay. The two factors most highly associated with the development of delirium were age over 80 years and a history of prior cognitive impairment. Fracture on admission also contributed to an increased risk of developing delirium.
Symptomatic infection, but not fever, was also an independent predictor of delirium. There was no link between surgery and delirium, suggesting that surgery and anesthesia are not as closely related to delirium as previously thought. Rather, the use of narcotic pain medications in conjunction with surgery may be the critical factor. An analysis of the medications traditionally associated with delirium found that neuroleptics and narcotics increased the risk of delirium.
The authors noted that the study cannot be generalized to patients admitted to intensive care units or to those with severe sensory impairments. The study did indicate, however, that the strongest risk factors for delirium were present at admission; risks that occur in the hospital were of secondary importance, but may still be controlled (eg, preventing and promptly treating infection, avoidance of all unnecessary medications) [JAMA. 1992; 267:827-831].
Beware of Bsirogen Dependence
Is it possible for women to become addicted to hormone replacement therapy (HRT)? According to an article in The Lancet, the possibility of estrogen dependence does exist.
The authors note that drug dependence is influenced by the ability of the drug to produce pleasant or euphoric effects and its route of administration; drugs that rapidly produce euphoria are more likely to induce dependence, and those that are injected can produce dependence faster than those taken orally. Estrogen satisfies both of these conditions.
Estrogen is highly effective in treating conditions that are a part of the normal aging process, but clear indications for its use should be documented. The authors warn clinicians to monitor patients using DSM-IH-R criteria of dependence. Estrogen is safe therapy if it is carefully prescribed for specific, clear-cut reasons [Lancet. 1992; 339:290-291].