Usefulness of Community Pharmacy for Early Detection of Cognitive Impairment in Older People Using the IQ-CODE Questionnaire.

BACKGROUND: People with cognitive impairment (CI) need to be identified early because of the risk of progression to dementia. OBJECTIVES: The primary objective of the study was to analyze the usefulness of the community pharmacy for early detection of CI in older people through their caregivers. As secondary objective the risk factors related to IQ-CODE classification of risk of CI were identified. DESIGN: A cross-sectional observational study was designed. SETTING: Caregivers were selected by pharmacists from Spanish community pharmacies. PARTICIPANTS: Subjects with a close relationship to persons over 70 years of age who were not previously diagnosed with CI and who did not live in a nursing home or were hospitalized participated in the study. MEASUREMENTS: The proportion of older people who were classified as "at risk of CI" was assessed using the Informant Questionnaire on Cognitive Decline in the Elderly (IQ-CODE), which was completed by the caregiver. RESULTS: A total of 197 pharmacists selected 910 caregivers with an average age of 53 years, 75.5% of whom were women. In 324 people over the age of 70 (38.5%), "risk of CI" was observed, increasing with age. The risk of CI was 4.3 times higher in older people who complained of memory loss (p<0.001), 2.5 times higher if they had had a stroke in the last two years (p=0.007), 1.9 times higher if they were smokers (p=0.045) and 1.6 times higher if they were diabetic (p=0.028). CONCLUSION: Detection of risk of CI from the community pharmacy showed prevalence figures consistent with the CI figures observed in the Spanish primary care setting, demonstrating the capacity of the community pharmacy to contribute to early detection of CI.

[Mild behavioural impairment as an antecedent of dementia: presentation of the diagnostic criteria and the Spanish version of the MBI-C scale for its evaluation]. / Deterioro comportamental leve como antecedente de la demencia: presentacion de los criterios diagnosticos y de la version española de la escala MBI-C para su valoracion.

INTRODUCTION: Neuropsychiatric symptoms are common in dementia and also in previous stages such as mild cognitive impairment. Their presence is related to greater conversion to dementia in cognitively healthy people or with mild cognitive impairment compared to those who do not suffer them. AIM: An international working group pertaining to the Alzheimer Association has proposed the concept of 'mild behavioral impairment' (MBI) to identify patients with mild neuropsychiatric symptoms and normal cognition or mild cognitive impairment and to study the further risk of developing dementia from any cause. A new scale, the Mild Behavioral Impairment-Checklist (MBI-C), has been developed for the assessment of MBI in clinical and research settings. DEVELOPMENT: Data on the greater risk of dementia in the presence of neuropsychiatric symptoms are shown to justify the development of the new concept of MBI, improving the previous attempts of categorization of these states. Diagnostic criteria of MBI and the process of creation of the MBI-C scale are described. The Spanish version is presented in this article. Finally, the next steps in the investigation of the concept and measurement of MBI and its future prospects are suggested. CONCLUSIONS: The new MBI criteria and their measurement using the MBI-C scale are promising for a better and earlier identification of patients at risk of developing dementia and as an aid to investigate the underlying neurodegenerative processes.

TITLE: Deterioro comportamental leve como antecedente de la demencia: presentacion de los criterios diagnosticos y de la version española de la escala MBI-C para su valoracion.Introduccion. Los sintomas neuropsiquiatricos son frecuentes en la demencia y tambien en estadios previos, como el deterioro cognitivo leve. Su aparicion se relaciona con mayor conversion a demencia en personas cognitivamente sanas o con deterioro cognitivo leve, en comparacion con las personas que no los presentan. Objetivo. Dar a conocer la importancia en las fases previas a la demencia del concepto 'deterioro comportamental leve' (DCoL) y mostrar los criterios consensuados de DCoL de la International Society to Advance Alzheimer's Research and Treatment. Estos criterios permitiran identificar a pacientes con sintomas neuropsiquiatricos leves y cognicion normal o deterioro cognitivo leve, y estudiar el riesgo ulterior de desarrollar demencia por cualquier causa. A su vez, se presenta una nueva escala, la Mild Behavioral Impairment-Checklist (MBI-C), para la valoracion clinica y en investigacion del DCoL. Desarrollo. Se muestran datos del mayor riesgo de demencia en presencia de sintomas neuropsiquiatricos para justificar el desarrollo del nuevo concepto de DCoL, que perfecciona los intentos previos de categorizacion de estos estados. Se describen los criterios diagnosticos de DCoL y el proceso de creacion de la MBI-C, y se presenta su version española. Finalmente, se plantean los proximos pasos en la investigacion del concepto y medicion del DCoL y sus perspectivas de futuro. Conclusiones. Los nuevos criterios de DCoL y su medicion mediante la MBI-C resultan prometedores de cara a una mejor y mas temprana identificacion de los pacientes con riesgo de desarrollar demencia y una ayuda para la investigacion de los procesos neurodegenerativos subyacentes.

[Psychological and behavioural symptoms of dementia: prevention, diagnosis and treatment]. / Sintomas psicologicos y conductuales de la demencia: prevencion, diagnostico y tratamiento.

INTRODUCTION: The psychological and behavioural symptoms of dementia (BPSD) [corrected] give rise to personal suffering, are the cause of added deterioration and worsen the economic and social cost of dementias. AIM: To offer a systematic approach to the prevention, diagnosis and treatment of BPSD. [corrected]. DEVELOPMENT: The study adopts a global perspective that takes into account biological, psychological and social factors in an attempt to avoid both excessive medicalisation and a purely psychology-based attitude. Satisfying basic needs, treating medical and psychiatric comorbidity, the adaptation of the setting, and the specific pharmacological treatment of dementia, as well as offering patients and their caregivers the counselling and support they need, all contribute to prevent the onset of BPSD. [corrected]. The diagnosis of BPSD [corrected] is based on the patient's medical history and on observation. It is useful to identify a primary or destabilising BPSD [corrected] on which to deploy hypotheses and specific treatments based on modifying the environment, drugs, non-pharmacological therapies and continuous assessment. Any action taken must be integrated within a person-focused care plan aimed at accomplishing the patients' and their caregivers' welfare and quality of life. CONCLUSIONS: BPSD [corrected] are the result of biological, psychological and social factors. In the present scenario, in which there are no curative treatments in most cases of dementia, a systematic and multidisciplinary approach aimed at preventing and treating BPSD [corrected] is a highly cost-effective therapeutic opportunity in both personal and social terms.

[A comparative study of the effectiveness and tolerability of a procedure involving slow dose-escalation of rivastigmine in patients with mild or moderate Alzheimer-type dementia: the SCALEX study]. / Estudio comparativo de la efectividad y tolerabilidad de un procedimiento de escalado lento de dosis de rivastigmina en pacientes con demencia tipo Alzheimer leve o moderada: estudio SCALEX.

AIMS: To determine and to compare the tolerability and effectiveness of a slow escalation of the dose of rivastigmine in patients with Alzheimer's disease with respect to using it with a faster escalation. PATIENTS AND METHODS: We conducted a multi-centre, naturalistic, open-label, randomised trial with 429 hospital outpatients diagnosed with Alzheimer-type dementia (according to DSM-IV and NINCDS-ADRA criteria) and in whom treatment with rivastigmine was clinically indicated. Two study groups were established: slow escalation and fast escalation (in accordance with usual clinical practice); effectiveness and tolerability variables were analysed in the two groups, as was the proportion of patients who reached therapeutic doses (> 6 mg/day). The scores obtained on the CGI, MMSE, NPI and Barthel index scales were analysed, together with adverse events and reactions concerning spontaneous communication, and scores on the UKU scale. RESULTS: The slow escalation group displayed slightly higher percentages of sub-therapeutic anticipated interruptions than the fast escalation group (chi-square test; p < 0.05). On comparing the two treatment groups, no statistically significant differences were observed for the evolution of the scores on the different scales of effectiveness; no statistically significant differences were found between the two groups in the safety and tolerability analyses (chi-square test, exact test; p > 0.05) for most of the parameters that were studied (adverse reactions in spontaneous communication and the modified UKU scale). CONCLUSION: Slow escalation of the dose of rivastigmine did not display greater effectiveness or tolerability in comparison to an escalation applied in accordance with usual clinical practice.

Estudio comparativo de la efectividad y tolerabilidad de un procedimiento de escalado lento de dosis de rivastigmina en pacientes con demencia tipo Alzheimer leve o moderada: estudio SCALEX / A comparative study of the effectiveness and tolerability of a procedure involving slow dose-escalation of rivastigmine in patients with mild or moderate Alzheimer-type dementia: the scalex study

Determinar y comparar la tolerabilidad y la efectividad de un escalado lento de dosis de rivastigminaen pacientes con enfermedad de Alzheimer frente a su uso en escalado más rápido. Pacientes y métodos. Estudio multicéntrico, naturalístico, abierto y aleatorizado con 429 pacientes ambulatorios diagnosticados de demencia tipo Alzheimer (según criterios DSM-IV y NINCDS-ADRA) y con indicación clínica de tratamiento con rivastigmina. Se determinaron dos grupos de estudio: escalado lento y escalado rápido (según práctica clínica habitual) y se analizaron variables de efectividad y tolerabilidadentre ambos grupos y la proporción de pacientes que alcanzaron dosis terapéuticas (> 6 mg/día). Se analizaron las puntuaciones en las escalas CGI, MMSE, NPI e índice de Barthel, acontecimientos y reacciones adversas de comunicación espontánea, y puntuaciones en la escala UKU. Resultados. El grupo de escalado lento presentó porcentajes ligeramente mayoresde interrupciones anticipadas subterapéuticas que el grupo de escalado rápido (test chi al cuadrado; p < 0,05). No se observaron diferencias estadísticamente significativas para la evolución en las puntuaciones de las distintas escalas de efectividad entre los dos grupos de tratamiento; en el análisis de tolerabilidad y seguridad tampoco se observaron diferencias estadísticamente significativas entre los grupos (test chi al cuadrado, prueba exacta; p > 0,05) para la mayoría de parámetros estudiados (reacciones adversas de comunicación espontánea y escala UKU modificada). Conclusión. El escalado lento de dosisde rivastigmina no demostró mayor eficacia ni mejor tolerabilidad frente a un escalado según la práctica clínica habitual

To determine and to compare the tolerability and effectiveness of a slow escalation of the dose of rivastigmine in patients with Alzheimer’s disease with respect to using it with a faster escalation. Patients and methods. We conducted a multi-centre, naturalistic, open-label, randomised trial with 429 hospital outpatients diagnosed with Alzheimer-type dementia(according to DSM-IV and NINCDS-ADRA criteria) and in whom treatment with rivastigmine was clinically indicated. Two study groups were established: slow escalation and fast escalation (in accordance with usual clinical practice); effectiveness and tolerability variables were analysed in the two groups, as was the proportion of patients who reached therapeutic doses(> 6 mg/day). The scores obtained on the CGI, MMSE, NPI and Barthel index scales were analysed, together with adverse events and reactions concerning spontaneous communication, and scores on the UKU scale. Results. The slow escalation group displayed slightly higher percentages of sub-therapeutic anticipated interruptions than the fast escalation group (chisquare test; p < 0.05). On comparing the two treatment groups, no statistically significant differences were observed for the evolution of the scores on the different scales of effectiveness; no statistically significant differences were found between the two groups in the safety and tolerability analyses (chi-square test, exact test; p > 0.05) for most of the parameters that werestudied (adverse reactions in spontaneous communication and the modified UKU scale). Conclusion. Slow escalation of the dose of rivastigmine did not display greater effectiveness or tolerability in comparison to an escalation applied in accordancewith usual clinical practice

Herbal products and serious side effects: a case of ginseng-induced manic episode.

OBJECTIVE: Ginseng root extract is a widely used herbal product not devoid of side effects. This report describes the development of manic symptoms after ginseng consumption in a patient with affective disorder. Other potentially harmful side effects of ginseng are also reviewed. METHOD: A single case report. RESULTS: A 56-year-old woman with previous affective disorder presented a manic episode during ginseng intake. Symptoms disappeared rapidly with low doses of neuroleptics and benzodiazepines after ginseng suppression. CONCLUSION: Ginseng may produce manic symptoms. A special risk situation seems to be affective patients under antidepressant medication. The case emphasizes the lack of harmlessness of herbal products. Patients should be routinely asked about the use of herbal products and diet supplements.

Patrones de uso ambulatorio de los antiguos y nuevos antidepresivos en pacientes geriátricos con depresión / Prescription patterns of older and newer antidepresants for geriatric depresive out-patients

Objetivos: Estudio del uso real que se hace de los medicamentos antidepresivos, en un episodio depresivo en población anciana, por parte de los psiquiatras de una red ambulatoria de salud mental. Material y método: Revisión de la evolución y manejo farmacológico de un episodio depresivo índice en 150 ancianos atendidos en el Área 11/Hospital 12 de Octubre de Madrid. Estudio de la eficacia de las distintas moléculas y la necesidad de cambios farmacológicos y estrategias de potenciación a lo largo del tratamiento en el episodio índice. Resultados: Demográficos: 75 por ciento mujeres. Edad media: 72,4 por ciento. Depresión mayor: 71 por ciento. Inicio tardío: 41 por ciento. Como primera opción los grupos terapéuticos más utilizados fueron: ISRS (48,6 por ciento) y tricíclicos (45 por ciento) y las moléculas: fluoxetina 26 por ciento, mianserina 13 por ciento y paroxetina 10 por ciento. Esta primera elección del tratamiento produjo una remisión satisfactoria en el 32,9 por ciento de los casos. El 53,3 por ciento de los casos precisó sólo un cambio de molécula, 23 por ciento recibió sólo dos moléculas, 16 por ciento tres, 5 por ciento cuatro y 11 por ciento cinco o más. En el primer cambio de molécula, el ISRS inicial fue sustituido por otro ISRS en el 48 por ciento de los casos y por un tricíclico en el 30 por ciento y en el caso de los tricíclicos éstos volvieron a ser utilizados como segunda opción en el 45 por ciento y se cambió a un ISRS en el 33 por ciento. Los patrones de uso de los tricíclicos y de los ISRS fueron básicamente semejantes y se utilizaron en la misma proporción, aunque globalmente las moléculas más utilizadas fueron fluoxetina, fluvoxamina y paroxetina. En ambos grupos las tasas de remisiones y de supresiones por intolerancia o ineficacia fueron similares, pero los tricíclicos se utilizaron en mayor proporción a medida que se efectuaban más cambios. (AU)

[Prescription patterns of older and newer antidepressants for geriatric depressive out-patients]. / Patrones de uso ambulatorio de los antiguos y nuevos antidepresivos en pacientes geriátricos con depresión.

OBJECTIVE: To study the prescription patterns of antidepressants for an elderly population. METHODS: 140 out-patients suffering an index depressive episode were studied and followed for at least one year. RESULTS: Demografics: 75% women. Mean age: 72.4%. Mayor depression: 71%. Late-onset: 41%. The most frequently used types the frist choice were SSRIs (48.6%) and Tricyclics (45%), the molecules initially most prescribed: Fluoxetine (26%), Mianserin (13%) and Paroxetin (10%). Initial choice of treatment achieves satisfactory remission in 32.9% of the cases. 57% of patients needed a frist malecule switch, 23% received only two molecules, 16% three, 5% four and 11% five molecules or more. After the first switch, the initial SSRI was substituted by another SSRI in 48% of the cases and by a Tricyclic in 30%. Initial Tricyclic chaged to a SSRI in 33% and another Tricyclic in 45%. The patterns of Tricyclics and SSRIs use were not essentially different and both were used globally in the same proportion, although the most prescribed molecules were Fluoxetine, Fluvoxamine and Paroxetine. Both groups achieved statistically similar number of remissions and suppressions by intolerance or ineficcacy but tricyclics were increasingly used from the frist switch onwards.

[Prevalence of psychiatric disorders in primary care using the PRIME-MD questionnaire]. / Prevalencia de los trastornos psiquiátricos en atención primaria usando el cuestionario PRIME-MD.

OBJECTIVE: To quantify the frequency of psychiatric disorders detected by primary care doctors, using the PRIME-MD questionnaire, and by psychiatrists using a structured clinical interview. DESIGN: An observational, descriptive, crossover study, using a questionnaire. One of each two patients was selected until reaching the total number of patients. SETTING: The study was conducted in five primary care centres in Madrid. PATIENTS: To be included in the study, patients had to consent verbally, be able to understand the questions asked and have been previously diagnosed as psychotic or demented. 395 patients were recruited, of which 312 completed the study. INTERVENTIONS: The primary care doctor administered the PRIME-MD questionnaire to each patient, and then a psychiatrist conducted the SCAN interview. RESULTS: The time spent by the doctor on the PRIME-MD questionnaire was usually 10 minutes. The doctor had previously detected psychiatric pathology in 18.5% of his/her patients; with the PRIME-MD questionnaire he/she detected it in 53.5%. The psychiatrist with the SCAN detected psychiatric pathology in 41.3% of patients. CONCLUSIONS: The high frequency of psychiatric disorders in primary care patients and primary care doctors' lack of ability in detecting these disorders was confirmed by this study. The PRIME-MD questionnaire, an instrument for rapid detection of the most commonly found psychiatric disorders within primary care, may considerably improve this situation.

[Capgras syndrome or delirium of doubles. Presentation of a new case]. / El síndrome de Capgras o delirio de dobles. A propósito de un nuevo caso.

Capgras syndrome is an unfrequent delusional disorder based on the patient's belief that a significant person for him or her, mainly the spouse, becomes a "double", undistinguishable from the real one, but threatening in some way. There are about two hundred reports of the syndrome in international psychiatric literature. This paper describes a new case in a woman aged 68, diagnosed of Major Affective Disorder, without signs of any other organic mental disease. The authors review some ethiological theories in relation with the disorder, which are contrasted with the characteristics of the new case.