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.

Is it time to revise the diagnostic criteria for apathy in brain disorders? The 2018 international consensus group.

BACKGROUND: Apathy is a very common behavioural and psychological symptom across brain disorders. In the last decade, there have been considerable advances in research on apathy and motivation. It is thus important to revise the apathy diagnostic criteria published in 2009. The main objectives were to: a) revise the definition of apathy; b) update the list of apathy dimensions; c) operationalise the diagnostic criteria; and d) suggest appropriate assessment tools including new technologies. METHODS: The expert panel (N = 23) included researchers and health care professionals working on brain disorders and apathy, a representative of a regulatory body, and a representative of the pharmaceutical industry. The revised diagnostic criteria for apathy were developed in a two-step process. First, following the standard Delphi methodology, the experts were asked to answer questions via web-survey in two rounds. Second, all the collected information was discussed on the occasion of the 26th European Congress of Psychiatry held in Nice (France). RESULTS: Apathy was defined as a quantitative reduction of goal-directed activity in comparison to the patient's previous level of functioning (criterion A). Symptoms must persist for at least four weeks, and affect at least two of the three apathy dimensions (behaviour/cognition; emotion; social interaction; criterion B). Apathy should cause identifiable functional impairments (criterion C), and should not be fully explained by other factors, such as effects of a substance or major changes in the patient's environment (Criterion D). CONCLUSIONS: The new diagnostic criteria for apathy provide a clinical and scientific framework to increase the validity of apathy as a clinical construct. This should also help to pave the path for apathy in brain disorders to be an interventional target.

[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.

Brain Donation by Proxy: Are There Predictors in Neurodegenerative Dementia?

OBJECTIVES: To describe the frequency and predictors of brain donation by relatives in patients with neurodegenerative dementia. DESIGN: Database review and quantitative analysis. SETTING: The Alzheimer Center Reina Sofia Foundation (ACRSF), a center devoted to the care and research of patients with neurodegenerative dementia. PARTICIPANTS: Patients with signed consent for participation in the ACRSF research program. MEASUREMENTS: A set of 38 demographic, clinical, and social variables related to patient and closest relative, which were collected by the ACRSF multidisciplinary team upon patient admission. RESULTS: Admission data were available for 198 patients who entered the ACRSF research program; 85 of them (42.9%) died during follow-up. Mean age (SD) at admission was 82.3 (6.8) years and 80.8% of the patients were female. Family link between patient and closest relative was spouse or partner (12.0%), son or daughter (74.9%), or other link (13.1%). Brain was obtained from 56 patients (65.9%). Consent by legal representative and patient's depressive symptoms were more frequent in the donors (p<0.05, corrected) and trend was observed for more aberrant motor symptoms in the donors (p<0.05, uncorrected). CONCLUSION: A high rate of brain donation was achieved, probably due to the unique characteristics of the ACRSF and consent for research policy. Wish of alleviating suffering, as well as general interest in dementia research, possibly exerted an influence in brain donation. More research is needed to ascertain the values, motivations, and circumstances that may lead to brain donation by proxy in neurodegenerative dementia.

Unexplained pain complaints and depression in older people in primary care.

OBJECTIVE: Chronic pain and depression are frequent conditions in primary care patients. Depression is frequently overlooked in the presence of pain of uncertain origin. The aim is to measure the prevalence and clinical correlates of unrecognized comorbid mood disorders and chronic pain of uncertain origin in older primary care patients, and to elucidate the differences with younger adults with the same conditions. DESIGN: Cross-sectional study. SETTING: Primary care centres in Spain. PARTICIPANTS: Patients (n= 2720) with persistent pain of uncertain origin. MEASUREMENTS: Pain characteristics, sites and intensity (Visual Analogical Scales), depression (PRIME-MD interview), clinical characteristics and health services use. RESULTS: We observed a similarly high (80.5%) prevalence of undiagnosed mood disorders (especially major depressive disorders) among older and younger adult patients with comorbid chronic pain complaints of uncertain origin. Older patients suffered pain that was more intense, longer lasting and located in a higher number of different areas, when compared to younger patients. Pain intensity was a factor associated with suffering from mood disorders among patients above 65 years, whilst the number of pain sites was a more important factor among younger patients. CONCLUSIONS: Depression is highly associated with pain of uncertain origin in older patients with differences in pain characteristics when compared to younger patients. The robust comorbid relationship between both conditions should alert clinicians to specifically look for depression in the presence of poorly explained painful symptoms.

[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.

Consenso de la SEPG sobre la depresión en el anciano / Consensus of the SEPG on depression in the elderly

Antecedentes. La limitación del conocimiento clínico epidemiológico y de la evidencia sobre efectividad terapéutica en la depresión en los pacientes ancianos y muy ancianos genera una excesiva variabilidad de prácticas en la atención clínica a estos pacientes en nuestro sistema sanitario. La Sociedad Española de Psicogeriatría (SEPG) se plantea la necesidad de unificar criterios mediante un método estructurado de consenso profesional. Objetivos. Desarrollar un consenso experto de recomendaciones clínicas para optimizar el abordaje clínico de la depresión en el paciente anciano en España, bajo auspicio de la Sociedad Española de Psicogeriatría (SEPG).Métodos. Consenso Delphi modificado en dos rondas. El estudio se efectuó en cuatro fases: 1) constitución de un comité científico, impulsor del proyecto y responsable de la revisión bibliográfica y de la formulación de las recomendaciones a debate; 2) constitución de un panel experto multicéntrico con representantes de la especialidad; 3) encuesta postal en dos rondas con procesamiento intermedio de opinión ese informe a los panelistas; y 4) discusión de resultados en sesión presencial del comité científico. Resultados. 61 expertos consultados completaron las dos rondas de evaluación del cuestionario. En la primera rondase logran consensuar 39 de las 54 cuestiones analizadas. Tras la interacción del panel se aumenta el consenso hasta un total de 46 ítems de la encuesta (85% de los contenidos propuestos). En las 8 cuestiones restantes no se consigue un consenso suficientemente unánime, bien por disparidad de opiniones entre los profesionales, bien por falta de criterio establecido en la mayoría de los expertos. Conclusiones. Se presenta un amplio listado de criterios profesionales y recomendaciones clínicas que pretenden racionalizar el manejo de la depresión en el paciente anciano y reducir el exceso de variabilidad en la práctica clínica. Las recomendaciones se cualifican según el grado de acuerdo profesional en que se sustentan y pueden considerarse vigentes hasta la aparición de nueva información científica que justifique su revisión (AU)

Background. The limitation of clinical-epidemiological know-how and evidence regarding therapeutic efficiency in depression among the elderly and extremely elderly patients has given rise to an excessive variety of practices in clinical care of these patients in the Spanish health system. The Spanish Society of Psychogeriatrics (SEPG) has raised the question of the need to unify criteria through a structured approach based on professional consensus. Objectives. To develop an expert consensus of clinical recommendations to improve the clinical treatment of depression in elderly patients in Spain, sponsored by the Spanish Society of Psychogeriatrics (SEPG). Methods. Modified Delphi Consensus, in two rounds. The study was conducted in four phases: 1) constitution of a Scientific Committee, project promoter and responsible for bibliographic review and formulation of recommendations for discussion 2) constitution of a multicenter Panel of Experts with representatives from this specialist field 3) postal survey comprised of two rounds, with interim processing of opinions and a report for the experts and 4) discussion of results during an onsite meeting of the Scientific Committee. Results. The survey evaluation was completed by 61experts consulted, in two rounds. In the first round, consensus was reached in 39 of the 54 questions analyzed. Following interaction by the panel, this consensus was increased to a total of 46 survey items (85% of the proposed contents). It was impossible to obtain a sufficiently unanimous consensus on the remaining 8questions, either due to differences of opinion among the professionals or a lack of established criterion in most of the experts. Conclusions. A full list of criteria and clinical recommendations for the purpose of rationalizing the treatment of depression in elderly patients and reducing excessive variability in clinical practice is presented. The recommendations are qualified in accordance with the degree of consensus of the professionals endorsing the mand can be considered valid until new scientific information becomes available that justifies their review (AU)

Consensus of the SEPG on depression in the elderly.

BACKGROUND: The limitation of clinical-epidemiological know-how and evidence regarding therapeutic efficiency in depression among the elderly and extremely elderly patients has given rise to an excessive variety of practices in clinical care of these patients in the Spanish health system. The Spanish Society of Psychogeriatrics (SEPG) has raised the question of the need to unify criteria through a structured approach based on professional consensus. OBJECTIVES: To develop an expert consensus of clinical recommendations to improve the clinical treatment of depression in elderly patients in Spain, sponsored by the Spanish Society of Psychogeriatrics (SEPG). METHODS: Modified Delphi Consensus, in two rounds. The study was conducted in four phases: 1) constitution of a Scientific Committee, project promoter and responsible for bibliographic review and formulation of recommendations for discussion 2) constitution of a multicenter Panel of Experts with representatives from this specialist field 3) postal survey comprised of two rounds, with interim processing of opinions and a report for the experts and 4) discussion of results during an on-site meeting of the Scientific Committee. RESULTS: The survey evaluation was completed by 61 experts consulted, in two rounds. In the first round, consensus was reached in 39 of the 54 questions analyzed. Following interaction by the panel, this consensus was increased to a total of 46 survey items (85% of the proposed contents). It was impossible to obtain a sufficiently unanimous consensus on the remaining 8 questions, either due to differences of opinion among the professionals or a lack of established criterion in most of the experts. CONCLUSIONS: A full list of criteria and clinical recommendations for the purpose of rationalizing the treatment of depression in elderly patients and reducing excessive variability in clinical practice is presented. The recommendations are qualified in accordance with the degree of consensus of the professionals endorsing them and can be considered valid until new scientific information becomes available that justifies their review.

Pain as a symptom of depression: prevalence and clinical correlates in patients attending psychiatric clinics.

BACKGROUND: The need to assess the prevalence and characteristics of painful symptoms among depressed patients attended by psychiatrists in their regular clinical practice. METHODS: A multi-centre, cross-sectional study was carried out in a large sample (n=3566) of patients attending out-patient psychiatric facilities in Spain. All types of DSM-IV-TR depressive disorders were included. Data on the diagnosis, specific symptoms, intensity of depression and antidepressant and analgesic drug treatments were collected. The presence and characteristics of significant pain (visual analogue scale score>40) at the time of the study were also recorded. RESULTS: The prevalence of pain in depressed patients was 59.1% (CI 95%: 57.7%; 60.7%). Factors associated independently with the existence of significant pain were: being female, presence of loss of energy and the diagnosis of dysthymia or depression induced by physical disorders. In addition, age and the intensity of depression were two risk factors, where each year of age and each point in the Hamilton scale increased the risk of having pain by 2% and 8% respectively. The presence of anhedonia and the diagnosis of depression induced by illegal drugs were factors inversely related to pain. LIMITATIONS: The cross-sectional naturalistic characteristics of the study. CONCLUSION: Our data show a high prevalence of pain among depressive patients attending psychiatric clinics. Painful symptoms are modulated differently depending on the type of depression and the presence of specific symptoms, such as loss of energy or anhedonia. Psychiatrists should ask their depressive patients for the presence of pain on a regular basis.

Diagnostic criteria for apathy in clinical practice.

BACKGROUND: Apathy is an important and distressing behavioural symptom in Alzheimer's disease and in various neuropsychiatric disorders. Recently, diagnostic criteria for apathy have been proposed. OBJECTIVES: In groups of patients suffering from different neuropsychiatric diseases, (i) to estimate the prevalence of patients meeting the proposed diagnostic criteria; (ii) to estimate the concurrent validity of the criteria with the neuropsychiatric inventory (NPI) apathy item; (iii) to identify the most frequently met criteria or sub-criteria in each specific neuropsychiatric disease and (iv) to estimate the inter-observer reliability of the diagnostic criteria for apathy. METHODS: This cross-sectional, multicentric, observational study was performed on 306 patients. Each of the participating centres had to check the presence of apathy according to the diagnostic criteria for apathy in consecutive patients belonging to the following diagnoses list: Alzheimer disease (AD), mixed dementia, mild cognitive impairment (MCI), Parkinson's disease (PD), Schizophrenia (DSM-IV) and major depressive episode. In addition to the clinical interview, the assessment included the Mini Mental Score Examination (MMSE) and the NPI. At the end of the visit, clinicians were required to check the diagnostic criteria for apathy. RESULTS: Using the diagnostic criteria for apathy, the frequency of apathy was of 53% in the whole population, 55% in AD, 70% in mixed dementia, 43% in MCI, 27% in PD, 53% in schizophrenia and 94% in major depressive episode. In AD, mixed dementia, MCI and PD, the NPI apathy score was significantly higher for patient fulfilling the apathy criteria. Goal-directed cognitive activity (criteria B2-Cognition) was the most frequently observed domain followed by goal-directed behaviour (criteria B1-Behaviour) and emotion (criteria B3), respectively. Inter-rater reliability was high for the overall diagnostic (κ coefficient = 0.93; p = 0.0001) and for each criteria. CONCLUSION: This study is the first one to test the diagnostic criteria for apathy in clinical practice. Results make the diagnostic criteria useful for clinical practice and research.

Treatment of tardive dyskinesia with aripiprazole.

Tardive dyskinesia (TD) is a severe and potential irreversible side effect of antipsychotic treatment. Treatment of established TD is often unsuccessful. In this article, we report three cases of psychogeriatric patients who suffered from TD as a side effect of long-term treatment with haloperidol that resolved after switching treatment to aripiprazole. Potential psychopharmacological mechanisms explaining this finding are briefly discussed.

Bupropión: farmacología e interacciones / Bupropion: pharmacology and interactions

Bupropión es una aminocetona monocíclica introducida en España para el tratamiento de la depresión en la formulación XR/XL de liberación modificada que permite su administración en una única toma diaria. Se metaboliza en su principal metabolito activo, el hidroxibupropión (OHBUP) por el citocromo P450 2B6 (CYP2B6), teniendo una vida media de eliminación de alrededor de 20 h. Es un inhibidor de la recaptación de la noradrenalina y la dopamina, con un efecto sobre el transportador de serotonina prácticamente nulo. Presenta una baja (12-35%), pero persistente ocupación del transportador estriatal de dopamina. No tiene efectos clínicamente significativos sobre los receptores histaminérgicos, muscarínicos, alfa-adrenérgicos o dopaminérgicos. Las interacciones principales están relacionadas con la inhibición o inducción del CYP2B6, responsable del metabolismo del bupropión, o la inhibición del CYP2D6 por el bupropión. Se aconseja un uso cuidadoso conjuntamente con fármacos que disminuyan el umbral convulsivo. Está contraindicado durante la supresión brusca de alcohol o sedantes y durante el tratamiento con inhibidores de la monoaminooxidasa. El presente artículo responde a preguntas frecuentes que se plantean durante el uso clínico del bupropión, especialmente en situaciones clínicas especiales o durante el tratamiento con otros fármacos habituales. Estas situaciones incluyen, entre otras, uso conjunto de fármacos anticonvulsivantes, antipsicóticos en depresión psicótica, corticosteroides, antidiabéticos, otros antidepresivos como venlafaxina, anticonceptivos orales, terapia hormonal sustitutiva, disulfiram, alcohol o drogas de abuso y vareniclina (AU)

Bupropion is a monocyclic aminoketone introduced into Spain for the treatment of depression with the extended release (XL) formulation that makes it possible to administer it in a single daily dose. It is metabolized in its principal active metabolite, the hydroxybupropion (OH-BUP) by the cytochrome P450 2B6 (CYP2B6), with a mean elimination half life of about 20 h. It is a norepinephrine and dopamine reuptake inhibitor with an almost null effect on the serotonin transporter. It has low (12%-35%) but persistent occupancy of the striatal dopaminetransporter. It has no clinically significant effects on the histaminergic, muscarinic, alpha-adrenergicor domaminergic receptors. Its principal interactions are related with inhibition or induction of CYP2B6, responsible for the bupropion metabolism, or inhibition of CYP2D6 by bupropion. It should be used carefully together with drugs that decrease the seizure threshold. This is contraindicated during sudden suppression of alcohol or sedatives and during treatment with monoaminooxidade inhibitors. The present paper answers frequent questions posed during the clinical use of bupropion, especially under special clinical situations or during treatment with other common drugs. These situations include, among others, combined use of anti-seizure drugs, antipsychotics in psychotic depression, corticosteroids, antidiabetics, other antidepressants such as venlafaxin, oral contraceptives, hormone replacement hormone therapy, disulfiram, alcohol or abuse drugs and varenicline (AU)

[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

[Effectiveness of venlafaxine extended release and conventional antidepressants in elderly patients with depressive disorder]. / Efectividad de la venlafaxina retard y los antidepresivos convencionales en pacientes ancianos con trastorno depresivo.

OBJECTIVES: To determine and compare effectiveness, tolerability and safety of venlafaxine extended release (VXR) and other conventional antidepressants, mainly selective serotonin reuptake inhibitors (SSRIs), for the treatment of elderly patients diagnosed of depressive disorder in an out-patient psychiatry setting. METHODS: Multicenter, naturalistic, randomized, openlabel study performed in elderly patients with depressive disorder (according to DSM-IV). Patients were randomized to 6 months of treatment with VXR or another conventional antidepressant (CA). Effectiveness was assessed using the Montgomery- AAsberg Depression Rating Scale (MADRS) and the Hamilton Anxiety Scale (HAM-A). Response was considered as a > or = 50 % decrease and remission as a < 9 score in the MADRS. RESULTS: Sample of 120 patients older than 60 years; 68 received VXR and 52 CA (SSRI: 94.1 %). Most frequently used SSRI were citalopram (40.8 %), paroxetine (24.5 %) and sertraline (20.4 %). After 6 months of treatment, VXR achieved a higher response (75 %, VXR; 50 %, CA; p = 0.048) and remission (50 %, VXR; 28.9 %, CA; p = 0.048) and a higher decrease in the HAM-A score (-14.77, VXR; -10.84, CA). There were no significant differences in compliance rates (67.6, VXR; 71.1 %, CA) and adverse reactions (14.7 %, VXR; 13.46 %, CA) between both treatment groups. Blood pressure and heart rate remained within normal limits in both treatment groups. CONCLUSIONS: In this study, venlafaxine extended release shows higher effectiveness than other conventional antidepressants, mainly SSRIs, in the treatment of depressive elderly patients in the out-patient psychiatry setting.

Efectividad de la venlafaxina retard y los antidepresivos convencionales en pacientes ancianos con trastorno depresivo / Effectiveness of venlafaxine extended release and conventional antidepressants in elderly patients with depressive disorder

Objetivos. Determinar y comparar la efectividad, tolerabilidad y seguridad de venlafaxina retard (VR) y otros antidepresivos convencionales, principalmente inhibidores selectivos de la recaptación de serotonina (ISRS), en el tratamiento de pacientes ancianos con diagnóstico de trastorno depresivo en el ámbito de la psiquiatría ambulatoria. Métodos. Estudio multicéntrico, naturalístico, abierto y aleatorizado en pacientes mayores con trastorno depresivo (criterios DSM-IV). Los pacientes recibieron aleatoriamente 6 meses de tratamiento con VR u otro antidepresivo convencional (AC). La efectividad fue evaluada mediante la escala de Montgomery-Åsberg para la depresión (MADRS) y la escala de Hamilton para la ansiedad (HAM-A). Se consideró respuesta como la reducción en la puntuación ≥ 50 % y remisión a una puntuación ≤ 9 en la MADRS. Resultados. Muestra formada por 120 pacientes mayores de 60 años, 68 tratados con VR y 52 con AC (ISRS: 94,1 %). Los ISRS más utilizados fueron citalopram (40,8 %), paroxetina (24,5 %) y sertralina (20,4 %). Tras 6 meses de tratamiento, VR consiguió mayor respuesta (VR: 75 %; AC: 50 %; p=0,048) y remisión (VR: 50 %; AC: 28,9 %; p= 0,048) y mayor decremento en puntuación HAM-A (VR: -14,77; AC: -10,84). No hubo diferencias significativas en las tasas de cumplimentación (VR: 67,6 %; AC: 71,1 %) y reacciones adversas (VR: 14,7 %; AC: 13,46 %) entre ambos tratamientos. La tensión arterial y frecuencia cardíaca se mantuvieron en límites normales en ambos grupos. Conclusiones. Venlafaxina retard muestra en este estudio una superior efectividad al comparar con otros antidepresivos convencionales, principalmente ISRS, en el tratamiento de pacientes ancianos depresivos en el ámbito de la psiquiatría ambulatoria

Objectives. To determine and compare effectiveness, tolerability and safety of venlafaxine extended release (VXR) and other conventional antidepressants, mainly selective serotonin reuptake inhibitors (SSRIs), for the treatment of elderly patients diagnosed of depressive disorder in an out-patient psychiatry setting. Methods. Multicenter, naturalistic, randomized, openlabel study performed in elderly patients with depressive disorder (according to DSM-IV). Patients were randomized to 6 months of treatment with VXR or another conventional antidepressant (CA). Effectiveness was assessed using the Montgomery- Åsberg Depression Rating Scale (MADRS) and the Hamilton Anxiety Scale (HAM-A). Response was considered as a ≥ 50 % decrease and remission as a < 9 score in the MADRS. Results. Sample of 120 patients older than 60 years; 68 received VXR and 52 CA (SSRI: 94.1 %). Most frequently used SSRI were citalopram (40.8 %), paroxetine (24.5 %) and sertraline (20.4 %). After 6 months of treatment, VXR achieved a higher response (75 %, VXR; 50 %, CA; p = 0.048) and remission (50 %, VXR; 28.9 %, CA; p = 0.048) and a higher decrease in the HAM-A score (-14.77, VXR; -10.84, CA). There were no significant differences in compliance rates (67.6, VXR; 71.1 %, CA) and adverse reactions (14.7 %, VXR; 13.46 %, CA) between both treatment groups. Blood pressure and heart rate remained within normal limits in both treatment groups. Conclusions. In this study, venlafaxine extended release shows higher effectiveness than other conventional antidepressants, mainly SSRIs, in the treatment of depressive elderly patients in the out-patient psychiatry setting

Practical psychological management of old age psychosis.

Late-onset forms of psychosis have been the object of increasing interest in recent years. Despite the fact that there are still many obscure areas, significant advances in the pathophysiology, delimitation of risk factors, clinical presentation, neuropsychology and the pharmacological treatment have been made. Nevertheless, the psychological aspects of both aetiology and treatment of these late forms of psychosis have received much less attention than the rest. In contrast with that, the clinician is confronted with the need to manage patients that are reluctant to take medications and in which the outcome of pharmacological treatments is not always optimal. The elderly psychotic patient should not be excluded from the possibility of receiving any kind of psychological help. He may benefit from adaptations of different psychotherapeutic measures that can include the more classical techniques as psychodynamic oriented and behavioural-cognitive therapies or the newer forms of treatment specially designed for the aged, as reminiscence or psychomotor therapy. In any case, to obtain any result the patient needs to be managed in a way that goes well further the prescription of a neuroleptic drug. In this paper we review some of the most important psychological cues for the understanding of the elderly psychotic patient. Furthermore, we divide the therapeutic relationship over the time in three parts: The initial contact, the central phase and the termination. We offer some keys for the practical management of the patient in each of these phases, with special attention to the adherence to treatment and early identification of treatment-emergent complications like depressive symptoms or hypochondriac concerns.

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.

[Tolerability and efficacy of combined antidepressant therapy]. / Eficacia y seguridad de la asociación de antidepresivos.

OBJECTIVES: Utilisation of antidepressant combination and augmentation strategies in management of treatment-resistant depression is very common in spite of have been hardly analysed with clinic and neuropharmacological rigor. The aim of this review is to analyse frequency of utilisation, neurobiological mechanisms involved and clinic results observed, with all combination usually used in clinical practice. METHODOLOGY: A bibliographic research was carried out by means of exhaustive review of scientific database (Medline and NLM), from specific key words. Subsequently we realised a cross with all bibliographic references obtained. Less some casuistical references published in difficult access journals, we have revised all outstanding open or controlled published studies. CONCLUSIONS: It is remarkable large quantity of casuistic information and lack of controlled studies. Most of combinations are justified and supported by hypothetical neurobiological augmentation mechanisms hardly verified. Some combinations (MAOI+TCA, MAOI+SSRI, TCA+TCA, SSRI+SSRI, SSRI+TCA), bring forward few advantages and important risks, so that it should be inadvisable. Nevertheless combinations using SSRI with another antidepressant, as Maprotiline, Mianserine, Bupropion or Mirtazapine, bring forward positive results and suppose low risks, so that should be recommended in resistant depressions or to reduce response latency.

Eficacia y seguridad de la asociación de antidepresivos / Tolerability and efficacy of combined antidepressant therapy

Planteamiento y objetivos. La utilización de asociaciones o combinaciones de antidepresivos para el tratamiento de las depresiones resistentes es una práctica habitual, pese a haber sido escasamente analizada con rigor clínico y neurofarmacológico. El objetivo de esta revisión es analizar la frecuencia de utilización, los mecanismos neurobiológicos implicados y los resultados clínicos observados, tanto en eficacia como en seguridad, con todas las asociaciones habitualmente utilizadas en la clínica. Metodología. Se realizó una búsqueda bibliográfica mediante una revisión exhaustiva de bases de datos (MEDLINE y NLM), partiendo de palabras clave. Posteriormente se realizó un cruce de todas las referencias bibliográficas recogidas en las publicaciones encontradas. Salvo algunas referencias casuísticas, publicadas en revistas de difícil acceso, se han analizado todos los estudios amplios, tanto abiertos como controlados publicados. Conclusiones. En general destaca la profusión de informaciones casuísticas y la escasez de estudios controlados. La mayor parte de las asociaciones se justifican y apoyan en mecanismos de potenciación neurobiológicos hipotéticos difícilmente verificables. Algunas asociaciones (IMAO+ADT, IMAO+ISRS, ADT+ADT, ISRS+ISRS, ISRS+ADT) aportan escasas ventajas y considerables riesgos, por lo que deben ser desaconsejadas.Sin embargo, las asociaciones de un ISRS con otros ADs, como maprotilina, mianserina, bupropión o mirtazapina aportan resultados positivos y suponen escasos riesgos, por lo que podrían recomendarse en depresiones resistentes o para acortar la latencia de respuesta. (AU)