[Activation of resources in elderly depressed patients. An overview of current knowledge]. / Ressourcenaktivierung bei depressiven älteren Patienten. Ein Uberblick zum gegenwärtigen Kenntnisstand.

Psychotherapeutic research has empirically proven the activation of resources to be a primary and pervasive activating principle. Equally empirically substantiated is psychotherapy with the aged. In the present article, the specific application of resources activation in psychotherapy for old-age depression is particularly emphasized and attempts at defining the concept of resources as well as hints towards the discovery of resources are explored. Contrary to earlier assumptions that ageing is a deficiency process, it has now been shown that despite evident losses in various life areas in aging, some resources can be defined which can be decisive for a sense of well-being among the elderly and for prophylaxis or therapy of old-age depression. Procedures and resource activation with content must be activated in parallel with problem actualization so that feelings of self-esteem and well-being increase, problems are solved and experiences of loss due to ageing are compensated. One of the most important resources among the elderly has proved to be the ability to accommodate and the social network. Group therapy as an effective and economical form of therapy as well as the therapeutic relationship itself can be employed as resources to promote social interaction among the aged.

[Ambulatory treatment of anxiety disorder. Behavior therapy and drug therapy approaches]. / Die ambulante Behandlung der Angststörung. Verhaltenstherapeutische und medikamentöse Strategien.

Phobic disorders and other anxiety disorders belong to the most frequent psychiatric illnesses. Since they can be overlapped by other mental illnesses, they are often overlooked in practice. For example, comorbidity between anxiety and depression is very high. Also, personality disorders and a person's biography can lay the ground to anxiety. A typical complication of anxiety disorders is dependence of substances, predominantly of tranquilizers and alcohol. By means of a clinical case example, the topic of anxiety disorders is discussed practically and the treatment concept is detailed. Already during ambulatory care in a general practitioner's office behavioral therapeutic strategies can be implemented besides drug treatment with relatively moderate effort.

Interactions of prefrontal cortex during eyeblink conditioning as a function of age.

Changes in regional cerebral blood flow (rCBF) in eleven elderly subjects during pairings of tone and air puff were compared to rCBF changes during pairings in young subjects. Although all subjects reported being aware of the relationship between tone and air puff, elderly subjects did not condition as well as young subjects and their rCBF measures were attenuated. Covarying the performance differences between young and old subjects did not change this conclusion suggesting that differences in neural activation during learning are related to binding of CS-US information prior to the impact of the association on performance. Both groups showed learning-specific rCBF changes in cerebellum, inferior right prefrontal cortex and posterior cingulate. However, only in young subjects were there learning-specific changes in rCBF in left temporal cortex, midbrain, caudate, and inferior left prefrontal cortex. Analysis of learning-dependent patterns of functional connectivity of inferior left prefrontal cortex showed only young subjects had a strong left prefrontal functional connectivity with cerebellum, hippocampus, thalamus and temporal cortex. Thus, beyond changes in regional activity, these data also suggest that age may alter the operations of functional networks underlying learning and memory.

Reliability in dream research: a methodological note.

The coefficients of internal consistency and retest reliability had been rarely investigated within the methodology of dream content analysis. Analyzing a dream series of elderly, healthy persons obtained from weekly telephone interviews, the internal consistency of a series of 20 dreams and retests after 4 or 22 weeks, respectively, had been computed. The findings indicate that dream recall and dream length are quite stable, but dream characteristics such as bizarreness and emotional tone underlie large intraindividual fluctuations. In order to obtain reliable measures for these variables which will be important for correlational studies, including waking-life trait measures, one has to obtain as many dreams as possible (about 20) in a very short time period. Further research is needed to extend the present findings to diary dreams and laboratory dreams.

A preliminary study of dream-telling among mentally healthy elderly: no adverse effects on life or sleep quality.

While there have been several studies about dreams and dreaming among the elderly, there does not seem to have been any study of the effects of regular dream-telling (without interpretation). Listening to dreams could become a regular part of caring for the elderly and infirm. The effects of regular dream-telling in mentally healthy elderly clinical research volunteers were measured on several variables using standardized testing and self-report: life satisfaction, intrapsychic boundaries, sleep quality, sleep duration, dream recall, dream tone, and dream epoch, and were compared with two control groups. The six variables showed no significant differences among the three groups, indicating that dream-telling produced no adverse effects. The present findings seem to imply that dream-telling is not dangerous for mentally healthy individuals and may thus serve as a baseline for future studies involving geriatric patients with mental disorders or elderly undergoing significant life-events, e.g., bereavement or retirement, using the method of regular dream-telling.

Oestrogens and Alzheimer's disease.

In the last decade, several reports suggest that oestrogen replacement therapy (ORT=ERT=estrogen replacement therapy) might prevent or delay Alzheimer's disease. Oestrogens influence and modulate brain structure and brain function. There are substantial arguments that the postmenopausal oestrogen loss might, together with other factors, accelerate the appearance of Alzheimer's disease. The evidence is suggestive, but not compelling, that ORT can reduce the relative risk to suffer from Alzheimer's disease. Furthermore, recent findings are consistent with the hypothesis that oestrogens might ameliorate the symptomatology in early stages of Alzheimer's disease. However, it has to be remembered that in most clinical trials the number of oestrogen users was quite small, and, usually, oestrogen use was not randomised. The aim of the present review is to discuss the data available today in view of their clinical relevance.

[Psychiatric complications of pharmacotherapy--a review]. / Psychiatrische Komplikationen internistischer Medikamente--eine Ubersicht.

Various commonly used drugs with somatic indications may give rise to a host of partially serious psychiatric side-effects. This overview details important prescribed drugs of daily use and their psychiatric complications. The problems of elderly patients are particularly considered. Also, polypharmacy will be given special attention.

[Improving communication between ambulatory and inpatient care. A pilot project]. / Verbesserung der Kommunikation zwischen ambulanter und stationärer Versorgung. Ein Pilotprojekt.

Medical care of our population has made dramatic progress during recent decades. However, problems arose from an increasing specialization and subspecialization on the one hand and from the complexity of care structures on the other hand. In light of scarce financial resources and of increasing demands regarding quality by both recipients and payers of medical care the analysis of diagnostic and treatment processes gained considerable attention. In this context, a lack of cooperation between ambulatory and in-patient care has been complained about for a long time. The aim of our pilot project introduced here was therefore to assess the cooperation between physicians in private practice and our psychiatric hospital by means of a random sample query. The results are communicated here.

[Depression in old age]. / Depressionen im Alter.

At least 4% of elderly patients living in the community suffer from a major depressive disorder and some 15% from less severe forms of depressive illness. However, physical and psychiatric comorbidity is high in elderly patients and the incidence of depression may reach 40% to 50% in common medical disorders such as diabetes mellitus or cardiac insufficiency. Therefore, elderly patients who are hospitalised or living in senior citizen homes suffer more frequently from depressive disorders, with prevalence rates up to 50%. The phenomenology and etiology of geriatric depression are very heterogeneous. Depression often presents atypically, e.g., behind a mask of complaints about physical symptoms or anxiety. Diagnostic and therapeutic measures follow the same standards as in younger adults, yet age-related differences must be taken into consideration. Thus, psychopharmacological management must be adapted to the altered metabolism of drugs in the elderly. Also, psychological treatment strategies should respect the distinctive psychosocial situation of elderly patients.

[Diagnosis and therapy of alcohol-withdrawal symptoms in the elderly: a case report]. / Der Alkoholentzug im fortgeschrittenen Lebensalter. Diagnose und Therapie anhand eines Fallbeispiels.

The incidence and prevalence of alcoholism in the elderly population are tendentially underestimated. There are some reasons for this fact. The pathway to the diagnosis of alcoholism may be considerably compromised in the often comorbid or multimorbid patient. To live up to an advanced age seems to be a good argument against chronic substance abuse. Elderly people and their relatives are often still more reluctant to report about socially stigmatizing disorders. On top of that, the amount of social control is reduced after the end of employment and upon entering retirement. Yet, if alcohol-withdrawal symptoms occur, e.g., following an admission of the addicted patient to a hospital, the missed diagnosis of alcoholism means a delay of the correct interpretation of such complications and of the necessary treatment. Aged patients with reduced physical and mental reserve capacity are at special risk of developing further serious complications. Progressive, sometimes irreversible decay of the cognitive functions in long lasting delirious states or, as an aftermath of withdrawal, epileptic seizures are of particular importance.

[Ethical aspects of the treatment of mentally and physically seriously ill patients--a case report of an elderly female schizophrenic patient with jaundice]. / Medizinethische Aspekte der Behandlung psychisch und körperlich schwer Erkrankter. Fallbeispiel einer betagten schizophrenen Patientin mit cholestatischem Ikterus.

The treatment of elderly patients with combined psychiatric and physical illness often implicates special challenges for physicians. A psychiatric disorder may significantly complicate diagnostic and therapeutic measures for somatic diseases. The realisation of planned procedures may be delayed or even become impossible in non-compliant subjects. Respect of the patient's will conflicts with the assessment of his/her judgement and protection of his/her supposed interests. Such considerations need an abstraction of the destructive, illness-bound will of these patients in the light of ethical and medical options. The increasing responsibility of physicians in such cases is limited by an often controversial legal frame. We present such practice-relevant problems which we encountered in the treatment of an 83-year-old woman with cholestatic jaundice of clinically unknown origin and chronic schizophrenia.

Longitudinal stability of CSF tau levels in Alzheimer patients.

BACKGROUND: Antemortem levels of tau in the cerebrospinal fluid (CSF) of Alzheimer's disease (AD) patients have repeatedly been demonstrated to be elevated when compared to controls. Although CSF tau has been reported to be elevated even in very mild AD, it is unknown how tau levels change during the course of the disease. METHODS: We have followed 29 mild-to-moderately affected AD subjects over 2 years with repeated CSF taps. Clinical measures of dementia severity (Clinical Dementia Rating Scale, Global Deterioration Scale and Mini-Mental Status Examination) were obtained at the start and conclusion of the observation period, and CSF tau was measured with a standard enzyme-linked immunoabsorbent assay (ELISA) using two monoclonal antibodies. RESULTS: Despite significant changes in the clinical measures consistent with progression of the disease, no significant overall change in CSF tau levels (548 +/- 355 vs. 557 +/- 275 pg/mL, NS) was observed. None of the clinical variables was significantly correlated with either baseline measures of CSF tau or delta CSF tau (last-first). Similarly, CSF tau at baseline and changes over time were not significantly related to Apolipoprotein E (APO E) phenotype. CONCLUSIONS: These data suggest that CSF tau levels are stable over extended periods of time in a group of mild-to-moderately demented AD subjects and that CSF tau levels do not predict the severity or rate of progression of AD, at least not during the middle stages of the illness.

[Suicide of psychiatric inpatients assisted by euthanasia advocacy groups. Cases of assisted suicide?]. / Suizide in der stationären Psychiatrie unter Beihilfe einer Sterbehilfevereinigung. Fälle aktiver Sterbehilfe?

The debate on passive and active euthanasia has met a controversial echo both in the German-speaking media and in professional publications within recent years. This discussion, however, largely excluded mentally ill patients. Also, euthanasia advocacy groups have usually distanced themselves from euthanasia in psychiatric patients. We report here two cases from our hospital in which inpatients with affective disorders committed assisted suicide during a hospital pass. We discuss these events under the assumption that these are cases of questionable active euthanasia in mentally ill patients whose judgement was considerably compromised by their disorder.

Physostigmine challenge before and after chronic cholinergic blockade in elderly volunteers.

BACKGROUND: As a test of possible muscarinic up-regulation, the cortisol response to intravenous (i.v.) physostigmine (an anticholinesterase) was measured in 9 elderly volunteers before and after chronic cholinergic blockade with the muscarinic cholinergic antagonist scopolamine. METHODS: Each of the 9 elderly control subjects was given two physostigmine (0.5 mg i.v.) infusions separated by 21 doses of nightly scopolamine (1.2 mg p.o.). No scopolamine was administered the night before infusions, and glycopyrrolate (0.2 mg i.v.) was administered prior to physostigmine, to block its peripheral effects. Vital signs were monitored and blood samples were collected at six time points surrounding the physostigmine infusion (-10, +10, +20, +30, +50, and +70 min). Behavioral measures and cognitive tests were administered prior to and 30 min after the physostigmine. RESULTS: The cortisol response to physostigmine was greater after the second (post-chronic scopolamine) infusion study compared to the first (p < .05) as measured by an area under the curve analysis of all time points. When individual time points were compared, the mean cortisol response was significantly increased after the second physostigmine infusion at the +50- and +70-min time points (p < .05). There were no significant changes in behavioral rating scales, cognitive tests, or vital signs between the two physostigmine infusion study days. CONCLUSIONS: This study demonstrates increased hypothalamic-pituitary-adrenocortical axis responsivity to a central nervous system cholinergic stimulus after chronic muscarinic blockade in 9 elderly control subjects. It also gives further evidence to support previous suggestions of muscarinic plasticity, specifically postsynaptic up-regulation, in the aging brain following exposure to chronic anticholinergic treatment.

The effects of scopolamine on changes in regional cerebral blood flow during classical conditioning of the human eyeblink response.

We examined the effects of scopolamine on the functional anatomy of classical conditioning of the human eyeblink response. Ten healthy young normal female volunteers (mean age +/- SEM: 26.7 +/- 0.9 years) were administered 0.4 mg scopolamine intravenously 1 h before regional cerebral blood flow (rCBF) was measured with positron emission tomography (PET) and H215O. Scans occurred during three sequential phases: (1) explicitly unpaired presentations of the unconditioned stimulus (airpuff to the right eye) and conditioned stimulus (binaural tone), (2) paired presentations of the two stimuli (associative learning) and (3) explicitly unpaired presentation of the stimuli (extinction phase). Scopolamine impaired acquisition of the conditioned eyeblink response (54.7 +/- 4.9%) relative to 18 untreated subjects from two previous PET studies. Regions that showed significant relative increases in rCBF during conditioning included the right lateral occipital cortex, the right inferior occipital cortex, the right lateral temporo-occipital cortex, the left medial temporo-occipital cortex, the posterior cingulate, the right cerebellum/brain stem area and the medial cerebellum. Significant relative decreases in rCBF were measured in the thalamus, the left putamen/insula area, the right putamen and the left and middle cerebellar cortex. The data partially replicate previous findings in unmedicated young volunteers of conditioning-specific rCBF changes in the cingulate cortex, the cerebellar cortex, the insula and the lateral temporo-occipital cortex. Our finding of decreased rCBF in the thalamus and increased rCBF in the occipital cortex may be attributable to effects of scopolamine per se rather than conditioning. Our data lend further support to the notion that classical conditioning involves distributed changes in multiple systems within the central nervous system.

Catatonia under medication with risperidone in a 61-year-old patient.

This report describes the case of a 61-year-old female schizophrenic patient with status post-frontal lobotomy some 35 years ago with prominent paranoid delusions. This woman developed severe catatonia under medication with a serotonergic/dopaminergic neuroleptic, risperidone, at a dose of up to 5 mg daily. The catatonic disorder was dose-dependent and subsided immediately after switching the medication to another atypical antipsychotic, clozapine. Given the negative history for catatonia in this patient, the temporal coincidence of administration of risperidone and catatonia is a novel finding.

Apnea syndrome in a patient with Alzheimer dementia under chlormethiazole treatment: a clinical experience report.

Sleep apnea syndromes in conjunction with dementia have attracted considerable interest among geropsychiatrists in recent years. This clinical case report describes a demented and delirious elderly patient with a history of alcoholism who developed a sleep apnea syndrome under treatment with chlormethiazole. The risk of chlormethiazole treatment may be underestimated in vulnerable patients, e.g. those suffering from severe respiratory diseases or dementia. Alternative treatments for delirious states need to be evaluated instead.

[Treatment of anxiety and panic attacks in geriatric psychiatry]. / Behandlung von Angst und Panikattacken in der Gerontopsychiatrie.

For the treatment of anxiety disorders and panic attacks in elderly patients a multidimensional approach including pharmacotherapy, psychotherapy and behavioral modification is crucial. More than in younger patients side effects of drugs have to be taken into account. For the long-term treatment only a few psychotropic drugs are recommended. Useful substances are antidepressants including tricyclics and the newer class of SSRI. Buspirone may also play a role in the long-term pharmacotherapy of anxiety disorders. Neuroleptics, benzodiazepines and betablockers should only be prescribed after careful evaluation; by and large, they are of minor significance in the long-term strategy due to significant adverse effects. The pharmacological treatment should always be accompanied by psychotherapy. In particular, behavioral therapy and behavioral modification strategies are of benefit.

The value of REM sleep parameters in differentiating Alzheimer's disease from old-age depression and normal aging.

Pseudodementia as a common trait in elderly depressives presents a major problem in gerontopsychiatry, especially for the differential diagnosis between Old-Age Depression (OAD) and Dementia of the Alzheimer Type (DAT). The present polysomnographic study examined parameters of sleep continuity, sleep architecture, and REM sleep to differentiate DAT from OAD. The investigation was based on the theoretical framework of the cholinergic-aminergic imbalance model of depression, the cholinergic deficit hypothesis of Alzheimer's disease and the reciprocal interaction model of Non-REM/REM sleep regulation, according to which REM sleep parameters should have high discriminative value to differentiate OAD and DAT. We investigated 35 DAT patients, 39 OAD patients and 42 healthy controls for two consecutive nights in the sleep laboratory. The DAT patients were in relatively early/mild stages of the disease, the severity of depression in the OAD group was moderate to severe. Depressed patients showed characteristic 'depression-like' EEG sleep alterations, i.e. a lower sleep efficiency, a higher amount of nocturnal awakenings and decreased sleep stage 2. Sleep continuity and architecture in DAT was less disturbed. Nearly all REM sleep measures differentiated significantly between the diagnostic groups. OAD patients showed a shortened REM latency, increased REM density and a high rate of Sleep Onset REM periods (SOREM), whereas in DAT REM density was decreased in comparison to control subjects. REM latency in DAT was not prolonged as expected. To assess the discriminative power of REM sleep variables a series of discriminant analyses were conducted. Overall, 86% of patients were correctly classified, using REM density and REM latency measures. Our findings suggest that REM density as an indicator of phasic activity appears to be more sensitive as a biological marker for the differential diagnosis of OAD and DAT than REM latency. The results support the role of central cholinergic neurotransmission in REM sleep regulation and the pathogenesis of DAT and OAD.