Relationships between psychotropic drug dosage, plasma drug concentration, and prolactin levels in nursing home residents.

This study aimed to characterize the relationships between administered dosages of psychotropic drugs, plasma drug concentration, and prolactin levels in a group of elderly nursing home residents. In a randomized, placebo-controlled, double-blind crossover design study, blood samples were drawn from 47 nursing home residents at least 6 hours after taking either haloperidol, thioridazine, or lorazepam. Correlations between drug dosage and plasma drug levels were significant for haloperidol and thioridazine, but not for lorazepam. Plasma drug levels were below the levels of detection for most of those taking haloperidol. Lorazepam was detected in the blood of 4 of the participants even after 3 weeks of downward titration to placebo and 6 weeks of placebo. Prolactin level was related to administered dosage only in those who were taking haloperidol. For those taking haloperidol or thioridazine, prolactin levels decreased when participants were on placebo. When an older person is taken off lorazepam, the possibility of residual drug in their bodies even 6 weeks after termination of drug use should be considered. Haloperidol may be clinically active in the brain despite no currently detectable plasma drug concentration.

Mental status change in older surgical patients. Cognition, depression, and other comorbidity.

The authors studied patients age 60 and over to assess the effect of elective surgery as a precipitating factor for cognitive decline over the postoperative year. They found an association between change in test performance and age, physical disability, and number of depressive symptoms. However, persistent decline in Mini-Mental State Exam scores was associated with identifiable factors related to the initial surgery in only 3/ 251 (1 percent of cases). Depression and new onset of acute illness were confounding factors in the assessment of cognitive decline.

Withdrawal of haloperidol, thioridazine, and lorazepam in the nursing home: a controlled, double-blind study.

BACKGROUND: Ongoing regimens of haloperidol, thioridazine, and lorazepam are commonly administered to manage behavior problems in nursing home residents. Nevertheless, there is controversy over whether periodic drug withdrawal should be attempted when those medications are prescribed. This study addressed that issue by examining the effects of discontinuing treatment with haloperidol, thioridazine, and lorazepam among residents of a large suburban nursing home. METHODS: In a double-blind, crossover study, half of 58 nursing home residents (43 women and 15 men with a mean age of 86 years) continued to take the psychotropic medication they had been prescribed, whereas the other half were tapered to placebo. After 6 weeks of taking placebo or original drug, patients were tapered to the reverse schedule and remained on it for 6 weeks. Assessments included informant ratings by the nursing staff who completed the Brief Psychiatric Rating Scale and the Cohen-Mansfield Agitation Inventory. RESULTS: Analyses comparing residents taking placebo to those taking medication after completion of the first phase showed no impact of drug therapy discontinuation on their behavior. Similarly, using the crossover design to compare residents' behaviors while taking placebo vs. taking drugs, withdrawal of medication had no impact on Cohen-Mansfield Agitation Inventory or Brief Psychiatric Rating Scale scores. CONCLUSIONS: Results of this work suggest that longterm use of haloperidol, thioridazine, and lorazepam in nursing homes to manage agitation should be closely monitored for their efficacy. Furthermore, routine attempts at drug withdrawal should be considered for most residents taking psychotropic medication.

The validity of cognitive testing in screening for dementia.

The concept of "cognitive impairment," as an indicator of dementia, defined in 1980 as a loss of intellectual abilities of sufficient severity to interfere with social or occupational functioning, is the model which has been adopted for a condition, which has recently been reclassified from an "organic" to a "cognitive disorder." Data derived from the assessment of a sample of older people demonstrated the extreme sensitivity of a widely employed cognitive assessment instrument to all levels of educational experience, and educational correlates, notably level of physical disability, were identified as other independent predictors of test performance. The analyses raise questions with regard to the reinterpretation of "lack of education," from a confounding factor in prevalence estimates of cognitive impairment to a "risk factor" for dementia, and support those who have questioned the validity of the one-dimensional "cognitive paradigm," and the trend to diagnosis based upon objective assessment with standardized instruments.

Management of agitation in nursing home patients.

Agitation in demented nursing home residents is a major clinical problem with which patients, families and staff are required to cope. Agitation may be secondary to a variety of psychiatric, environmental and medical problems, and thus attempts must be made to [correction of be] clarify aetiological issues before initiating a treatment plan. Treatments for agitation are imperfect, and clinicians should be prepared to work through several to find the best for a given patient and clinical situation. Cognitive/behavioural/environmental treatments have the advantage of few or no adverse effects and no drug-drug interactions. Some of these define rather basic nursing management techniques for coping with agitated older adults, while others attempt to diminish specific behaviours. The use of pharmacological interventions should be reserved for those patients in whom other measures have been unsuccessful. While the range of medications that have been used to treat various kinds of agitated behaviours is large, there are few double-blind, placebo-controlled trials in this area and fewer still in nursing home populations. No one class and no one medication has been identified as a treatment of choice. While we work to find the aetiological mechanisms of irreversible forms of dementia, and the possible treatments for the underlying disorders, the challenge to develop more effective medications with better adverse effect profiles is before us.

Outcomes of cataract surgery in nursing home residents.

A prospective study of vision-related outcomes of cataract surgery as well as cognitive functioning, activities of daily living (ADL) functioning, and depressed affect was conducted with 19 nursing home residents scheduled for cataract surgery. Also studied were 22 candidates for cataract surgery who decided against it. Comparison of both groups at baseline revealed that residents who chose cataract surgery were less cognitively and ADL impaired. Analysis after cataract surgery showed that visual acuity improved significantly at 4 months and was maintained at 1 year after surgery.

Improving practicing physicians' knowledge of geriatric mental health issues.

Elderly patients are most likely to seek mental health care from primary care physicians. Ironically, recent research findings show that primary care physicians fail to adequately detect mental health problems in their older patients. These findings raise questions about: 1) the adequacy of geriatric mental health training for physicians and 2) the possible methods for improving practicing physicians' knowledge and skills in detecting, treating, and referring patients with mental health needs. With a projected doubling in the number of people older than age 65 in the next 40 years, it is even more important that recognition and treatment of geriatric mental health problems be made a priority for primary care physicians.

Factors influencing hospital patients' preferences in the utilization of life-sustaining treatments.

Ninety-seven elderly hospitalized patients were asked about their preferences for several treatments under three hypothetical levels of future cognitive functioning: intact, confused, and unconscious. Levels of cognitive functioning and depression were also assessed. Sixty-six percent of the patients were more likely to want treatment if they expected to be cognitively intact than when a future condition involved impaired cognition; 36% did not want any treatment in at least 75% of the conditions; and 16% wanted treatment in at least 75% of the conditions studied. A minority (12%) did not show any pattern in their preferences. The absence of a definite pattern was related to lower levels of education and to higher levels of depressive symptoms. Patients self-reported their preferences for treatments being influenced most by their personal values, religion, and by experiences with illnesses of others.

The utilization of the durable power of attorney for health care among hospitalized elderly patients.

OBJECTIVE: To explore the potential use of the durable power of attorney for health care (DPAHC), considerations in executing a DPAHC, and influences in making decisions related to it. DESIGN: Interview with follow up. SETTING: A teaching hospital. SUBJECTS: 37 males, 60 females, aged 64-97. METHODS: Interview of ninety-seven hospitalized patients and followup telephone interview of those who had not originally executed a DPAHC after 3 months. Patients were asked whom they would appoint as an agent for health care decisions, how this person was related to them, and why they chose this person. Patients' cognitive functioning and level of depression were assessed. RESULTS: Most patients (65%) chose their closet relative to make health care decisions for them if they were unable to. Reasons for choosing this person included: the agent knew the patient best, was the closest relative, and was most accessible geographically. Over half of the participants had not discussed their feelings about health care decisions with anyone. Sixteen percent had previously executed a durable power of attorney for health care, and 46% said they intended to execute one. Executing a durable power of attorney for health care was associated with higher levels of cognitive functioning but not with level of depression. CONCLUSIONS: Both an understanding of advanced directives and a general outlook on matters of life and death seem to affect people's utilization of the DPAHC. The ability to execute a DPAHC and the choice of an agent are affected by individuals' interpersonal relations.

Pharmacological treatment of agitation in a nursing home.

Agitation is a significant problem in the management of residents in long-term care settings. This study assessed the pharmacological treatment of agitation in a 550-bed nursing home and correlated nurses' ratings of agitation with pharmacological treatment. It further examined the differential use of various psychotropic agents in the management of several sub-types of agitated behavior. Significant results included: (1) subjects designated as demented and agitated were most likely to receive neuroleptics, while non-demented agitated residents were most likely to be treated with a benzodiazepine; (2) agitated individuals received significantly less antidepressant treatment than non-agitated patients. The sub-typing of agitation may allow for the possibility of more selective treatment of various agitation syndromes.

Deceptions in psychotherapy: case report and considerations.

Deliberate deception by a patient in psychotherapy is a deviation from a fundamental requirement of the patient-therapist relationship. When deceptions are discovered or admitted, it is crucial to analyze them for their value in understanding conflicts, transference relationships, and current stresses. These issues are illustrated with a case involving an elaborate deception carried out over several months by a patient in psychotherapy.

Attitude and burden in families of depressed elderly patients: strategies for care.

Family members and others who must care for depressed older adults have received relatively little clinical and research attention, despite their extensive special needs and burden. Attitudes and burden of caregivers affect the initial assessment and continuing treatment of depressed elderly patients. Clinicians can focus evaluation and therapeutic efforts to include the needs of family and patient. Certain strategies for clinical work with caregivers and patients can facilitate optimal care.

Validation of sleep observations in a nursing home.

Most of the studies on sleep patterns in elderly people have been performed on small samples in sleep laboratories and with the use of advanced technology. Such technology is generally unavailable either for research studies or clinical interventions with elderly people residing in the community. Additionally, the utility of the sleep laboratory in assessing sleep in the very demented patient is limited because of irregularities of electroencephalogram (EEG) patterns in this population. For these reasons, systematic sleep observations are presented as important tools in the assessment of sleep in the nursing home. Nursing homes have night-shift staff who are frequently not fully occupied and could be trained to perform sleep observations. The Observational Sleep Assessment Instrument (OSAI) documents the occurrence of sleep, as well as disruptions in sleep, breathing, snoring, myoclonic movements, and body restlessness. This study documented the validity of the OSAI by establishing interrater reliability and by correlating its results to those of a portable sleep monitor, namely, a four-channel ambulatory sleep respiratory monitor and a wrist activity monitor. Results show that the OSAI is a reliable and valid tool for examining sleep and sleep pathology in this population, and can become a useful screening tool for detecting sleep and breathing disorders.

Medical correlates of agitation in nursing home residents.

This paper examines the relationship between agitation and medical and psychiatric diagnoses. Agitation marked by aggressive behaviors (e.g., hit, kick) was related to dementia and impairments in activities of daily living. Physically nonaggressive behaviors (e.g., pacing, disrobing inappropriately) correlated with cognitive impairment, fewer medical diagnoses, and absence of a hearing loss. Verbally agitated behaviors (e.g., constant complaints) were manifested by residents with more physical diagnoses, mental disease (other than schizophrenia and affective disorders), more reported pain, and higher cognitive functioning than the population as a whole.

Alzheimer's disease. A psychiatrist's perspective.

Alzheimer's disease is a catastrophic disease for both the patient and family with medical, psychologic, and social ramifications. The psychiatrist can function as the primary clinician, team leader, or consultant in the effort to manage the process of diagnosis and treatment through the months and years of progressive deterioration of the patient. Psychiatrists consult and collaborate with neurologists, internists, and other medical specialists and participate with nurses, social workers, dietitians, and physical therapists in the care of patients with AD and their families. Although the present state of treatment is limited to palliative therapies, basic and clinical psychiatric research is directed at the quest for etiologies and definitive treatments.

Approaches to senior care #1. Hip fracture, depression, and cognitive impairment: a follow-up study.

Hip fractures in the elderly are accompanied by depression and cognitive impairment--two factors that impact on morbidity, mortality, and rehabilitation. This follow-up study assesses 35 elderly patients at three and six months post-hip fracture after earlier evaluations in the immediate post-fracture period. Mortality is increased in subjects with cognitive impairment at the time of fracture. Rehabilitation, as measured by activities of daily living, is slowed in subjects with combined depression and cognitive impairment. The study alerts physicians to the need for careful mental status evaluation at the time of trauma and surgery.

Special considerations in integrating elderly patients into a general hospital psychiatric unit.

Geriatric patients with psychiatric disorders are highly treatable in an acute general hospital setting, but they require special attention in assessment, treatment, and discharge planning. Assessment must include the active involvement of a broad multidisciplinary team led by the psychiatrist. In the treatment process, staff must stay aware of the psychiatric symptoms, which may be obscured by medical problems, and should take therapeutic advantage of the transference issues that an age-mixed population can generate. Discharge planning must attend to resistances and the realistic dilemmas that are unique to the geriatric population. In discussing these issues, the authors describe how a university hospital inpatient unit with a full age range of adult patients adapted its milieu and staffing to treat a larger proportion of geriatric patients.

Agitated behaviors in the elderly. I. A conceptual review.

Agitation is a significant problem for the elderly, their families, and their caretakers. Although much of the literature on agitation is pharmacologic in nature, several papers demonstrate demographic and environmental approaches to the problem. The literature review accentuates the gaps in both assessment and knowledge of the phenomenon. A conceptual framework and a rigorous methodology need to be developed for studying agitation. On these bases, research could explore the manifestations of agitation and the frequency of occurrence, predisposing factors for agitation, precipitating factors which trigger agitation, consequences of agitation for the elderly and for their caretakers, and the efficacy of alternative interventions. This paper proposes a definition of agitation and develops an initial conceptual framework in which to examine it.