Predictive value of geriatric assessment for patients older than 70 years, treated with chemotherapy.

INTRODUCTION: Comprehensive geriatric assessment (CGA) gives useful information on the functional status of older cancer patients. However, its meaning for a proper selection of elderly patients before chemotherapy and, even more important, the influence of chemotherapy on the outcome of geriatric assessment is unknown. METHODS: 202 cancer patients, for whom an indication for chemotherapy was made by the medical oncologist, underwent a GA before start of chemotherapy by Mini Nutritional Assessment (MNA), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Groningen Frailty Index (GFI) and Mini Mental State Examination (MMSE). After completion of a minimum of four cycles of chemotherapy or at 6 months after the start of chemotherapy the GFI and MMSE assessment was repeated. RESULTS: Frailty was shown in 10% of patients by means of MMSE, 32% by MNA, 37% by GFI and in 15% by IQCODE. Compared to patients who received 4 or more cycles of chemotherapy, the MNA and MMSE scores were significantly lower for patients treated with less than 4 cycles (p = 0.001 and p = 0.04 respectively). The mortality rate after start of chemotherapy was increased for patients with low MNA and high GFI scores with hazard ratios of 2.19 (95% confidence interval [CI]: 1.42-3.39; p < 0.001) and 1.80 (95% CI: 1.17-2.78; p = 0.007), respectively. After adjusting for sex, age, purpose of chemotherapy and type of malignancy these hazard ratios remained significant (p < 0.001 and p = 0.004), respectively. Finally, for the 51 patients who underwent repeated post-chemotherapy evaluation by GFI and MMSE, a statistically significant deterioration for the MMSE (p = 0.041) was found but not for the GFI. CONCLUSIONS: Both inferior MNA and MMSE scores increased the probability not to complete chemotherapy. Also, an inferior score for MNA and GFI showed an increased mortality risk after the start of chemotherapy. The mean MMSE score worsened significantly during chemotherapy.

Electroconvulsive therapy for the treatment of clozapine nonresponders suffering from schizophrenia--an open label study.

OBJECTIVE: This open label study describes the efficacy of electroconvulsive therapy (ECT) as adjunctive treatment in clozapine nonresponders suffering from schizophrenia. METHOD: The results of clozapine and ECT treatment in 11 clozapine nonresponders suffering from schizophrenia are reported in terms of remission and relapse. RESULTS: Eight patients had a remission with this combination treatment. After remission of symptoms five patients had a relapse. Three of the five patients who relapsed had a second successful ECT course and remained well with maintenance ECT and clozapine. No evidence for adverse effects was found. CONCLUSION: Adjunctive ECT can be efficacious in clozapine nonresponders suffering from schizophrenia.

A study into predictors for the speed of response to electroconvulsive therapy.

The efficacy of electroconvulsive therapy (ECT) has been firmly established in the treatment of depression. However, prediction of the speed of response to ECT is an issue that needs to be further explored. This study aims to examine the presence of predictors for the speed of response. In a retrospective chart review using 57 patients suffering from major depression who received ECT, the relation of several patient and ECT variables with the speed of response was explored. Response was defined as a drop of at least 35% in Hamilton rating scale of depression (HRSD) score from baseline after 3 or 4 ECT sessions. Patients received ECT with an aged-based stimulus dosage in a clinical setting. Multiple regression analysis showed that high baseline HRSD score and high seizure energy index (SEI) were significantly and independently associated with a rapid response. In a regression model, baseline HRSD score and SEI can be used to predict the speed of response to ECT. Rapid responders to ECT achieved remission significantly more often than slow responders did. SEI can be modified by the clinician. This offers the possibility to optimize ECT treatment.

Effects of maintenance electroconvulsive therapy on cognitive functions.

BACKGROUND: This study examined cognitive side effects of maintenance electroconvulsive (ECT) in comparison with maintenance pharmacotherapy after index ECT. METHOD: Clinical outcome data and neuropsychological measurements were compared in 11 maintenance ECT patients and 13 control patients treated with maintenance pharmacotherapy after index ECT. Data were gathered in a prospective naturalistic study during follow-up. RESULTS: There were no significant differences in patient characteristics and effects of index ECT between groups. In control patients treated with maintenance pharmacotherapy, cognitive function as well as depression ratings remained stable. During maintenance ECT neuropsychological test performance and depression ratings improved slightly but not significantly. CONCLUSIONS: Neuropsychological functioning during the maintenance phase of treatment did not differ between the two treatment groups. Cognitive function remained stable during maintenance ECT.

Prevalence of dementia in centenarians.

Above age 65, the prevalence of dementia rises exponentially from 1 to 15% at age 85. Despite many studies concerning dementia, little is known about the prevalence of dementia in the 'oldest old'. Whether the prevalence levels off around age 95 is yet unanswered. This question is important because it addresses whether dementia is an inevitable consequence of ageing or a disorder occurring within a specific age range. All 17 persons aged 100 or more in three Dutch towns with 250 000 inhabitants were examined by means of cognitive tests, informant questionnaires, clinical interviews and anamneses. Fifteen out of 17 Dutch centenarians in a complete population sample of 250 000 were found to be demented. Two could not be examined.

Prevalence of dementia over age 100.

All nine persons aged 100 or older in a Dutch town with some 100,000 inhabitants were examined by means of cognitive tests, informant questionnaires, and clinical interviews. Formal testing was difficult in most subjects because of visual, auditory, and motor handicaps. By combining the results of cognitive tests and clinical examinations, a diagnosis of moderate to severe dementia could be made in eight subjects. One subject was not examined but by informant questionnaire was found to be mildly demented.

The course of alcohol amnestic disorder: a three-year follow-up study of clinical signs and social disabilities.

Forty-four patients with alcohol amnestic disorder were prospectively studied from 1987 to 1990. The cognitive impairment, social disability and mental symptoms of patients under different conditions were compared. Thirty-three patients (75%) had no symptoms of Wernicke's disease nor a medical history to suggest its existence. The course of mean cognitive impairment of patients in different settings was stable. Change in intelligence quotient correlated with alcohol consumption during the study. The development of social disability differed remarkably in different settings. Patients in a large nursing home deteriorated and patients in small-scale sheltered accommodation improved.

Korsakoff minus Wernicke syndrome.

It is commonly believed that Korsakoff's amnesic state in alcoholics is characteristically the sequel to Wernicke's disease. However, in a study of 44 Korsakoff patients it was found that 33 had developed serious memory impairment without having had alarming neurological symptoms. This insidious nature of the onset of the disease indicates that all alcohol-dependent patients should be treated with vitamin B.

The localization of memory.

MRI showed severe lesions, thought to be specific for the Wernicke-Korsakoff syndrome, in an alcohol dependent patient with an excellent memory. The morphological abnormalities thought to be typical of Wernicke-Korsakoff syndrome might be features of chronic alcoholism and malnutrition. This contention has important implications for the localization of memory functions. Recent literature on the anatomical basis and mechanism of memory is reviewed. Memory probably resides in multifocal neural networks rather than in specific anatomical sites.

Similar brain lesions in alcoholics and Korsakoff patients: MRI, psychometric and clinical findings.

MRI examination revealed similar brain lesions in 5 alcoholic Korsakoff patients and 5 chronic alcoholics without cognitive impairment. Not only cerebral atrophy and demyelination, but also lesions thought to be specific for the Wernicke-Korsakoff syndrome were equally prominent in both groups. The morphological abnormalities thought to be typical of Wernicke-Korsakoff syndrome are probably common features of chronic alcoholism and malnutrition. Marked atrophy of the operculae was found in all Korsakoff patients and in 3 out of 5 chronic alcoholics. Alcohol amnestic disorder may not exclusively result from diencephalic lesions, but also from temporal lesions.

No transketolase abnormalities in Wernicke-Korsakoff patients.

Transketolase isoenzyme patterns of Wernicke-Korsakoff patients, relatives, alcoholics and controls, obtained by isoelectric focusing of purified erythrocyte transketolase, were all identical. After a series of investigations published by several authors little evidence remains to support the hypothesis of an inborn transketolase abnormality in Wernicke-Korsakoff patients.

Isolated cataplexy of more than 40 years' duration.

For over 40 years, a 55-year-old woman had suffered from cataplexy, which had been mistakenly identified as hysteria. Sleepiness, hypnagogic hallucinations and sleep-onset paralysis were not present. This is the longest duration of isolated cataplexy reported so far.

DSM III in outreach emergency psychiatry.

As making a diagnosis in emergency psychiatry is often difficult, whether the systematic use of a diagnostic classification is worthwhile can be questioned. In the psychiatric emergency service in the Hague, The Netherlands, the use of a DSM III classification list was evaluated by comparing emergency service diagnoses during subsequent psychiatric treatments in 237 out of 300 consecutive contacts. For Organic Mental Disorders, Psychoactive Substance Use Disorders, Schizophrenia and Mood Disorders, the Kappa coefficient of agreement was found to lie between 0.5 and 0.6. The application of DSM III categories is considered to be suited to diagnostic classification in outreach emergency psychiatry.

Treatment strategy in depression. I. Non-tricyclic and selective reuptake inhibitors in resistant depression: a double-blind partial crossover study on the effects of oxaprotiline and fluvoxamine.

Antidepressants are ineffective in about 30% of patients with major depression. Some authors then advise treatment of non-responders with (non-tricyclic) more selective reuptake inhibitors. In a double-blind, partial crossover study, 71 patients were selected for treatment during 4 weeks with oxaprotiline and/or fluvoxamine, two non-tricyclic antidepressants that are selective reuptake inhibitors or noradrenaline and serotonin respectively. All patients had failed to respond to earlier treatment with cyclic antidepressants during the current episode. Only 13% of the patients responded, with 27% of them responding to oxaprotiline and none to fluvoxamine. Moreover, a low response of 27% was also obtained in the crossover phase, which included all non-responders to the first treatment, oxaprotiline being effective in 39% and fluvoxamine in 10% of the patients. The results indicate that selective reuptake inhibitors are not an effective alternative for non-responders to other cyclic antidepressants and that non-responders to "noradrenergic" antidepressants do not appear to have much chance of responding to "serotonergic" antidepressants and vice versa.

Treatment strategy in depression. II. MAO inhibitors in depression resistant to cyclic antidepressants: two controlled crossover studies with tranylcypromine versus L-5-hydroxytryptophan and nomifensine.

Antidepressants are ineffective in about 30% of the patients with major depression. Besides electroconvulsive therapy (ECT) and lithium, MAO inhibitors have been suggested as an alternative in such patients. In 2 controlled, partial crossover studies involving 47 patients with major depression who had already been treated unsuccessfully with at least 2 cyclic antidepressants, the effect of the MAO inhibitor tranylcypromine was studied. The first study was an open comparison with L-5-hydroxytryptophan (L-5HTP), the second study a double-blind comparison with nomifensine. Neither the patients treated with L-5HTP nor the patients treated with nomifensine, except one, improved. In contrast, tranylcypromine was effective in 50% of the patients. The depressions of the responders to tranylcypromine appeared to be more endogenous (according Newcastle Scale II) and of shorter duration than those of the non-responders. It is concluded that MAO inhibitors such as tranylcypromine are an effective alternative to ECT and lithium in patients with major depression who have failed to respond to cyclic antidepressants.