Vocally disruptive behavior: A case report and literature review.

Vocally disruptive behavior (VDB) is a common and particularly difficult symptom to manage in dementia. VDB is usually considered collectively with agitation and aggression as a component of behavioral and psychological symptoms in dementia and is therefore poorly understood as an individual symptom. A review of the literature is described where VDB as a challenging behavior has been individually examined as a symptom. A case of VDB occurring in patient with dementia is described where the patient's repetitive vocalizations responded to treatment with pregabalin. This has not been previously reported in the literature. The prevalence of VDB, the factors associated with it and the current management guidelines for clinicians are outlined with a review of the drug treatment strategies for VDB. Pregabalin with its unique pharmacological profile and excellent tolerability should be considered as a possible treatment for VDB where drug treatment is indicated.

Diagnostic Accuracy of Tests for Polyuria in Lithium-Treated Patients.

In lithium-treated patients, polyuria increases the risk of dehydration and lithium toxicity. If detected early, it is reversible. Despite its prevalence and associated morbidity in clinical practice, it remains underrecognized and therefore undertreated. The 24-hour urine collection is limited by its convenience and practicality. This study explores the diagnostic accuracy of alternative tests such as questionnaires on subjective polyuria, polydipsia, nocturia (dichotomous and ordinal responses), early morning urine sample osmolality (EMUO), and fluid intake record (FIR). This is a cross-sectional study of 179 lithium-treated patients attending a general adult and an old age psychiatry service. Participants completed the tests after completing an accurate 24-hour urine collection. The diagnostic accuracy of the individual tests was explored using the appropriate statistical techniques. Seventy-nine participants completed all of the tests. Polydipsia severity, EMUO, and FIR significantly differentiated the participants with polyuria (area under the receiver operating characteristic curve of 0.646, 0.760, and 0.846, respectively). Of the tests investigated, the FIR made the largest significant change in the probability that a patient experiences polyuria (<2000 mL/24 hours; interval likelihood ratio, 0.18 and >3500 mL/24 hours; interval likelihood ratio, 14). Symptomatic questioning, EMUO, and an FIR could be used in clinical practice to inform the prescriber of the probability that a lithium-treated patient is experiencing polyuria.

Risk factors for polyuria in a cross-section of community psychiatric lithium-treated patients.

OBJECTIVES: Polyuria increases the risk of dehydration and lithium toxicity in lithium-treated patients. Risk factors have been inconsistently described and the variance of this adverse effect remains poorly understood. This study aimed to establish independent risk factors for polyuria in a community, secondary-level lithium-treated sample of patients. METHODS: This was a cross-sectional study of the lithium-treated patients attending a general adult and an old age psychiatry service. Participants completed a 24-hour urine collection. Urine volume and the presence of polyuria were the outcomes of interest. The relationship between outcome and the participant's demographic and clinical characteristics was explored with univariable and multivariable analysis. RESULTS: A total of 122 participants were included in the analysis, with 38% being diagnosed with polyuria. Female gender and increased body weight independently predicted the presence of polyuria (standardized regression coefficient 1.01 and 0.94, respectively; p = 0.002 and p = 0.003, respectively). Female gender and increased body weight, lithium dose, and duration of lithium treatment independently predicted higher 24-hour urine volumes (standardized regression coefficients 0.693, p < 0.0005; 0.791, p < 0.0005; 0.276, p = 0.043; 0.181, p = 0.034, respectively). Of three different weight metrics, lean body weight was the most predictive. CONCLUSIONS: Female gender and increased body weight explain part of the variance of this adverse effect. Both risk factors offer fresh insights into the pathophysiology of this potentially reversible and dangerous adverse effect of lithium treatment. Future research should focus on understanding the differences between the genders and between different body compositions in terms of lithium pharmacokinetics and pharmacodynamics.

Use of low-dose gabapentin for aggressive behavior in vascular and Mixed Vascular/Alzheimer Dementia.

Recent reports highlighting serious adverse effects of antipsychotic medication in behavioral and psychological symptoms of dementia (BPSD) has led to calls for research on alternative agents. The authors describe the use of low-dose gabapentin to treat seven patients with a diagnosis of ICD-10 vascular or Mixed Vascular/Alzheimer Dementia with serious aggressive behavior. All seven patients had impressive and clinically significant responses to treatment. Treatment was tolerated in each case without adverse reactions. Our findings suggest that gabapentin should be considered for treating aggressive behavior in patients with vascular or mixed dementia and that it is well tolerated in this context.

Diogenes syndrome and autistic spectrum disorder.

Diogenes syndrome or senile squalor syndrome has been described in the psychiatric literature with an associated mental illness in between one half and two thirds of the cases cited. The occurrence of the syndrome in the absence of a psychiatric disorder has received much attention with many hypotheses proposed. We present the case of a 72-year-old man living for many years in domestic squalor whose presentation, neuropsychological profile and history suggest an underlying autistic spectrum disorder. We are not aware of any similar case in an older adult reported in the medical literature. The co-occurrence of these two conditions is an intriguing one as certain key features of autistic spectrum disorder may predispose to Diogenes syndrome.

Lithium and prevention of cognitive impairment.

OBJECTIVE: To examine the rate of cognitive decline and occurrence of dementia among patients attending a lithium clinic for those aged 65 years and over. METHOD: Retrospective chart review of the cognitive function of 29 patients receiving maintenance lithium treatment attending the Dublin South East Old Age Psychiatry service, over a nine-year time period. RESULTS: Twenty-nine patients were included in the study (20 female, nine males), with a mean age of 79 years. Two patients had concurrent dementia. Six patients fulfilled ICD10 criteria for mild cognitive disorder and all of these patients also fulfilled revised consensus criteria for mild cognitive impairment amnestic subtype. Sixteen patients were commenced on lithium as an augmentation treatment for recurrent depressive disorder, 12 patients were on treatment for bipolar affective disorder and one patient on treatment for schizoaffective disorder. Patients had been receiving lithium treatment for an average of 109 months with follow-up by the service for a mean duration of 38 months. The initial mean MMSE score of patients at first presentation to the service was 26.9 (SD = 5.6) compared to a mean MMSE score 25.8 (SD = 5.8) (CI of change in MMSE score at 95% level = -2.1 and 0) at follow-up. The mean MMSE of patients with mild cognitive impairment prior at first contact with the service was 26.8 (SD = 3.2) and at follow-up was 26 (SD = 3.2) which was not statistically significantly different (p=0.40) (CI for change in MMSE at 95% level = -3.2 to 1.5). No patient had developed incident dementia during the follow-up period of the study. CONCLUSION: The results tentatively suggest that lithium may have a protective effect against cognitive decline and a neuroprotective role in patients with concurrent affective disorder and cognitive impairment. Multi-centre prospective studies of cognitive function in patients attending lithium clinics are needed to examine the neuroprotective properties of lithium.

Relapse of postictal psychosis following 14-year symptom-free period.

Neuropsychiatric sequelae in patients with epilepsy have been vastly studied and documented. These may be affective, cognitive or psychotic. Certain risk factors may predispose some epileptics more to these sequelae. In general, good epileptic control may minimize these outcomes. We present in this report, a case of postictal psychosis (PIP), superimposed on delirium, in a 68-year-old woman, with history of a single previous psychotic illness following a cluster of seizures. This report shows a collaborative management of the neuropsychiatric complications of temporal lobe epilepsy (TLE), by the neurology, geriatric medicine and psychiatry teams.

Carer-rated needs assessment of a cohort of people with dementia.

OBJECTIVES: With increasing longevity, more people will develop dementia. These people will have a wide range of needs according to their circumstances. Services in the community struggle to meet these needs. This study aimed to identify needs of dementia sufferers attending the South Dublin Old Age Psychiatry service as rated by their carers, to assess the extent of unmet need and the implication of this. METHOD: The carers of 40 community-dwelling people with dementia attending the service were interviewed by one researcher using the Camberwell Assessment of Need for the Elderly (CANE). This measures a wide range of needs over 24 areas, from personal care, to social, financial and psychological care needs. Qualitative information was also obtained from carers regarding services available and their accessibility. A measure of carer stress and satisfaction with help for this was also obtained. RESULTS: Overall, the highest levels of need identified (both met and unmet) were in the areas of psychological functioning (memory and psychological distress), followed by social needs in the areas of managing money, daytime activities, self-care, and looking after the home. Highest unmet social needs were in the areas of daytime activities, home care and managing money. For 23/24 domains, carers were satisfied rather then unsatisfied with help received. The areas of greatest dissatisfaction to them concerned daytime activities, household skills and self-care. Over half of the carers reported psychological distress. CONCLUSION: High levels of need, both met and unmet were identified. Many identified needs related to the provision of community supports in the areas of selfcare, household skills and daytime activities, in addition to psychiatric needs. Assessment of needs is important to ensure adequate and responsive service provision, in keeping with the ethos of community care.

Abuse of vulnerable people with dementia by their carers: can we identify those most at risk?

OBJECTIVE: We wanted to explore possible associations between characteristics of carers, dementia sufferers and the caring situation and the presence of abuse that was acknowledged by carers. METHODS: Eighty-two carers of dementia sufferers were interviewed in their homes about three types of abuse (verbal abuse, physical abuse and neglect) using a structured questionnaire. RESULTS: Fifty-two percent (n = 43) carers admitted to having carried out some form of abuse. Verbal abuse was the most common form (n = 42, 51%), while 20% (n = 16) of carers admitted to physical abuse and 4% (n = 3) to neglect abuse. Significant associations were found between verbal abuse and psychological ill health in the carer and behavioural problems in the dementia sufferer. Physical abuse was significantly associated with higher levels of self-reported good health by the carer. High expressed emotion measured in carers was highly correlated with all types of abuse. CONCLUSION: It is possible to identify situations where people with dementia may be at high risk of abuse from their carers. Any effective intervention strategy should address psychological health problems in the carer, behavioural problems in the dementia sufferer and a strategy to manage high levels of expressed emotion in these situations.

Delirium in the hospitalised elderly: An audit of NCHD prescribing practice.

OBJECTIVES: This study was carried out to determine the prescribing of psychotropic medication of non-consultant hospital doctors in the management of delirium and to compare this with best practice guidelines. METHOD: A structured questionnaire was forwarded to all non-consultant hospital doctors (n = 95) working at St Vincent's University Hospital and data was collected over a six month period. The questionnaire addressed type, dose and route of psychotropic medication use in delirium as well as adjunctive measures used to manage delirium. RESULTS: There was a 55% response rate (n = 52). Haloperidol and lorazepam were the two most frequently prescribed psychotropic agents used and over one third of respondents (n = 20) reported the use of risperidone. There was wide variation in doses used and a substantial proportion of NCHDs used higher than recommended starting doses for elderly patients with delirium. In addition, the intramuscular route was reported as the commonest route of administration with a majority of respondents reporting infrequent intravenous route of administration. CONCLUSIONS: The drug choice reported by respondents followed best practice guidelines. However, the wide variation in drug doses used and frequency of parenteral route of administration (particularly intramuscular) indicate the need for increasing awareness of best practice international guidelines. Guidance and clarification regarding the use of atypical antipsychotic medication is required following concerns about their use in dementia.

An audit of psychotropic prescribing practice of general adult psychiatrists in elderly demented patients.

OBJECTIVES: In Ireland elderly patients with behavioural and psychological symptoms of dementia (BPSD) are frequently prescribed anti-psychotic and other psychotropic agents. Elderly patients with dementia are more sensitive to adverse effects of medications. Despite this, little is known of the psychotropic prescribing practice of psychiatrists who treat this population. General adult psychiatrists in the Republic of Ireland continue to treat elderly patients with BPSD. The aim of this audit was to identify the prescribing practice of general adult psychiatrists in elderly patients with BPSD. We compare this practice to that of old age psychiatrists in the UK and that recommended by the American Psychiatric Association in 1997. METHODS: We devised a structured anonymous questionnaire, which was forwarded to all general adult psychiatrists in the Republic of Ireland. RESULTS: Atypical anti-psychotics are frequently prescribed by general adult psychiatrists to manage BPSD in elderly patients. The anti-psychotic agent of first preference chosen to treat psychotic symptoms in dementia is risperidone. Overall, sedative typical anti-psychotics are still the most frequently chosen anti-psychotic agents, chosen to manage behavioural symptoms in dementia. Benzodiazepines and trazadone are the most frequently prescribed other psychotropic agents chosen to manage agitated behaviour. In general the median doses of antipsychotics and other psychotropic medication used are in keeping with both the APA guidelines and practice of old age psychiatrists in the UK. A minority of practitioners (10%) specified at least one dosage regime that was grossly outside recommended ranges. CONCLUSIONS: Overall, prescribing practice in terms of choice of treatment and dosage regime, of general adult psychiatrists in BPSD is in keeping with the best practice guidelines. However, sedating typical anti-psychotics and on occasion extraordinarily high doses of anti-psychotics are still prescribed.