Association of Renal Clearance with Cerebral White Matter Vascular Disease in Hospitalized Veterans With and Without Delirium.

OBJECTIVES: To assess the relation between renal function and delirium and to assess and compare the relation between cerebral white matter lesion (WML) and renal function as estimated by three formulas for the estimated glomerular filtration rate (eGFR) in older adult hospitalized veterans with and without delirium. METHODS: Commonly used formulas to assess renal function-the four-variable Modification of Diet in Renal Disease (MDRD), the six-variable MDRD, and the Cockcroft-Gault eGFR equations-were used to assess renal function in 100 older adult hospitalized veterans with delirium (delirium group) and 100 hospitalized veterans without delirium (nondelirium group) that were age, sex, and race matched. WML location and volumes were assessed using brain computed tomography imaging for each of the 200 veterans in the study. One radiologist, blinded to the diagnoses of the veterans, examined head computed tomography scans for WML in the cortex, subcortex (frontal, temporal, parietal, occipital lobes), basal ganglia (globus pallidus, caudate, putamen), and internal capsule. WML were graded as not present, <1 cm, 1 to 2 cm, or >2 cm. Exploratory χ2 analyses were used to determine the association between the stage of chronic kidney disease and WML. Simple logistic regression analyses were then used to estimate the strength of association between the stages of kidney disease and WML for particular regions of the brain. RESULTS: The mean age of delirium group and nondelirium group veterans was 66 years. χ2 tests revealed no reliable relation between stages of renal disease and delirium. χ2 exploratory analyses of WML in brain regions by renal disease stages demonstrated significant differences in associations among the MDRD-4, MDRD-6, and Cockcroft-Gault formulas for measuring eGFR. The MDRD-4 formula was least associated with the presence or absence of WML. The Cockcroft-Gault estimation of eGFR was most associated with the presence or absence of WML. Simple logistic regressions showed notable increases in the association between stages of renal failure and WMLs in specific areas of the brain, with the MDRD-4 being the least associative with the fewest specific areas and the Cockcroft-Gault formula being the most associative with the most specific areas. CONCLUSIONS: The association between stages 2 through 5 of chronic kidney disease and WLM support the role of kidney function as a potential risk factor for WML in older adult military veterans. The Cockcroft-Gault formula is an important renal index of suspected WML and renal stages 2 through 5, superior to the MDRD-6 and MDRD-4, respectively, in association with WML in older adult military veterans.

Veterans in substance abuse treatment program self-initiate box gardening as a stress reducing therapeutic modality.

OBJECTIVES: To assess the experiences of a veteran initiated horticultural therapy garden during their 28-day inpatient Substance Abuse Residential Rehabilitation Treatment Program (SARRTP). DESIGN: Retrospective study. SETTING: Veterans Affairs Medical Center (VAMC), Salem, Virginia, USA INTERVENTIONS: Group interviews with veterans from the last SARRTP classes and individual interviews with VAMC greenhouse staff in summer of 2016. OUTCOME MEASURES: Time spent in garden, frequency of garden visits, types of passive and active garden activities, words describing the veterans' emotional reactions to utilizing the garden. RESULTS: In 3 summer months of 2016, 50 percent of the 56 veterans interviewed visited and interacted with the gardens during their free time. Frequency of visits generally varied from 3 times weekly to 1-2 times a day. Amount of time in the garden varied from 10min to 2h. The veterans engaged in active and/or passive gardening activities during their garden visits. The veterans reported feeling "calm", "serene", and "refreshed" during garden visitation and after leaving the garden. CONCLUSIONS: Although data was secured only at the end of the 2016 growing season, interviews of the inpatient veterans revealed that they used their own initiative and resources to continue the horticulture therapy program for 2 successive growing years after the original pilot project ended in 2014. These non-interventionist, therapeutic garden projects suggest the role of autonomy and patient initiative in recovery programs for veterans attending VAMC treatment programs and they also suggest the value of horticulture therapy as a meaningful evidence- based therapeutic modality for veterans.

Cocaine Abuse, Traumatic Brain Injury, and Preexisting Brain Lesions as Risk Factors for Bupropion-Associated Psychosis.

BACKGROUND AND OBJECTIVE: Bupropion is generally considered safe and is widely used both as a monotherapy and as an augmentation agent for the treatment of major depression. Concerns have been raised about bupropion's propensity to precipitate new psychosis and worsen existing psychotic symptoms, although the mechanism is poorly understood. Three cases are reported in which bupropion use was associated with psychosis. The aim of the study was to explore the risk factors and possible mechanisms of psychosis in each case. CASE REPORTS: Case 1 describes the interaction of cocaine abuse sensitization in a patient who developed psychosis with a lower dosage of bupropion. Cases 2 and 3 discuss the role of traumatic brain injury and structural brain lesions in increasing the risk of psychosis when using bupropion. CONCLUSIONS: Cocaine abuse, traumatic brain injury, and preexisting brain lesions appear to be risk factors for developing psychosis in persons taking bupropion. In such cases, clinicians should carefully assess the risks and benefits and closely monitor patients for symptoms of psychosis.

Association of White Matter Lesions, Cerebral Atrophy, Intracranial Extravascular Calcifications, and Ventricular-Communicating Hydrocephalus with Delirium Among Veterans.

OBJECTIVES: The literature regarding the underlying neuropathogenesis of delirium on head computed tomography (CT) is limited. The aim of this research was to investigate, using case-control retrospective chart review, the association of white matter lesions (WML), cerebral atrophy, intracranial extravascular calcifications, and ventricular-communicating hydrocephalus in older adult military veterans with and without delirium hospitalized in a Veterans Affairs Medical Center. METHODS: Head CT scans were examined for WML, atrophy, and intracranial extravascular calcifications globally in the cortex, subcortex (frontal, temporal, parietal, occipital lobes), basal ganglia (globus pallidus, caudate, putamen), and internal capsule, in addition to the presence of ventricular-communicating hydrocephalus. WML were graded as not present, <1 cm, 1 to 2 cm, or >2 cm. Atrophy, cerebral atrophy, intracranial extravascular calcifications, and ventricular-communicating hydrocephalus were graded as present or not present. RESULTS: There was a significant association of WML in the temporal lobe periventricular cortical and subcortical brain and a significant association of atrophy in the parietal lobes and the cerebellum in hospitalized older adult military veterans with delirium compared with hospitalized older adult military veterans without delirium. There were no differences between the delirium and nondelirium groups for intracranial extravascular calcifications and ventricular-communicating hydrocephalus. CONCLUSIONS: The results suggest that atrophy in the parietal lobes and the cerebellum of hospitalized older adult military veterans may be associated with an elevated risk of delirium when compared with age, race, and sex-matched control veterans. Continuing efforts are needed to clarify the role of atrophy during delirium in the veteran and nonveteran older adult population to reduce progressive frailty and decreased quality of life secondary to hospital and posthospital-discharge delirium.

Treatment of Post-Traumatic Stress Disorder Nightmares at a Veterans Affairs Medical Center.

The effectiveness of medications for PTSD in general has been well studied, but the effectiveness of medicatio.ns prescribed specifically for post-traumatic stress disorder (PTSD) nightmares is less well known. This retrospective chart review examined the efficacy of various medications used in actual treatment of PTSD nightmares at one Veteran Affairs Hospital. Records at the Salem, VA Veterans Affairs Medical Center (VAMC) were examined from 2009 to 2013 to check for the efficacy of actual treatments used in comparis.on with treatments suggested in three main review articles. The final sample consisted of 327 patients and 478 separate medication trials involving 21 individual medications plus 13 different medication combinations. The three most frequently utilized medications were prazosin (107 trials), risperidone (81 trials), and quetiapine (72 trials). Five medications had 20 or more trials with successful results (partial to full nightmare cessation) in >50% of trials: risperidone (77%, 1.0-6.0 mg), clonidine (63%, 0.1-2.0 mg), quetiapine (50%, 12.5-800.0 mg), mirtazapine (50%; 7.5-30.0 mg), and terazosin (64%, 50.0-300.0 mg). Notably, olanzapine (2.5-10.0) was successful (full remission) in all five prescription trials in five separate patients. Based on the clinical results, the use of risperidone, clonidine, terazosin, and olanzapine warrants additional investigation in clinically controlled trials as medications prescribed specifically for PTSD nightmares.

PTSD in Combat Veterans With Cognitive Decline.

Patients may exhibit posttraumatic stress disorder symptoms prior to the onset of dementia or uncover long quiescent symptoms of the disease, adding to the challenge of treating this population.

Horticultural therapy: a pilot study on modulating cortisol levels and indices of substance craving, posttraumatic stress disorder, depression, and quality of life in veterans.

CONTEXT: Horticultural therapy (HT) is a subgroup of occupational therapy (OT). Both HT and OT have been successful as adjunctive treatment modalities in substance abuse treatment. Studies have indicated that gardening promotes neuroendocrine and affective restoration from stress. OBJECTIVES: The study intended to assess the effect of HT versus nonhorticultural OT on cortisol levels, depression, symptoms of posttraumatic stress disorder (PTSD), alcohol cravings, and quality of life. METHODS: The research team designed a randomized pilot study. SETTING: The study was open for participation from July 2012-October 2012. It took place during multiple occurrences of a 28-d treatment programs for substance use disorder at a Veterans Affairs medical center. Participants • Participants were 49 veterans, averaging 46.4 y old (SD = 11.9); the dropout rate was 37%. INTERVENTION: Participants were randomly assigned to the HT or the OT group. They attended supervised HT and OT groups 5 h/d for 3 wk. Outcome Measures • Pre- and posttreatment, participants completed the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF), the Alcohol Craving Questionnaire (ACQ-NOW), the Posttraumatic Stress Disorder Checklist Civilian Version (PCLC), and the Center for Epidemiologic Studies Depression Scale (CES-D). Salivary cortisol samples were taken at wk 1, 2, and 3. RESULTS: A repeated measures analysis of variance (ANOVA) (F2,20 = 0.878) revealed that the HT performed was associated with a 12% reduction in salivary cortisol levels from wk 1 to wk 3, but the difference was not statistically significant (P = .43). Separate 1-way analyses of covariance (ANCOVAs) revealed no statistically significant differences in the self-administered tests, although both the Q-LES-Q-SF and CES-D showed a trend toward improving quality of life and depressive symptoms in the HT group compared with the OT group. Additional analysis of the nonbiologic tests suggests that most participants in the HT and OT had some benefit from the programmed activities. CONCLUSIONS: The trends suggest that HT may modulate stress in veterans, as evidenced by decreased cortisol levels and depressive symptoms, and may improve quality of life more than the programs in which the OT group participated. Further investigation with larger samples, including a nontreatment control group, is needed to determine whether the observed trends are treatment effects or due to abstinence.

Comparison of advance medical directive inquiry and documentation for hospital inpatients in three medical services: implications for policy changes.

Following the introduction of the Patient Self-Determination Act of 1990, the Veterans Health Administration developed its own advance medical directive (AMD) policy, which most recently states that documentation is mandatory for all hospital patients in all settings. The object of this study was to assess the effectiveness of AMD documentation at a local Veterans Affairs Medical Center. AMD documentation was compared among three inpatient services: surgery, medicine, and psychiatry. Retrospective in nature, 594 inpatient cases were compared. Results revealed that, overall, the rate of AMD documentation was 37.7%. AMD documentation on surgery was statistically more frequent (45.6%) than for either medicine (33.2%) or psychiatry (34.5%). The difference between the numbers of days to AMD documentation for all three services was not statistically significant. While there was no statistically significant difference across gender, Caucasians had AMDs documented more frequently than African Americans (p < .001). Logistic regression reveals that social worker and physician intervention, not patient-specific variables, are the primary predictors of AMD incidence. Policy makers may need to consider the realities of hospital care, especially in emergency settings, and be more specific in the steps of implementation of the policy in the evenings, weekends, and holidays. True adherence to policy implementation may require hospital administrators to increase staff and educational efforts so that the concept of AMD communication and documentation is completely explained to all staff and patients. Policy should include an electronic record reminder that is renewed every 3 years and provisions for accommodating patients who arrive on weekends and holidays, with special awareness of the particular communication needs of minority groups. The study conclusions are that further inquiry is needed to understand these policy nuances to enable the Veterans Affairs Administration to improve its policies and performance in this important aspect of healthcare.

Organophosphate intermediate syndrome with neurological complications of extrapyramidal symptoms in clinical practice.

Organophosphates (OPs) are ubiquitous in the world as domestic and industrial agricultural insecticides. Intentional poisoning as suicides attempts are clinical phenomena seen in emergency departments and clinics in agricultural areas. Intermediate syndrome with the neurological complication of extra pyramidal symptoms following acute OP ingestion may occur in pediatric and adult cases. While death is the most serious consequence of toxic OP doses, low levels of exposure and nonfatal doses may disrupt the neurobehavioral development of fetuses and children in addition to bring linked to testicular cancer and male and female infertility. These are disturbing. Chronic and acute toxicity from OPs are barriers to the health of our present and future generations. Symptoms and treatment of acute and chronic OP exposure are briefly referenced with inclusion of the intermediate syndrome. Suggestions for local and systemic reduction of the acute and long term consequences of OP ingestion are opined.

Can improved intra- and inter-team communication reduce missed delirium?

To assess the prevalence and the team interaction in cases of missed delirium in acute care veterans coded as not having a diagnosis of delirium in admission or discharge notes. In this retrospective study, the records of 183 hospitalized veterans admitted to the emergency department (ED), medicine, surgery and psychiatry services and coded as not having a diagnosis of delirium were analyzed. Clinical notes of each case were examined using DSM IV TR criteria for delirium. Of the 52 cases assessed to have delirium, 5 cases had been miscoded as not having delirium. In the remaining 47 cases the diagnosis of delirium had been missed. The rates of undiagnosed delirium were ED 46/160, medicine 39/132, surgery 4/17, psychiatry 4/29 and consult liaison (CL) 0/9. Of the 5 cases of delirium identified by the CL service, 2 consult diagnoses were accepted and 3 were rejected. Nursing notes had words suggesting delirium in 70.2 % of 47 cases compared to 41.3 and 43.6 % of the clinician case notes for these patients admitted to ED and medicine respectively. No delirium or cognitive screening scales were utilized in the work up of the 52 cases involving delirium. The study results suggest that continuing education by the CL service of all hospital personnel involved in patient care may improve the diagnosis of delirium. Also, increased clinician-nursing intra-team communication, in addition to careful scrutiny of the nursing and clinician notes may contribute to the reduced incidence of missed delirium.

Case reports of neuroleptic malignant syndrome in context of quetiapine use.

A retrospective analysis was followed on 20 case reports covering the possible correlation between the atypical antipsychotic, quetiapine, and neuroleptic malignant syndrome (NMS), determined by the study of 7 different NMS criteria guidelines. A great majority (19) of the case studies did not meet the requirements of all 7 guidelines, frequently due to unreported information. Nor was quetiapine proven to be the sole cause of the possible NMS in the two age groups investigated. Only one case was found to have no other medication or medical conditions confounding the relationship of quetiapine and NMS symptoms, and that case was in the context of a significant quetiapine overdose. The other 19 cases demonstrated the difficulty of identifying the cause of NMS when polypharmacy and other medical conditions are involved. The authors note the need for caution in deciding both the presence of NMS and the causal factors of the symptoms.

What is the evidence to support the use of therapeutic gardens for the elderly?

Horticulture therapy employs plants and gardening activities in therapeutic and rehabilitation activities and could be utilized to improve the quality of life of the worldwide aging population, possibly reducing costs for long-term, assisted living and dementia unit residents. Preliminary studies have reported the benefits of horticultural therapy and garden settings in reduction of pain, improvement in attention, lessening of stress, modulation of agitation, lowering of as needed medications, antipsychotics and reduction of falls. This is especially relevant for both the United States and the Republic of Korea since aging is occurring at an unprecedented rate, with Korea experiencing some of the world's greatest increases in elderly populations. In support of the role of nature as a therapeutic modality in geriatrics, most of the existing studies of garden settings have utilized views of nature or indoor plants with sparse studies employing therapeutic gardens and rehabilitation greenhouses. With few controlled clinical trials demonstrating the positive or negative effects of the use of garden settings for the rehabilitation of the aging populations, a more vigorous quantitative analysis of the benefits is long overdue. This literature review presents the data supporting future studies of the effects of natural settings for the long term care and rehabilitation of the elderly having the medical and mental health problems frequently occurring with aging.

Salem VAMC-U.S. Army Fort Bragg Warrior Transition Clinic telepsychiatry collaboration: 12-month operation clinical perspective.

OBJECTIVE: To describe the clinical experience in the first Veterans Affairs (VA)-U.S. Army Warrior Transition Clinic (WTC) telepsychiatry operation (September 2008-August 2009). MATERIALS: Joint VA and U.S. Army records. METHODS: Analysis of intake, follow-up, and last visit records. RESULTS: One hundred twenty active-duty U.S. Army soldiers were seen (394 clinic visits). Ninety-eight soldiers had one or more combat tours, principally in Iraq and Afghanistan. Posttraumatic stress disorder was diagnosed in 50.0% of the cases by the WTC telepsychiatrists. The majority of the soldiers had medical comorbidities, especially chronic pain (75.0%), in addition to mental health problems. Several of the soldiers were recovering from trauma (20.8%) and/or surgery (23.3%), 11.7% exhibited traumatic brain injuries, and 17.5% had headaches. Disrupted relationships (74.2%) were notable for non-family members, especially military cohorts such as other persons in the same WTC squad or platoon. CONCLUSION: The observations in this report come from a cross-section of soldiers who were triaged to meet WTC admission criteria. As this is the prototype VA-U.S. Army telepsychiatry collaboration, there are no comparative data at this time. The nature of the medical and psychiatric problems treated in the military WTC represents an index of the more severe combat trauma treated on military bases from ongoing combat operations and may predict future VA-U.S. Army collaborative telepsychiatry clinic experiences.

Risperidone for post-traumatic combat nightmares: a report of four cases.

OBJECTIVE: To report the response to low-dose risperidone in individuals with combat-related post-traumatic stress disorder (PTSD) combat nightmares. DESIGN: Case series. SETTING: Veterans Affairs Medical Center Mental Health Clinic and collaborative VA-U.S. Army Fort Bragg Warrior Transition Telepsychiatry Clinic. PRACTICE DESCRIPTION: Veterans at the VA; soldiers that have severe medical and mental health problems in the Warrior Transition Telepsychiatry Clinic. MAIN OUTCOME MEASURE(S): No response: no change in frequency and/or severity of nightmares; partial response: decrease in frequency and/or severity of nightmares; full response: total cessation of recall of nightmares. RESULTS: The four individuals included one active duty soldier and three veterans, ranging from 40 to 76 years of age. All served in the infantry, each in a different combat theater. Two participants had a reduction in the frequency and severity of nightmares at risperidone 1 mg at night. One veteran with blood alcohol levels greater than 300 mg/mL had a partial response with risperidone 3 mg at night. Without active substance abuse, the four individuals had a total cessation of nightmares the first night at a risperidone dose of 2 mg at night. The total cessation of nightmares with risperidone continued despite changes in concurrent antidepressants, anxiolytics, and hypnotics. No medication side effects were reported. CONCLUSION: The use of low-dose risperidone (1-3 mg) at night can reduce the severity and frequency or stop the recall of PTSD combat nightmares in some veterans and active duty soldiers. Risperidone may be an effective medication for combat nightmares of PTSD and merits additional exploration.

A telepsychiatry transition clinic: the first 12 months experience.

To improve the management of soldiers with combat-related mental health problems, an interdisciplinary telepsychiatry service was established between a clinic at the Fort Bragg army base and the Veterans Affairs (VA) Medical Center in Salem. In the first 12 months of operation, 120 soldiers (105 males) were seen in a total of 394 telepsychiatry sessions. The time spent on telepsychiatry by the six VA psychiatrists increased from 13 hours in the first month to 41 hours in the twelfth month. The number of telepsychiatry sessions increased from nine in the first month to 56 in the twelfth month. The mean global assessment of function score (GAF) in the soldiers increased significantly (P < 0.001) from 58.0 at intake to 62.3 at the last visit. Soldiers received VA telepsychiatry on average 22 days after the initial consultation with a primary care provider, a reduction of at least eight days compared to the previous delay. The majority of soldiers (89%) who were treated by VA psychiatrists enrolled in the VA within about six months of discharge. Similar VA-US Military collaborations may prove beneficial for other military bases that have returning combat soldiers.

Bupropion-induced psychosis: folklore or a fact? A systematic review of the literature.

OBJECTIVE: Bupropion is a substituted phenyl-ethylamine that is extensively utilized for the treatment of major depressive disorder and for smoking cessation. It is a reuptake inhibitor of dopamine and norepinephrine, and it also has some nicotinic antagonism. There are concerns that it may increase the risk of psychosis due to its dopaminergic effects. Our objective is to review the literature and analyze the risk of bupropion precipitating a psychotic illness in the general population as well as in the populations with a history of psychotic symptoms. METHODS: A Medline database search limited to human and English-language studies was conducted using the keywords "bupropion" and "psychosis." A total of 23 articles were selected based on the relevance of the articles and their references. The data from these articles were collated. RESULTS: Collated data show that there is some evidence to suggest that bupropion may cause or worsen psychosis in selected subpopulations. Higher doses of bupropion appear more likely to be associated with the outcome severity. Preexisting psychotic symptoms, substance abuse and drug interactions also seem to increase the risk. Concurrent use of antipsychotics at adequate doses appears to be protective. CONCLUSIONS: The literature is incomplete and in some cases contradictory. In selected cases, bupropion appears to be associated with the induction of psychotic symptoms in addition to the precipitation or worsening of an existing psychotic syndrome. Further research including controlled studies is required to clarify the risk of bupropion precipitating a psychotic illness in vulnerable populations.

Scheduled medications and falls in dementia patients utilizing a wander garden.

Little has been reported about the relationship of a dementia wander garden with scheduled psychiatric medications in addition to changes in fall number and severity. The 28 participating residents of a dementia unit were divided into high (HUG) and low (LUG) wander garden user groups and assessed for the number and severity of falls. The type and dose of scheduled psychiatric medications were monitored for 12 months before and 12 months after the wander garden was opened. Results indicated that the residents experienced about a 30% decrease for the raw number of falls and fall severity scores. The HUG had a significant reduction in high-dose antipsychotics, whereas there was relatively no change in antidepressant, hypnotic, and anxiolytic use. High wander garden user group required fewer scheduled medications and experienced reduced falls and lower fall morbidity than the LUG. The most significant changes in scheduled psychiatric medications were reductions in scheduled antipsychotics and an increase in residents requiring no antipsychotics.

Delirious mania and malignant catatonia: a report of 3 cases and review.

Delirious mania is often difficult to distinguish from excited catatonia. While some authors consider delirious mania a subtype of catatonia, the distinction between the two entities is important as treatment differs and effects outcome. It appears that as catatonia is described as having non-malignant and malignant states, the same division of severity may also apply to delirious mania. Non-malignant delirious mania meets the criteria for mania and delirium without an underlying medical disorder. The patients are amnestic, may lose control of bowel and bladder, but still respond to atypical antipsychotics and mood stabilizers. However, with increasing progression of the disease course and perhaps with an increasing load of catatonic features, delirious mania may convert to a malignant catatonic state (malignant delirious mania) which is worsened by antipsychotics and requires a trial of benzodiazepines and/or ECT. Three case reports are presented to illustrate the diagnostic conundrum of delirious mania and several different presentations of malignant catatonia.

Ruptured intracranial dermoid cyst presenting with neuropsychiatric symptoms: a case report.

Psychiatric symptoms associated with frontal lobe unruptured or ruptured intracranial dermoid cysts are rarely described in the medical literature. The case of a 58-year-old man with a chronic history of anxiety, major depression, and obsessive compulsive disorder who presented with new onset auditory and visual phenomena is described. This case illustrates the need to include an underlying brain tumor in the differential diagnosis when encountering new onset auditory and visual phenomena in patients with chronic mood and/or anxiety disorders.