Double-blind, placebo-controlled trial of methylphenidate in older, depressed, medically ill patients.

OBJECTIVE: The authors examined the efficacy of methylphenidate in the treatment of depression in a group of older, medically ill patients. METHOD: Sixteen patients underwent an 8-day double-blind, randomized, placebo-controlled crossover trial; 13 completed the trial. RESULTS: Statistically and clinically significant treatment responses were found. CONCLUSIONS: These results support the use of methylphenidate in older, medically ill patients in whom rapid resolution of depressive symptoms is crucial.

Advance directives and the cost of terminal hospitalization.

BACKGROUND: It has been assumed that patients using advance directives would direct terminal care away from the intensive care unit and choose shorter, less costly, less technological terminal hospital stays. METHODS: This retrospective cohort study examined 336 consecutive patients who died in a university tertiary care medical center: 242 without advance directives, 66 with a previously completed advance directive, 13 admitted for the express purpose of terminal care, and 15 who signed an advance directive during their terminal hospitalization. Total charges (hospital and physician) were calculated for all patients and were adjusted using both physician and hospital diagnosis-related group weights. Patient participation in end-of-life decisions was determined by chart review. RESULTS: The group without advance directives had dramatically higher mean total ($49,900 vs $31,200) terminal hospitalization charges than the group with previously completed advance directives, producing a charge ratio of 1.6. After diagnosis-related group adjustment, the charge ratio was 1.35 (95% confidence interval, 1.07 to 1.72) for physician charge, 1.36 (95% confidence interval, 1.06 to 1.74) for hospital charge, and 1.35 (95% confidence interval, 1.08 to 1.73) for total charge. Multiple regression analysis controlling for age, sex, and cancer diagnosis confirmed these findings. Patients with advance directives were significantly more likely to limit treatment and to participate in end-of-life decisions. CONCLUSION: Patients without advance directives have significantly higher terminal hospitalization charges than those with advance directives. Our investigation suggests that the preferences of patients with advance directives are to limit care and these preferences influence the cost of terminal hospitalization.

Treatment of patients with psychiatric and psychoactive substance abuse disorders.

The treatment of individuals with coexisting psychoactive substance abuse and severe psychiatric disorders requires an integration of principles from the mental health and chemical dependency fields. The authors outline a conceptual model for treating dually diagnosed patients that consists of four treatment phases--engagement, persuasion, active (or primary) treatment, and relapse prevention. The components of these phases include case management, group therapy, psychopharmacology, toxicologic screening, detoxification, family involvement, and participation in self-help groups. Due to the high morbidity and mortality associated with dual diagnoses, the authors encourage the development, implementation, and scientific evaluation of integrated treatment models targeted toward this population.

Chemical monitoring of disulfiram compliance: a study of alcoholic outpatients.

Poor compliance with disulfiram (Antabuse) therapy may reduce its efficacy in the treatment of alcoholism. This study was designed to examine two questions: (a) Could use of a chemical test for disulfiram ingestion be used clinically to improve disulfiram compliance and if so, (b) could improved disulfiram compliance contribute to improved compliance with other aspects of treatment? The results suggest that disulfiram compliance rates can be increased by clinical use of chemical monitoring data; however in this sample increased compliance with disulfiram did not correlate with improvements in other aspects of treatment compliance.

Treatment compliance of older alcoholics: an elder-specific approach is superior to "mainstreaming".

A sample of 24 alcoholics (mean age, 58.8 years) treated in typical mixed-age outpatient groups, is compared to a sample of 25 alcoholics (mean age, 60.2 years) treated in special elderly peer groups. Patients treated in the special peer group program remained in treatment significantly longer and were more likely to complete treatment than those treated in mixed-age groups. These findings support the continued development and evaluation of elder-specific treatment approaches for older alcoholics.

Early versus late onset alcoholism in older persons: preliminary findings.

Systematic data comparing early onset (EO) versus late onset (LO) subgroups of older alcoholics is presented in this preliminary clinical report. Thirty-six older active problem drinkers, ages 53 to 76 years at the time of entry into a special outpatient treatment program, were assessed on selected demographic, psychological, alcohol history, and alcohol treatment compliance variables. There were 14 EOs (first alcohol problem prior to age 40 years) and 22 LOs (first problem after age 40). Compared to EOs, LOs reported less family alcoholism and greater current psychological stability. Treatment compliance in both groups was similarly high, compared to overall clinic norms.

OTC drug overuse in the elderly: what to watch for.

Just as specific age-related factors increase OTC use and risk, so age also complicates diagnosis. Drug abuse and alcoholism in older patients tend to present nonspecifically. This is also true for OTC drug overuse. Diagnosis of OTC misuse or abuse can only be made if clinicians have an index of suspicion, seek multiple sources of information, interview family members, obtain urine toxicologies, and critically analyze routine laboratory data.

Alcohol and drug abuse in old age: a clinical perspective.

The literature on elderly alcohol and drug use and abuse is reviewed. Factors in old age which influence usage patterns, risks, clinical presentations, diagnosis and treatment are emphasized. Several themes for clinical research are defined. While substance abuse is less prevalent in the elderly than in younger cohorts, it is common enough to constitute a significant public health problem, may increase in the future, is often overlooked by clinicians, and may be successfully managed if treatment is tailored to the special requirements of this age group.