Valproate-induced delirium in a demented patient.

In this study we report a case of valproate-induced delirium in a patient affected with Alzheimer's disease (AD). A 75-year-old woman with AD presented moderate cognitive impairment associated to behavioral disorders, characterized by aggression, agitation, severe insomnia. She was treated with galantamine, promazine, acetylsalicylic acid and pantoprazole. Since behavioral disorders worsened more and more, home neurological consultation was asked. The neurologist prescribed a mood stabilizer, sodium valproate 500 mg daily for the first week and then, twice a day and stopped promazine. After an apparent initial benefit, about 16 days later, patient suddenly developed hyperactive delirium. It was characterized by worsening of insomnia and agitation, severe confusion, delusions, visual hallucinations alternated to sedation. She became progressively unable to walk and completely dependent in daily living activities. An urgent geriatric consultation was performed at patient's home; physical examination showed mild dehydration, normal blood pressure. Oxygen saturation and electrocardiogram were normal. Sodium valproate was immediately stopped and rehydration was performed. The patient was admitted to a Geriatric Unit, where organic and metabolic damages were excluded. During the hospital stay the patient was agitated, aggressive, confused; intramuscular haloperidol 5mg and saline intravenous infusion 1500 cc daily were performed, they were partly successful. Three days after she was discharged and continued treatment with oral haloperidol 5mg daily. One week later the patient recovered and she is at present healthy. This is a case report of valproate-induced delirium. The Naranjo scale scored 7, classifying this drug-related event as probable. The present case report suggests the need for minimizing the use of psychoactive drugs in elderly demented patients, whether possible; age-related changes in pharmacokinetics and pharmacodynamics suggest the opportunity of a careful evaluation and a slow titration of treatments in these patients.

Management of heart failure in elderly people.

AIMS: To review currently available knowledge on presentation, clinical features and management of heart failure (HF) in elderly people. METHODS: To review currently available evidence, we performed a thorough search of several evidence-based sources of information, including Cochrane Database of Systematic Reviews, Clinical Evidence, Evidence-based guidelines from National Guidelines Clearinghouse and a comprehensive MEDLINE search with the MeSH terms: 'heart failure', 'elderly' and 'management'. RESULTS: A number of features of ageing may predispose elderly people to HF, and may impair the ability to respond to injuries. Another hallmark of elderly patients is the increasing prevalence of multiple coexisting chronic conditions and geriatric syndromes that may complicate the clinical presentation and evolution of HF. Although diagnosis may be challenging, because atypical symptoms and presentations are common, and comorbid conditions may mimic or complicate the clinical picture, diagnostic criteria do not change in elderly people. Drug treatment is not significantly different from that recommended in younger patients, and largely remains empiric, because clinical trials have generally excluded elderly people and patients with comorbid conditions. Disease management programmes may have the potential to reduce morbidity and mortality for patients with HF. CONCLUSIONS: Heart failure is the commonest reason for hospitalisation and readmission among older adults. HF shows peculiar features in elderly people, and is usually complicated by comorbidities, presenting a significant financial burden worldwide, nevertheless elderly people have been generally excluded from clinical trials, and thus management largely remains empiric and based on evidence from younger age groups.

Effectiveness and safety of hypnotic drugs in the treatment of insomnia in over 70-year old people.

Good sleep is an important index of the quality of life in people and above all in old subjects. Among all the symptoms reported to general practitioner, insomnia is at the 3(rd) place and this is present in particular in the elderly. In elderly people high comorbidity and polytreatment are often present. We have studied 60 elderly people with history of insomnia and concomitant diseases: depression, dementia and behavioral disturbances. All the patients of the present study were visited in our outpatients' department. Three hypnotic drugs were used for the treatment of insomnia: zolpidem, or triazolam, or oxazepam, respectively at doses of 10mg/day, 0.125-0.25mg/day and 15.0mg/day. All the three drugs showed to be effective and safe; no paradoxical effects were observed.

Anticholinergic drug-induced delirium in an elderly Alzheimer's dementia patient.

Drug-induced delirium is a common matter in the elderly and anticholinergics, together with a number of different drugs, may significantly contribute to the delirium onset, especially in demented people. We report a case of a probable anticholinergic drug-induced delirium in an elderly patient. An 80-year-old man with Alzheimer's dementia presented with wandering, depressed mood with crying, somatic worries, anedonism and suicide recurrent ideas. A first external psychiatric assessment led to the diagnosis of melancholic depression and therapy with haloperidol 2mg/day, orphenadrine 100mg daily, amitriptyline 40 mg/day, lorazepam 2mg/day was started. Two weeks later patient suddenly developed delirium, characterized by nocturnal agitation, severe insomnia, daytime sedation, confusion, hallucinations and persecutory delusions. These symptoms progressively worsened, with the consequent caregiver's stress. A geriatric consultation excluded the main causes of delirium, therefore both Operative Units of Pharmacovigilance and Psychiatry were activated, for a clinical pharmacological and psychiatric assessment. Haloperidol, amitriptyline and orphenadrine were promptly dismissed. The patient began a treatment with quetiapine 25mg/day for two days, then twice a day, and infusion of saline 1000 ml/day for two days; psychiatric symptoms gradually diminished and therapy with galantamine was begun. We postulate that this clinical report is suggestive for an anticholinergic drug- induced delirium since the Naranjo probability scale indicated a probable relationship between delirium and drug therapy. In conclusion, a complete geriatric, pharmacological, and psychiatric evaluation might be necessary in order to reduce the adverse drug reactions in older patients treated with many drugs.

Use of zolpidem in over 75-year-old patients with sleep disorders and comorbidities.

The aim of the present study was to evaluate the efficacy and safety of zolpidem in elderly subjects with disorders of sleep and comorbidities. The patients of this study had to present the following requirements: age over 70 years, reported disorders of sleep such as insomnia, and they had to be affected with diabetes and arterial hypertension. Patients presenting diseases that could interfere with sleep, i.e., anxiety, depression, panic attacks,alcohol abuse, some drugs were excluded from the study. All the jobs potentially causing insomnia carried out in the past from the patients were considered, too. A questionnaire of sleep was administered to all the patients (World Psychiatric Association: WPA, 1971).Insomnia, whenever present, was classified according to the criteria of the American Sleep Disorders (ASD) Society and the American Professional Sleep Society (APSS). The following scales were also administered: instrumental activities of daily living scale (IADL),activities of daily living (ADL), geriatric depression scale (GDS), cumulative illness rating scale (CIRS), short portable mental status questionnaire (SPMSQ), mini nutritional assessment (MNA), disease medical index (DMI), sleep questionnaire, social and environmental status. Two groups of patients were evaluated. Group A: 50 patients, 35 women and 15 men, mean age 78.9 years, with a history of insomnia, and Group B 30 patients, 20 women and 10 men, mean age 78.4 years, with onset of insomnia in the last three weeks. The two groups were further divided into three subgroups, diabetic, hypertensive and healthy patients. Zolpidem showed to be effective and well tolerated in both groups of patients.

Comparison of the efficacy of new and conventional antipsychotic drugs in the treatment of behavioral and psychological symptoms of dementia (BPSD).

This double-blind study evaluated the efficacy and safety of risperidone or olanzapine vs. promazine in the treatment of behavioral and psychological symptoms in dementia(BPSD). Patients were required to be 65 years or older, to have DSM-IV diagnoses of Alzheimer's disease (AD), vascular dementia (VD) or a combination of both. A brain computerized tomography (CT) was performed for all the patients; 60 demented patients,27 men (45 %) and 33 women (55 %) were selected for this study. The University of California Los Angeles neuropsychiatric inventory (NPI) was administered at baseline, then after 4 and 8 weeks. Patients had at least a score of 24 or more. The Hoehn and Yahr scale was used for evaluating parkinsonism. The scales were administered by an examinator who was not aware of the kind of treatment of the patients. After a wash-out period of 10 days,20 patients, 9 men and 11 women, mean age 76.6 +/- 6.0 years, were randomly assigned torisperidone 1 mg daily in divided doses (morning and bedtime) (Group A); 20 patients, 9 men and 11 women, mean age 82.5 +/- 9.3 years were randomly assigned to olanzapine 5mg at bedtime (Group B), and 20 patients, 9 men and 11 women, mean age 77.6 +/- 4.6 years, were randomly assigned to promazine 50 mg daily (morning and bedtime) (Group C). In case of lack of clinical response, after 4 weeks, the dose could be increased to 2 mg/day of risperidone, 10 mg/day of olanzapine, and to 100 mg/day of promazine in the respective groups. Repeated measures ANOVA was used for the statistical analysis of rating scales over time (baseline, 4 and 8 weeks). At the end of the 8th week, a global improvement was obtained in 80% of patients treated with risperidone and olanzapine, vs. 65 % of patients treated with promazine (p < 0.01). The results show that risperidone in doses of 1-2 mg/day and olanzapine in doses of 5-10 mg/day are effective and safe in the treatment of BPSD. Risperidone presents a major and dose-dependent antidopaminergic action and seems to be preferable when hallucinations and delusions are prevailing symptoms, even if it gives good results on aggression and wandering. Olanzapine seems to be faster in its sedative effect, probably for H1 receptor blockade. Moreover, 5-HT6 antagonism may favor acetylcholine release and this explains why these patients have not presented a cognitive worsening. However, both drugs are comparable or even superior to promazine, with significantly fewer side effects of both anticholinergic and extrapyramidal character.

[Prevalence and features of peptic ulcers in the elderly: a retrospective study on a not hospitalized population aged 65 or over]. / Caratteristiche e prevalenza dell'ulcera peptica nell'anziano: studio endoscopico retrospettivo su una coorte di pazienti ultrasessantacinquenni non istituzionalizzati.

BACKGROUND: The prevalence of peptic ulcer increases with aging. Data relative to peptic ulcer in the elderly are around 5.2% to 9.9%. The aim of the present study was to evaluate the prevalence and the features of peptic ulcer in a non hospitalized population aged 65 or over. METHODS: We performed, for the first time, EGDS on 706 patients with symptoms related to the superior gastroenteric tract. We considered the following risk factors: familiarity for peptic disease, habits, eventual use of FANS, infection of Hp. RESULTS: Our data show that peptic ulcer increases with aging and with physiopathological age-related changes. 114 (16.1%) patients were affected by DU; 84 (11.9%) patients were affected by GU Symptoms thereafter were not clear: epigastralgy was present in 46.4% of patients affected by GU; pyrosis, belchings, swellings, epigastric headness were present in 37.7% of patients with DU. Several times PU may arise with some complications: melena was present in 14.9% of patients with DU vs 11.9% of patients with GU, hematemesis was present in 1.7% of patients with DU vs 5.9% of patients with G.U. The most important risk factor was the infection of Hp, at was present in 71.9% patients with GU and 81.6% patients with DU FANS assumption, often with high dose, was present in 30.9% of patients with GU and 18.4% of patients with DU.

[Cerebral hypoperfusion symptoms in elderly subjects with hyperkinetic and/or hypokinetic arrhythmia. Study of institutionalized and non- institutionalized patients]. / Sintomatologia da ipoperfusione cerebrale nei soggetti anziani portatori di aritmie ipercinetiche e/o ipocinetiche. Indagine su pazienti istituzionalizzati e non.

BACKGROUND: We evaluated the symptomatology caused by cerebral hypoperfusion in a group of over-65 year old hospitalized and non-patients, with hyperkinetic and hypokinetic arrhythmias. METHODS: 2441 clinical records of hospitalized and ambulatory patients at the unit of Cardiology, "Pugliese-Ciaccio" Hospital of Catanzaro between January 1st 1991 and March 31st 1995 were examined. The clinical records of those patients who had showed anamnestic episodes of syncope, lipothymia and dizziness were selected. The selected sample was made of 36 hospitalized patients and 36 ambulatory patients. The Holter-ECGs of these patients were examined. RESULTS: Six episodes of syncope (16.7%) were found in the hospitalized patients and 4 in the ambulatory patients (11.1%). Ten (27.8%) and 8 (22.2%) episodes of lipothymia, were found in the hospitalized and ambulatory patients respectively. Dizziness was found in 20 (55.5%) hospitalized and in 24 (66.6%) ambulatory patients. In all the patients the symptoms appeared during the recording and were linked to hyperkinetic arrhythmias in 22 (61.1%) hospitalized patients and in 25 (69.4%) ambulatory patients and to hypokinetic arrhythmias in 14 (39.9%) and 11 (30.5%) hospitalized and ambulatory patients. CONCLUSIONS: The present study pointed out that patients with hyperkinetic arrhythmias (both hospitalized and ambulatory) show symptoms of cerebral hypoperfusion more frequently than those with hyperkinetic arrhythmias.

Hypertension in a group of centenarians.

The aim of the present study was to evaluate the frequency of hypertension in a group of extremely old persons: 73 centenarians resident in Calabria were studied, aged 100-110 years, (mean age 102.95 +/- 2.0), 54 women (73.9%) and 19 men (26.1%), in the period January 1st and April 30th, 1994. All the centenarians were visited at their homes. Hypertensive centenarians were 14 (19.1%), women 12 (85.7%) and men 2 (14.3%). Even if blood pressure progressively increases with age, we have not found it in centenarians. The lesser frequency of hypertension in centenarians certainly depends on genetic and constitutional factors, but also their way of life and alimentary habits (decreased sodium intake, increase of calcium and potassium intake), as we have proven in a recent work, could be determinant. Moreover, the presence of hypertensive centenarians might mean that hypertension does not prevent to reach an age by far above the average, if it is the only risk factor.

Multidimensional evaluation in a group of centenarians.

A group of 40 Calabrian centenarians (12 males, 28 females) was studied from June 1 to December 31, 1993. Their age was ranging from 100 to 107 years (mean age: 102.3 +/- 1.8 years). Clinical evaluation was performed by recording anamnestic data, an objective examination, and by assessing cognitive performance, emotional and nutritional status, as well as functional activity. The following tests were applied: mini mental state examination (MMSE), geriatric depression scale (CDS), activity of daily living (ADL), and instrumental activity of daily living (IADL). The nutritional status was estimated by collecting answers to a questionnaire regarding nutritional habits and by measuring body weight, height and calculating body mass index (BMI). In assessment of the socio-economic conditions, the following parameters were considered: years of education, type of job, type of residence ownership, heating system used, toilet set available and the regular income. Our multidimensional evaluation has revealed, in agreement with other findings, that the Calabrian centenarians seem to be a selected population with an amazingly high activity, who overcame severe age-dependent diseases, probably because of their genetic pattern and of the environmental factors which may favor longevity.

Benign edematous polysynovitis in the elderly (RS3PE syndrome).

The Authors provide an update on benign edematous polysynovitis in the elderly and propose clinical and laboratory criteria for a correct diagnosis. They also propose the use of the term "polysynovitis" rather than polyarthritis, as they think it describes the histopathological findings of the disease better. Finally, they attempt to correctly distinguish RS3PE syndrome from polymyalgia rheumatica, rheumatoid arthritis and chondrocalcinosis.