Biomarkers in geriatric psychiatry: the promise and the reality.

This guest editorial seeks to address the promise and the reality of biomarkers in geriatric psychiatry by tying together the three articles on biomarkers of depression included in this issue of the Journal. They represent different streams of biological research, which have developed over the last 40 years. We will try to put each area of research into context.

Financing academic departments of psychiatry.

OBJECTIVE: The authors describe the many financial challenges facing academic departments of psychiatry and the resulting opportunities that may arise. METHOD: The authors review the history of financial challenges, the current economic situation, and what may lie ahead for academic departments of psychiatry. RESULTS: The current environment has many risks and opportunities for departments of psychiatry. Successful departments will be those that assess their particular strengths and limitations and explore their options for funding. CONCLUSION: Departments of psychiatry should have multiple funding streams and take advantage of opportunities in their local or regional service area.

Public's view of mental health services for the elderly: responses to Dear Abby.

The need for adequate mental health services for older adults is an increasingly urgent issue as the life expectancy of Americans continues to extend; yet there are unresolved questions regarding the public's perception of service needs. The Group for the Advancement of Psychiatry collaborated with advice columnist Jeannie Phillips of "Dear Abby" to invite public feedback on mental health services for the elderly. Feedback was invited on access to services as well as perceived need for improvement in the quality or quantity of those services. The effort resulted in 800 responses that identified three primary issues: problems in accessing care, inadequate detection of mental health conditions by general practitioners, and a need for more psychotherapy services. It is hoped that this Open Forum will stimulate discussion throughout the country for the benefit of older persons with mental health needs as the country grapples with changes to come after the passage of health care reform.

Testamentary capacity and delirium.

BACKGROUND: With the aging of the population there will be a substantial transfer of wealth in the next 25 years. The presence of delirium can complicate the evaluation of an older person's testamentary capacity and susceptibility to undue influence but has not been well examined in the existing literature. METHODS: A subcommittee of the IPA Task Force on Testamentary Capacity and Undue Influence undertook to review how to assess prospectively and retrospectively testamentary capacity and susceptibility to undue influence in patients with delirium. RESULTS: The subcommittee identified questions that should be asked in cases where someone changes their will or estate plan towards the end of their life in the presence of delirium. These questions include: was there consistency in the patient's wishes over time? Were these wishes expressed during a "lucid interval" when the person was less confused? Were the patient's wishes clearly expressed in response to open-ended questions? Is there clear documentation of the patient's mental status at the time of the discussion? CONCLUSIONS: This review with some case examples provides guidance on how to consider the question of testamentary capacity or susceptibility to undue influence in someone undergoing an episode of delirium.

Quality improvement, pay for performance, and "outcomes measurement": what makes sense?

The author argues against the use of pay-for-performance programs based on broad-based measures of patient outcomes in behavioral health care. He describes various problems with such programs. The purpose for collecting data is often not clear. Generic instruments do not measure improvement in specific mental disorders. Risk adjustment systems for behavioral health populations are not adequate. Mandated use of different instruments by payers is burdensome and precludes meaningful comparisons. The methodology for using outcomes-based approaches needs further development, and therefore the data collected will have little utility. The author discusses alternative approaches.

End-of-life issues in elderly patients.

OBJECTIVE: To describe elderly-specific issues in end-of-life care. METHODS: Literature review and case examples. RESULTS: There is great heterogeneity in elderly patients' responses to end-of-life care. SIGNIFICANCE OF RESULTS: Developmental and individual issues need to be considered in end-of-life discussions.

Donepezil in the prevention and treatment of post-surgical delirium.

OBJECTIVE: Delirium is a frequent complication of major surgery in older persons. The authors evaluated the possible benefit of donepezil versus placebo in the prevention and treatment of postoperative delirium in an older population without dementia undergoing elective total joint-replacement surgery. METHODS: A sample of 80 patients participated in this randomized, double-blind, placebo-controlled trial of donepezil. Each participant was evaluated before surgery and then received donepezil or placebo for 14 days before surgery and 14 days afterward. Postoperative delirium was assessed with the Delirium Symptom Interview, Confusion Assessment Method, daily medical record, nurse-observation reviews, and DSM-IV diagnostic criteria for delirium. Subsyndromal delirium was also assessed for each participant. RESULTS: Delirium, diagnosed by DSM-IV criteria, was found on at least 1 postoperative day in 18.8% of subjects, but there were no significant differences between the donepezil and placebo groups. When delirium was present, it lasted only 1 day, and there was no difference between the groups. Subsyndromal delirium was found on at least 1 postoperative day for 68.8% of subjects, and, when this occurred, lasted 2 days or less, on average. There was no difference between the groups in the occurrence or duration of subsyndromal delirium. There was no difference between the groups in disposition to home or to another facility. CONCLUSIONS: This pilot study was unable to demonstrate a benefit for donepezil in preventing or treating delirium in a relatively young and cognitively-intact group of elderly patients undergoing elective orthopedic surgery. Furthermore, postoperative delirium was not a major problem in this population.

Subsyndromal Delirium.

The authors sought to determine whether subsyndromal delirium is a qualitatively distinct clinical entity or a spectrum of cognitive and behavioral abnormalities. They conducted a prospective, longitudinal study on 325 patients in an acute care hospital with 3- and 6-month follow-ups. Patients were classified into one of three groups: those meeting full DSM criteria for delirium, those with subsyndromal delirium, and those with no symptoms of delirium. There were no differences in risk factors between those developing DSM-defined delirium or subsyndromal delirium. Number of independent risk factors was a significant predictor of delirium. Patients with subsyndromal delirium fall on a continuum between those with DSM-defined delirium and those with no symptoms of delirium. These data suggest that delirium does represent a spectrum of neurobehavioral impairment. Patients with symptoms of subsyndromal delirium are at risk for considerable morbidity; therefore clinicians should attempt to reduce and treat the onset of occurrence of subsyndromal delirium.

Progression and Resolution of Delirium in Elderly Patients Hospitalized for Acute Care.

The authors describe the clinical course of delirium in 325 elderly patients hospitalized for acute care. Of those patients who developed DSM-III delirium (n = 91), over two-thirds of patients (69.2%) experienced a prodromal period of at least 1 day prior to meeting full DSM-III criteria. Clinical evidence of delirium frequently persisted after hospital discharge although there was evidence of lessening of the extent of symptoms over time. These findings have implications for discharge planners concerned with providing appropriate supports for those still experiencing delirium symptoms at the time of hospital discharge.