Evolution and psychiatry: the formation of a special interest group.

This editorial outlines the formation of a new special interest group (SIG) in evolution and psychiatry. The formative beginnings of the evolutionary psychiatry field and founding of the group in Ireland are presented, identifying central figures of the field and their contributions. Furthermore, key milestones and accomplishments are discussed with current and future directions. Additionally, foundational texts and seminal papers are included to guide the reader in their journey to discover more about evolution and psychiatry. We hope this will be of relevance to those interested in how SIGs form and also to clinicians with an interest in evolutionary psychiatry.

Does the Etiology, Phenomenology and Motor Subtype of Delirium Differ When It Occurs in Patients With An Underlying Dementia?: A Multi-Site, International Study.

OBJECTIVES: To compare the etiology, phenomenology and motor subtype of delirium in patients with and without an underlying dementia. METHODS: A combined dataset (n = 992) was collated from two databases of older adults (>65 years) from liaison psychiatry and palliative care populations in Ireland and India. Phenomenology and severity of delirium were analysed using the Delirium Symptom Rating Scale Revised (DRS-R98) and contributory etiologies for the delirium groups were ascertained using the Delirium Etiology Checklist (DEC). Delirium motor subtype was documented using the abbreviated version of the Delirium Motor Subtype Scale (DMSS4). RESULTS: Delirium superimposed on dementia (DSD) showed greater impairment in short term memory, long term memory and visuospatial ability than the delirium group but showed significantly less perceptual disturbance, temporal onset and fluctuation. Systemic infection, cerebrovascular and other Central nervous system etiology were associated with DSD while metabolic disturbance, organ insufficiency and intracranial neoplasm were associated with the delirium only group. CONCLUSION: The etiology and phenomenology of delirium differs when it occurs in the patient with an underlying dementia. We discuss the implications in terms of identification and management of this complex condition.

Banging the drum: evolutionary and cultural origins of music and its implications for psychiatry.

SUMMARY: There is growing interest in music-based therapies for mental/behavioural disorders. We begin by reviewing the evolutionary and cultural origins of music, proceeding then to discuss the principles of evolutionary psychiatry, itself a growing a field, and how it may apply to music. Finally we offer some implications for the role of music and music-based therapies in clinical practice.

How do delirium motor subtypes differ in phenomenology and contributory aetiology? a cross-sectional, multisite study of liaison psychiatry and palliative care patients.

OBJECTIVES: To investigate whether delirium motor subtypes differ in terms of phenomenology and contributory aetiology. DESIGN: Cross-sectional study. SETTING: International study incorporating data from Ireland and India across palliative care, old age liaison psychiatry and general adult liaison psychiatry settings. PARTICIPANTS: 1757 patients diagnosed with delirium using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM IV). PRIMARY AND SECONDARY OUTCOME MEASURES: Hyperactive, mixed and hypoactive delirium subtypes were identified using the abbreviated version of the Delirium Motor Subtype Scale. Phenomenology was assessed using the Delirium Rating Scale Revised. Contributory aetiologies were assessed using the Delirium Aetiology Checklist (DEC), with a score >2 indicating that the aetiology was likely or definitely contributory. RESULTS: Hypoactive delirium was associated with dementia, cerebrovascular and systemic infection aetiologies (p<0.001) and had a lower overall burden of delirium symptoms than the other motor subtypes. Hyperactive delirium was associated with younger age, drug withdrawal and the DEC category other systemic aetiologies (p<0.001). Mixed delirium showed the greatest symptom burden and was more often associated with drug intoxication and metabolic disturbance (p<0.001). All three delirium motor subtypes had similar levels of impairment in attention and visuospatial functioning but differed significantly when compared with no subtype (p<0.001). CONCLUSIONS: This study indicates a pattern of aetiology and symptomatology of delirium motor subtypes across a large international sample that had previously been lacking. It serves to improve our understanding of this complex condition and has implications in terms of early detection and management of delirium.

The neurology-psychiatry interface in epilepsy.

Epilepsy and mental illness have a bidirectional association. Psychiatrists are likely to encounter epilepsy as comorbidity. Seizures may present as mental illness. Equally, the management of psychiatric conditions has the potential to destabilise epilepsy. There is a need for structured epilepsy awareness and training amongst psychiatrists. This paper outlines key considerations around diagnosis, treatment and risk while suggesting practical recommendations.

A systematic review and meta-analysis of the accuracy of the clock drawing test (CDT) in the identification of delirium in older hospitalised patients.

Objective: Delirium is a common neurocognitive syndrome among hospitalised older adults. The clock drawing test (CDT) is a relatively simple bedside test of cognitive function. This systematic review and meta-analysis examine the accuracy of the CDT in identifying delirium in hospitalised older adults.Methods: PRISMA guidelines were used to report the identified studies. Pubmed, SCOPUS, and Ovid and EBSCO platforms (including MEDLINE ®, PsycINFO, PsycEXTRA, EMCARE, CINAHL and EMBASE databases) were searched. Studies were assessed for methodological quality using the Downs and Black Tool. Data were extracted regarding the number of delirious/not delirious, number with normal and abnormal CDT, age, and MMSE scores, and information regarding CDT scoring, criteria for diagnosis of delirium and setting of the study. Analysis was carried out with the "Mada" and "Metatron" packages of R software.Results: Fifteen studies were examined. The number of participants was 2199, of whom 597 (27.15%) were diagnosed with delirium. The overall sensitivity of CDT in the absence of any formal cognitive test was 0.76 (0.58-0.87) with specificity of 0.70 (0.51-0.83). When the MMSE was taken into account, the specificity and sensitivity reduced to 0.51. Diagnostic criteria for delirium, scoring method of CDT, age of participants and setting significantly (p < 0.05) affect the sensitivity and specificity of the CDT.Conclusion: Although, the CDT is generally considered to be a simple and easy to administer screening tool for cognitive impairment in older hospitalised adults, when a more formal cognitive test is used its sensitivity and specificity to detect delirium is low.

"How are you?" Estimation of anxiety, sleep quality, and mood using computational voice analysis.

We developed a method of estimating impactors of cognitive function (ICF) - such as anxiety, sleep quality, and mood - using computational voice analysis. Clinically validated questionnaires (VQs) were used to score anxiety, sleep and mood while salient voice features were extracted to train regression models with deep neural networks. Experiments with 203 subjects showed promising results with significant concordance correlation coefficients (CCC) between actual VQ scores and the predicted scores (0.46 = anxiety, 0.50 = sleep quality, 0.45 = mood).

Comparison of novel tools with traditional cognitive tests in detecting delirium in elderly medical patients.

BACKGROUND: Efficient detection of delirium and comorbid delirium-dementia is a key diagnostic challenge. Development of new, efficient delirium-focused methods of cognitive assessment is a key challenge for improved detection of neurocognitive disorders in everyday clinical practice. AIM: To compare the accuracy of two novel bedside tests of attention, vigilance and visuospatial function with conventional bedside cognitive tests in identifying delirium in older hospitalized patients. METHODS: 180 consecutive elderly medical inpatients (mean age 79.6 ± 7.2; 51% female) referred to a psychiatry for later life consultation-liaison service with delirium, dementia, comorbid delirium-dementia and cognitively intact controls. Participants were assessed cross-sectionally with conventional bedside cognitive tests [WORLD, Months Backward test (MBT), Spatial span, Vigilance A and B, Clock Drawing test and Interlocking Pentagons test] and two novel cognitive tests [Lighthouse test, Letter and Shape Drawing test (LSD)-4]. RESULTS: Neurocognitive diagnoses were delirium (n = 44), dementia (n = 30), comorbid delirium-dementia (n = 60) and no neurocognitive disorder (n = 46). All conventional tests had sensitivity of > 70% for delirium, with best overall accuracy for the Vigilance-B (78.3%), Vigilance-A (77.8%) and MBT (76.7%) tests. The sustained attention component of the Lighthouse test was the most distinguishing of delirium (sensitivity 84.6%; overall accuracy 75.6%). The LSD-4 had sensitivity of 74.0% and overall accuracy 74.4% for delirium identification. Combining tests allowed for enhanced sensitivity (> 90%) and overall accuracy (≥ 75%) with the highest overall accuracy for the combination of MBT-Vigilance A and the combined Vigilance A and B tests (both 78.3%). When analyses were repeated for those with dementia, there were similar findings with the MBT-Vigilance A the most accurate overall combination (80.0%). Combining the Lighthouse-SA with the LSD-4, a fail in either test had sensitivity for delirium of 91.4 with overall accuracy of 74.4%. CONCLUSION: Bedside tests of attention, vigilance and visuospatial ability can help to distinguish neurocognitive disorders, including delirium, from other presentations. The Lighthouse test and the LSD-4 are novel tests with high accuracy for detecting delirium.

Attention, vigilance, and visuospatial function in hospitalized elderly medical patients: relationship to delirium syndromal status and motor subtype profile.

ABSTRACTBackground:The early and effective detection of neurocognitive disorders poses a key diagnostic challenge. We examined performance on common cognitive bedside tests according to differing delirium syndromal status and clinical (motor) subtypes in hospitalized elderly medical inpatients. METHODS: A battery of nine bedside cognitive tests was performed on elderly medical inpatients with DSM-IV delirium, subsyndromal delirium (SSD), and no delirium (ND). Patients with delirium were compared according to clinical (motor) subtypes. RESULTS: A total of 198 patients (mean age 79.14 ± 8.26) were assessed with full syndromal delirium (FSD: n = 110), SSD (n = 45), and ND (n = 43). Delirium status was not associated with differences in terms of gender distribution, age, or overall medication use. Dementia burden increased with greater delirium status. Overall, the ability to meaningfully engage with the tests varied from 59% for the Vigilance B test to 85% for Spatial Span Forward test and was lowest in patients with FSD, where engagement ranged from 32% for the Vigilance B test to 77% for the Spatial Span Forwards test. The ND group was distinguished from SSD group for the Months of the year backwards, Vigilance B, global VSP, Clock Drawing test, and Interlocking Pentagons test. The SSD group was distinguished from the FSD group by Vigilance A, Spatial Span Forward, and Spatial Span Backwards. Regarding differences among motor subtypes in terms of percentage engagement and performance, the No subtype group had higher ratings across all tests. Delirious patients with no subtype had significantly lower scores on the DRS-R98 than for the other three subtype categories. CONCLUSIONS: Simple bedside tests of attention, vigilance, and visuospatial ability are useful in distinguishing neurocognitive disorders, including SSD from other presentations.

Development of the four-item Letter and Shape Drawing test (LSD-4): A brief bedside test of visuospatial function.

Conventional bedside tests of visuospatial function such as the Clock Drawing (CDT) and Intersecting Pentagons (IPT) lack consistency in delivery and interpretation. We compared performance on a novel test of visuospatial ability - the LSD - with the IPT, CDT and MMSE in 180 acute elderly medical inpatients [mean age 79.7±7.1 (range 62-96); 91 females (50.6%)]. 124 (69%) scored ≤23 on the MMSE; 60 with mild (score 18-23) and 64 with severe (score ≤17) impairment. 78 (43%) scored ≥6 on the CDT, while for the IPT, 87 (47%) scored ≥4. The CDT and IPT agreed on the classification of 138 patients (77%) with modest-strong agreement with the MMSE categories. Correlation between the LSD and visuospatial tests was high. A four-item version of the LSD incorporating items 1,10,12,15 had high correlation with the LSD-15 and strong association with MMSE categories. The LSD-4 provides a brief and easily interpreted bedside test of visuospatial function that has high coverage of elderly patients with neurocognitive impairment, good agreement with conventional tests of visuospatial ability and favourable ability to identify significant cognitive impairment. [181 words].

Attention, vigilance and visuospatial function in hospitalized elderly medical patients: Relationship to neurocognitive diagnosis.

OBJECTIVE: Efficient detection of neurocognitive disorders is a key diagnostic challenge. We explored how simple bedside tests of attention, vigilance and visuospatial function might assist in identifying delirium in hospitalized patients. METHODS: Performance on a battery of bedside cognitive tests was compared in elderly medical inpatients with DSM-IV delirium, dementia, comorbid delirium-dementia, and no neurocognitive disorder. RESULTS: 193 patients [mean age 79.9±7.3; 97 male] were assessed with delirium (n=45), dementia (n=33), comorbid delirium-dementia (n=65) and no neurocognitive disorder (NNCD) (n=50). The ability to meaningfully engage with the tests varied from 84% (Spatial Span Forwards) to 57% (Vigilance B test), and was especially problematic among the comorbid delirium-dementia group. The NNCD was distinguished from the delirium groups for most tests, and from the dementia group for the Vigilance B test and the Clock Drawing Test. The dementia group differed from delirium groups in respect of the Months Backward Test, Vigilance A and B tests, Global assessment of visuospatial ability and the Interlocking Pentagons Test. Overall, patients with delirium were best identified by three tests - the Months Backward Test, Vigilance A test and the Global Assessment of visuospatial function with failure to correctly complete any two of these predicting delirium status in 80% of cases. CONCLUSION: Simple bedside tests of attention, vigilance and visuospatial ability can help to distinguish neurocognitive disorders, including delirium, from other presentations. There is a need to develop more accurate methods specifically designed to assess patients with neurocognitive disorder who are unable to engage with conventional tests.

A survey of patients' knowledge about lithium therapy in the elderly.

OBJECTIVE: Lithium is commonly used in the treatment of various psychiatric disorders. It has a narrow therapeutic range and a mortality rate of 9% in patients intoxicated during maintenance therapy. Therefore, for lithium to be prescribed safely, clinicians must ensure that patients are aware of features of lithium toxicity. We aim to identify patients' knowledge of lithium in the elderly population and associated factors that may influence this knowledge. METHOD: The Lithium Knowledge Test (LKT) is a brief questionnaire that was developed as a means of identifying patients' practical and pharmacologic knowledge, which is important if therapy is to be safe and effective. The survey was conducted in the outpatient service of the Department of Old Age Psychiatry attached to a university teaching hospital in an urban area in Ireland between January 2011 and July 2011. A total of 33 patients participated in the survey, and the LKT questionnaires were completed by all participants. The LKT scores are obtained by adding up the responses to the questions, while the LKT hazard scores are obtained by adding together the responses to the questions on symptoms of toxicity. The result was analyzed using SPSS version 20 (SPSS Inc, Chicago, Illinois), and the relationships between LKT scores and LKT hazard scores as well as other variables were examined using Pearson's correlation coefficient. RESULTS: The mean LKT score of our sample population was 4.45, suggestive of poor knowledge of lithium, and the mean LKT hazard score was 5.85, highly suggestive of potentially hazardous lack of knowledge. There was a significant negative correlation between the LKT score and hazard score (r = -0.65, P < .01 [1-tailed]). CONCLUSIONS: The survey results highlight the need for patients to be given comprehensive information about lithium prior to commencement of treatment and a refresher educational program during lithium therapy.

Subjective well-being amongst community-dwelling elders: what determines satisfaction with life? Findings from the Dublin Healthy Aging Study.

BACKGROUND: Life satisfaction is a subjective expression of well-being and successful aging. Subjective well-being is a major determinant of health outcomes in older people. The aim of this study was to determine which factors predicted well-being in older people living in the community as measured by their satisfaction with life. METHODS: The relationship between life satisfaction, as measured by the Life Satisfaction Index (LSI-A) and physical, cognitive and demographic variables was examined in 466 older people living in the community using a stepwise regression model. RESULTS: Depression, loneliness, neuroticism, extraversion, recent participation in physical activity, age and self-reported exhaustion, were the independent predictors of life satisfaction in our elderly cohort. CONCLUSION: Subjective well-being, as measured by the Life Satisfaction Scale, is predicted by depression, loneliness, personality traits, recent participation in physical activity and self-reported exhaustion. The mental and emotional status of older individuals, as well as their engagement in physical activity, are as important as physical functionality when it comes to life satisfaction as a measure of well-being and successful aging. These areas represent key targets for intervention.

Alfred Russel Wallace (1823-1913): evolution and medicine.

The theory we now know simply as 'evolution' was first presented to the scientific world one and a half centuries ago, on 1 July 1858, when the work of two men, Alfred Russel Wallace and Charles Robert Darwin (1809-82), was jointly read at the Linnean Society. While Charles Darwin has rightly taken his place in history as one of the greatest scientists of all time, Alfred Russel Wallace has been largely forgotten outside of the scientific community. However, Wallace was a prolific researcher and writer with interests in a wide range of topics, from medicine to economics.

Vascular biomarkers of cognitive performance in a community-based elderly population: the Dublin Healthy Ageing study.

BACKGROUND: population studies suggest that cardiovascular risk factors may be associated with cognitive impairment. Epidemiological studies evaluating individual markers of vascular disease as risk factors for cognitive dysfunction have yielded inconsistent results. Homocysteine has emerged as a marker consistently associated with poorer outcomes. Existing studies have largely examined individual vascular risks in isolation and have tended to ignore patient psychological status. OBJECTIVE: to investigate the association between markers of vascular disease and cognition in a community-dwelling non-demented elderly population while adjusting for vascular and non-vascular confounds. DESIGN: cross-sectional community based assessment. PARTICIPANTS: 466 subjects with mean age 75.45 (s.d., 6.06) years. 208 (44.6%) were male. RESULTS: higher levels of homocysteine were consistently associated with poorer performance in tests assessing visual memory and verbal recall. No other vascular biomarker was found to be associated with cognitive performance. Factors such as alcohol use, tea intake, life satisfaction, hypertension and smoking were positively correlated with global cognitive performance. Negative correlations existed between cognitive performance and depression, past history of stroke, intake of fruit and use of psychotropic medication. CONCLUSIONS: homocysteine was the only vascular biomarker associated with poorer function in a number of domains on neuropsychological testing, independent of vascular and non-vascular confounds. Other psychosocial factors may need to be taken into account as potential confounds in future studies investigating cognition.