Anxiety, depression and disability across the lifespan.

The authors examined the relationship between anxiety, depression and physical disability, after controlling for demographic and health variables, in a sample of 374 adults aged 18-94. Results indicate that anxiety, depression and comorbid anxiety and depression are associated with higher levels of disability, after controlling for factors such as age, gender, income, self-rated health, number of medical conditions and number of physician visits in the past year. Furthermore, anxiety, depression and comorbid anxiety and depression have a differential effect on disability according to age, with older adults with any of these symptoms reporting higher levels of disability than younger adults. These findings suggest that physicians working with older adults should assess for and treat anxiety as well as depressive symptoms.

Changes in psychiatric diagnoses from admission to discharge: review of the charts of 159 patients consecutively admitted to a geriatric psychiatry inpatient unit.

The diagnosis of psychopathology among geriatric acute inpatients requires comprehensive evaluation. To our knowledge, no recently published papers in the geriatric psychiatry literature have systematically examined diagnostic changes during single admissions. We reviewed the charts of 159 patients consecutively admitted to an acute geriatric psychiatry unit over 18 months. We recorded admission diagnoses from initial treatment plans, and discharge diagnoses from discharge summaries. Mean patient age was 80 years and average length of stay was 17 days. The most common primary diagnoses were psychotic and depressive disorders. The most common secondary diagnoses were dementias and depressive disorders. Primary diagnoses changed from admission to discharge in 31 patients (20%), and secondary diagnoses changed in 76 patients (48%). There was a significant change involving the diagnosis of dementia, but not that of depressive or psychotic disorders. A large proportion of inpatients had their diagnoses altered, especially those involving dementias, during hospitalization. Inpatient admission may be valuable for clarifying the diagnoses of elderly psychiatric patients.

Psychopathology at initial diagnosis in dementia with Lewy bodies versus Alzheimer disease: comparison of matched groups with autopsy-confirmed diagnoses.

Dementia with Lewy bodies (DLB) is believed to be the second most common form of dementia, after Alzheimer disease (AD). DLB has been reported to be associated with an increase in psychopathology; however, antemortem diagnosis of DLB cannot always be made with certainty. We searched the database of University of California, San Diego SOCARE (Seniors Only Care) outpatient program. There were 26 autopsy-confirmed cases of DLB. We matched them individually with 26 autopsy-confirmed cases of 'pure' AD on gender, ethnicity, and Mini-Mental State Examination score at the baseline evaluation. We compared the two groups on psychopathologic measures and possible risk factors for psychopathology based on the data obtained at the time of the initial diagnosis of dementia. Five psychiatric symptoms: hallucinations, delusions, anxiety, anhedonia, and loss of energy were significantly more common in DLB patients than in AD patients. DLB patients were younger at initial evaluation and death as compared to AD patients, but there was no difference in age of onset of dementia, level of education, or family or past history of any major neuropsychiatric disorder, prescription of psychotropic medications, or sensory impairment. Psychiatric symptoms were more common at time of initial diagnosis of dementia in DLB than in AD patients. This difference could not be attributed to any known risk factors for psychopathology examined. Psychopathology should be considered an integral part of DLB, and should be taken into account in the initial diagnosis of the type of dementia.

Lower incidence of tardive dyskinesia with risperidone compared with haloperidol in older patients.

OBJECTIVE: To compare the 9-month cumulative incidence of tardive dyskinesia (TD) with risperidone to that with haloperidol in older patients. DESIGN: A prospective longitudinal study. SETTING: An outpatient psychiatric clinic. PARTICIPANTS: Subjects were middle-aged and older (mean age 66 years) patients with schizophrenia, dementia, mood disorders, or other conditions with psychotic symptoms or severe behavioral disturbances. Sixty-one patients on risperidone were matched with 61 patients from a larger sample of haloperidol-treated patients in regard to age, diagnosis, and length of pre-enrollment neuroleptic intake to create clinically comparable groups. The median daily dose of each medication was 1.0 mg. MEASUREMENTS: Abnormal Involuntary Movement Scale, modified Simpson-Angus' scale for extrapyramidal symptoms, Brief Psychiatric Rating Scale, and Mini-Mental State Examination were administered at baseline, 1 month, and 3, 6, and 9 months. The diagnosis of TD was based on specific research criteria. The raters were blind to the patient's medication status. RESULTS: Life table analysis revealed that patients treated with haloperidol were significantly more likely to develop TD than patients treated with risperidone (P < .05, Peto-Prentice). CONCLUSIONS: The atypical antipsychotic risperidone is significantly less likely to result in TD than the conventional neuroleptic haloperidol in a high-risk group of older patients, at least over a 9-month period.

Incidence of tardive dyskinesia in early stages of low-dose treatment with typical neuroleptics in older patients.

OBJECTIVE: The authors studied the risk of tardive dyskinesia for older patients in the early stages of treatment with typical neuroleptics. METHOD: They examined the cumulative incidence of tardive dyskinesia 1, 3, 6, 9, and 12 months after the institution of neuroleptic therapy among 307 psychiatric outpatients over age 45. The patients' median dose was 68.4 mg/day of chlorpromazine equivalent. RESULTS: In the patients who had never received neuroleptics at baseline (N = 87), the mean cumulative incidence of tardive dyskinesia was 3.4% and 5.9% at 1 and 3 months, respectively. There was no significant difference in the 12-month cumulative incidence of tardive dyskinesia among patients who had been neuroleptic-naive at baseline (22.3%) and the 89 patients who had received neuroleptics before baseline for 1-30 days (24.6%); however, the 131 patients who had received neuroleptics before baseline for more than 30 days tended to have a greater cumulative 12-month incidence of tardive dyskinesia (36.9%). CONCLUSIONS: The risk of tardive dyskinesia in older outpatients is high, even with relatively short treatment with low doses of conventional neuroleptics.

Conventional vs. newer antipsychotics in elderly patients.

Elderly patients with schizophrenia and dementia patients with agitation are frequently candidates for antipsychotic treatment. Conventional neuroleptics have relatively little effect on negative symptoms and may cause considerable side effects, especially in elderly patients. The authors have found a 29% cumulative annual incidence of tardive dyskinesia (TD) in middle-aged and elderly outpatients treated with relatively low doses of conventional neuroleptics Newer antipsychotics are less likely to cause extrapyramidal symptoms and may be associated with a lower risk of TD. They are generally effective for both positive and negative symptoms and may also improve some aspects of cognition, but these drugs have their own side effects. Dosing requirements for elderly patients tend to be much lower than those for younger adults.

Adverse neurobiological effects of long-term use of neuroleptics: human and animal studies.

Neuroleptics have revolutionized the treatment of schizophrenia and other psychoses since the early 1950s. Several adverse neurobiological effects are, however, associated with the long-term use of these agents. This article will review human and animal studies of these adverse effects, and also present some new data. Tardive dyskinesia (TD) is the most widely studied potentially persistent movement disorder resulting from long-term neuroleptic treatment, and several risk factors for TD development have been identified. Although drug-induced parkinsonism (DIP) usually disappears after the offending agent is withdrawn, a small portion of patients may have persistent parkinsonism. It is however, unclear if this is an aging-related effect. Persistent cognitive impairment associated with long-term use of typical neuroleptics has not been well documented. Atypical antipsychotics may produce improvement in cognitive performance in patients with chronic schizophrenia. MRI changes that are secondary to neuroleptics are possible, but have not yet been studied adequately. There is one unconfirmed report of neurofibrillary tangles associated with long-term neuroleptic use. A number of investigators have reported vacuous chewing movements, and neuropathologic changes following prolonged administration of neuroleptics in animals. We discuss the implications of the various reported adverse effects of long-term use of neuroleptics.

Extrapyramidal side effects in patients with Alzheimer's disease treated with low-dose neuroleptic medication.

The authors examined whether the presence of extrapyramidal side effects (EPS), measured before neuroleptic treatment was initiated, could be used to predict the development and severity of neuroleptic-induced parkinsonism (NIP) in Alzheimer's disease (AD). Twenty-four newly medicated probable AD patients were assessed with a battery of measures of extrapyramidal motor function. Assessments were made before neuroleptic therapy, and 3 and 9 months after treatment. Posttreatment clinical findings revealed that 66.7% of the AD patients developed NIP. Patients who developed NIP exhibited more severe pretreatment bradykinesia on instrument-derived measures. These findings suggest that a substantial proportion of AD patients treated with neuroleptics develop significant EPS and that the risk for EPS can be estimated before intervention by use of instruments measuring motor function.

Incidence and risk factors for severe tardive dyskinesia in older patients.

BACKGROUND: Severe tardive dyskinesia (TD) represents a serious and potentially disabling movement disorder, yet relatively little is known about the incidence of and risk factors for severe TD. METHOD: We report the results of a longitudinal prospective incidence study of severe TD in 378 middle-aged and elderly neuropsychiatric patients. Psychiatric, neuropsychological, pharmacological and motor variables were obtained at intake and at regular intervals for 36 months. RESULTS: The cumulative incidence of severe TD was 2.5% after one year, 12.1% after two years, and 22.9% after three years. Individual univariable Cox regression analyses were conducted to identify demographic, psychiatric, motor and pharmacological predictors of severe TD. Results indicated that higher daily doses of neuroleptics at study entry, greater cumulative amounts of prescribed neuroleptic, and greater severity of worsening negative symptoms were predictive of severe TD. CONCLUSIONS: These findings suggest that conventional neuroleptics may be prescribed to older patients only when necessary and at the lowest effective dosage. Additional caution is recommended in patients exhibiting negative symptoms.

Psychotic symptoms in Parkinson's disease patients with dementia.

OBJECTIVE: To assess the prevalence of psychotic symptoms in a group of patients with Parkinson's disease (PD) and dementia and examine the association of psychotic symptoms with neuropsychiatric problems, the level of distress reported by caregivers, and cognitive and functional impairment. DESIGN: The psychotic and nonpsychotic patients with PD dementia were compared on a series of demographic, neuropsychiatric, behavioral, caregiver complaint, and cognitive measures. SETTING: The database from nine university-based State of California Alzheimer's Disease Diagnostic and Treatment Centers (ADDTCs). PARTICIPANTS: 101 patients diagnosed with PD. RESULTS: A total of 36 of the 101 patients (35.6%) had either hallucinations, delusions, or both. The psychotic patients had significantly more insomnia, confusion, agitation, personality changes, and self-care problems and were noted by their caregivers to be significantly more unmanageable at home than their nonpsychotic counterparts. On cognitive scales, psychotic patients were significantly more impaired. CONCLUSION: Many patients with PD and dementia experience psychosis. Psychotic symptoms in PD dementia patients are associated with major behavioral, cognitive, and functional problems.

Late-onset psychosis with somatic delusions.

The authors studied 10 patients who had late-onset psychosis with somatic delusions and 2 comparison groups similar in age and education: 9 late-onset psychosis patients without somatic delusions and 10 normal control subjects. Demographic, clinical, and neuropsychological data were obtained. Brain magnetic resonance imaging was also done and compared. The patients with somatic delusions were somewhat more likely to be women, have been ill longer, and meet DSM-III-R criteria for delusional disorder, compared with late-onset psychotic patients without somatic delusions. Patients with somatic delusions also had lower scores on a full-scale IQ test, compared with the normal comparison subjects. The patients with somatic delusions rarely benefitted from and poorly complied with treatment with psychotropics. The study's limitations, such as small sample size and heterogeneity of diagnosis, as well as the possible clinical implications of these findings are also discussed.

A videotape analysis procedure for assessing conversational fluency in hearing-impaired adults.

This article describes a method for analyzing conversational difficulties and communication breakdown management in hearing-impaired adults and their communicative partners. The focus of the analysis is placed on the examination of conversational floor control, the proportion of repaired and nonrepaired communication breakdowns, and the strategies used by each member of the dyad to repair breakdowns. A case study illustrating the application of the procedure for aural rehabilitation is presented.

Drug and alcohol abuse in patients with acute burn injuries.

We reviewed records of adult patients admitted to our burn unit who were reported to abuse drugs or alcohol from 1985 to 1988. The proportion of patients reported as abusing drugs increased significantly from 1987 to 1988, compared to previous years. However, there was no increase in the proportion of patients reported to abuse alcohol. Patients identified as abusing drugs had longer hospital stays, compared to patients who were not reported to abuse substances. Methamphetamine and cocaine were the drugs most often abused by patients who abused drugs or both drugs and alcohol. Mechanisms of burn injury in these patients included "accidental" burn injury related to acute intoxication, and self-injury due to psychosis or depression.

Cognitive function testing in comprehensive geriatric assessment. A comparison of cognitive test performance in residential and clinic settings.

Tests of cognitive function are frequently used in geriatric assessment, but the effect of test setting has rarely been explored. To determine the effect of testing site on the performance of elderly patients undergoing a comprehensive geriatric assessment, we administered the Mini-Mental State Exam to 116 geriatric patients in the clinic and at their residence. Their cognitive abilities varied from normal to severely impaired. The patients' scores were 1.5 +/- 3.6 (mean +/- SD) higher at their residence. The clinical importance of a difference in score of 1.5 is not clear. For this reason a second analysis was performed in which a difference in scores of five points or greater between settings was considered clinically meaningful. Twenty-five percent (29 of 116) differed by five points or more. Of these 29 patients, 22 (76%) tested better in the residential setting. These differences were statistically significant (P = .001). We conclude that the testing site may affect test performance and that in-home assessment may reveal the optimal cognitive function of geriatric patients.

Antidepressant drug studies in the elderly.

This article reviews the literature on antidepressant drug trials conducted in elderly populations. Only 27 studies of cyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and psychostimulants deal specifically with subjects that were over age 60. Methodologic problems were found in many studies, including lack of diagnostic criteria and inadequate controlling for cognitive impairment, concurrent medical illnesses, and nonpsychotropic medications. Most studies compared second-generation antidepressants against placebo or tricyclic antidepressants (TCAs). Antidepressant drugs are effective treatments for geriatric depression, and limiting side effects are comparable with those seen in younger populations.

Preexisting psychiatric disorders in burn patients.

The authors studied 51 of 56 consecutive eligible patients admitted to a burn unit. Sixty-nine percent of the patients had a preburn psychiatric diagnosis. Depression alone was present in more than half the sample. Few burns were strictly accidental; 68% involved some degree of complicity on the victim's part, but intentional burns were rare. Patients with depression were more likely to sustain their burns in a setting of risk-enhancing behavior.

Successful treatment of psychotic depression with carbamazepine.

A patient with recurrent episodes of major depression with psychotic features was treated successfully with carbamazepine after unsatisfactory response to other interventions. Since psychotic depression is often difficult to treat with medications, carbamazepine may be a useful addition to the clinician's pharmacological armamentarium.

Outpatient repair of inguinal hernia.

Fifty men with hernias were operated on as outpatients: 42 went home the evening after surgery. The best results were obtained in patients with unilateral indirect hernias; those with direct hernias did not do quite as well. No patient required readmission to the hospital for complications. The cost was significantly less than that for adults operated on as inpatients. The outpatient approach is now being used for elective repair of inguinal hernias in all adult male patients.