Subject(s)
Decision Making , Mental Competency , Patient Rights , Personal Autonomy , Third-Party Consent , Aged , Humans , Legal Guardians , Male , United StatesABSTRACT
The authors examine the less-studied components of patients' autonomous decision making, or decisional autonomy, in the light of current research in psychiatry and neuropsychology and developments in the construct of informed consent. The three components of decisional autonomy-understanding, intentionality, and noncontrol or voluntariness-are related to clinical constructs in psychiatry and neuropsychology, in particular to executive control functions. The authors review studies that examine deficits in prefrontal cerebral function in schizophrenia, depression, and some anxiety disorders that are related to intentionality and voluntariness. Assessment of decisional autonomy should encompass evaluation of impaired intentionality and voluntariness, not simply impaired understanding. The main response to finding such impairments should be to provide treatment to ameliorate them. New strategies for psychiatric care should be developed to address the clinical challenges of an increasingly complex view of decisional autonomy.
Subject(s)
Decision Making , Depressive Disorder, Major/physiopathology , Informed Consent , Prefrontal Cortex/blood supply , Prefrontal Cortex/physiopathology , Schizophrenia/physiopathology , Anxiety Disorders/diagnosis , Anxiety Disorders/physiopathology , Cerebrovascular Circulation/physiology , Cognition Disorders/diagnosis , Depressive Disorder, Major/diagnosis , Humans , Mental Competency , Mood Disorders/diagnosis , Mood Disorders/physiopathology , Neuropsychological Tests , Schizophrenia/diagnosis , Severity of Illness Index , Tomography, Emission-Computed , Tomography, Emission-Computed, Single-PhotonABSTRACT
The authors identify the clinical and ethical implications of impaired executive control functions for patient autonomy. Executive control functions are processes that orchestrate relatively simple ideas, movements, or actions into complex goal-directed behavior, and impairments in these functions are becoming more common as the population ages. The authors examine difficulties that individuals with impaired executive control functions may have in making treatment decisions and describe a practical, ethically justified framework for making treatment decisions for patients with impairments in these functions. Three components of autonomy are identified-intentionality, understanding, and voluntariness. Intentionality and voluntariness are especially affected by impaired executive control functions. Impairments of these aspects of autonomy may often be overlooked when only traditional mental status examinations are employed, with adverse consequences for the health of patients wrongly thought to possess intact ability to make and carry out plans of care. Two case vignettes illustrate the complexities faced by clinicians intervening with patients who have deficits in decision-making capacity caused by impaired executive control functions.
Subject(s)
Cognition Disorders/diagnosis , Ethics, Medical , Freedom , Informed Consent , Mental Competency , Personal Autonomy , Aged , Attitude to Health , Cognition Disorders/psychology , Cognition Disorders/therapy , Comprehension , Decision Making , Ethical Analysis , Humans , Intention , Male , Neuropsychological TestsABSTRACT
BACKGROUND: Specific behavioral disturbances in dementia may be associated with underlying disorders such as the presence of psychosis and depression. The objective of this study was to examine the association of depression and psychosis with behavioral disturbances in geropsychiatric inpatients with dementia. METHODS: All admissions between October 1993 and May 1995 were reviewed to identify those patients admitted to the Houston Veterans Affairs Geropsychiatry Unit with a diagnosis of dementia; 208 patients were included in the study. Hierarchical regression models were constructed to explore the contribution of depressive and psychotic symptoms, and depression and psychosis diagnoses to Cohen-Mansfield Agitation Inventory (CMAI) scores. RESULTS: Both depression and psychotic symptoms were significantly and positively correlated with behavioral disturbances. Psychotic symptoms were associated with aggressive behavioral symptoms, and depressive symptoms were associated with constant requests for help, complaining, and negativism. Dementia severity accounted for significant variance in CMAI scores and was positively associated with behavioral disturbance; though disorder symptoms accounted for more behavioral disturbance variance than did depressive symptoms. CONCLUSIONS: Both depressive and psychotic symptoms were associated with overall behavioral disturbances in patients with dementia. Psychotic symptoms and depressive symptoms were associated with different types of behavioral disturbances. Our findings support the contention that underlying depression or psychosis may partially account for different behavioral disturbances and that not all behavioral disturbances should be globally labeled "agitation." Future studies should address symptom-specific treatment of behaviorally disturbed patients.
Subject(s)
Dementia/complications , Depression/complications , Mental Disorders/etiology , Psychotic Disorders/complications , Aged , Aged, 80 and over , Aggression/psychology , Female , Hospitalization , Hospitals, Veterans , Humans , Male , Middle Aged , Negativism , Patient Admission , Psychiatric Department, Hospital , Psychomotor Agitation/etiology , Regression Analysis , Retrospective StudiesABSTRACT
Investigations of the duration of combat-related posttraumatic stress symptoms have focused mainly on survivors of World War II and the Vietnam War, with little attention to surviving veterans of World War I. The authors describe a case in which posttraumatic stress symptoms persisted for 75 years in a World War I combat veteran and increased in frequency toward the end of his life accompanied by advancing dementia and hospitalization. The case illustrates that posttraumatic stress symptoms may be lifelong and exacerbated by various consequences of aging, even if they are not disabling.
Subject(s)
Dementia , Stress Disorders, Post-Traumatic/psychology , Warfare , Aged , Hospitalization , Humans , Male , Time FactorsABSTRACT
This study investigated the correlates of change in behavioral disturbance in geropsychiatric inpatients with dementia. It was hypothesized that improvement in specific psychiatric symptoms, such as psychosis and depression, contribute to the improvement of specific behavioral disturbances. All admissions between October 1993 and May 1995 were reviewed to identify those patients admitted to the Houston VA geropsychiatry unit with a diagnosis of dementia; 233 patients were included in the study. Improvement in behavioral disturbance symptoms was associated with decreases in depression, thought disorder, and hostility. However, the relative importance of depressive and psychotic symptoms varied depending upon the type of behavioral disturbance examined. These results may support a focused approach employing therapies specific to the type of behavioral disturbance.
Subject(s)
Behavioral Symptoms/diagnosis , Cognition Disorders/diagnosis , Dementia/therapy , Depressive Disorder/diagnosis , Hospitalization , Psychotic Disorders/diagnosis , Aged , Aged, 80 and over , Behavioral Symptoms/psychology , Behavioral Symptoms/therapy , Cognition Disorders/psychology , Cognition Disorders/therapy , Comorbidity , Dementia/diagnosis , Dementia/psychology , Depressive Disorder/psychology , Depressive Disorder/therapy , Geriatric Assessment , Geriatric Psychiatry , Hostility , Humans , Male , Middle Aged , Prognosis , Psychiatric Status Rating Scales/statistics & numerical data , Psychotic Disorders/psychology , Psychotic Disorders/therapy , Treatment OutcomeABSTRACT
The authors compared patients in a geropsychiatric unit who showed marked cognitive decline during hospitalization with those who did not. Patients who declined in cognitive function were older, were more likely to have a diagnosis of dementia, and were more anergic on admission. These patients were also discharged to more restrictive living environments. The subgroup of demented patients who declined in cognitive function were also older and improved less on anxiety and depression.
Subject(s)
Cognition Disorders/diagnosis , Geriatric Psychiatry/statistics & numerical data , Hospitalization , Age Factors , Aged , Anxiety/complications , Chi-Square Distribution , Cognition Disorders/complications , Dementia/complications , Depression/complications , Discriminant Analysis , Disease Progression , Female , Geriatric Psychiatry/methods , Hospitalization/statistics & numerical data , Hospitals, Veterans/statistics & numerical data , Humans , Inpatients/psychology , Male , Neuropsychological Tests , Patient Discharge/statistics & numerical data , Prognosis , Retrospective StudiesABSTRACT
Behavioral disturbances are commonly encountered in elderly demented patients. The records of all patients admitted to a geropsychiatric inpatient unit within a 2-year period who had a primary diagnosis of dementia and an accompanying behavioral disturbance treated with divalproex sodium were reviewed. Of the 13 patients identified, all tolerated divalproex sodium without significant side-effects. General psychiatric symptoms, overall agitation, physical aggression and non-aggressive physical agitation decreased significantly, but verbal agitation did not. Divalproex sodium is well tolerated and may be effective in ameliorating certain behavioral disturbances in elderly demented patients with agitation.
Subject(s)
Dementia/psychology , GABA Agents/therapeutic use , Psychomotor Agitation/drug therapy , Psychomotor Agitation/etiology , Valproic Acid/therapeutic use , Aged , Aged, 80 and over , Antipsychotic Agents/therapeutic use , Dementia/diagnosis , Drug Tolerance , Female , Humans , Male , Neuropsychological Tests , Psychiatric Status Rating Scales , Treatment Outcome , Valproic Acid/bloodABSTRACT
The authors determined the outcome of geropsychiatric hospitalization for 73 very low-functioning demented patients (GAF score < 21). General psychiatric symptoms, depression, and agitation decreased significantly, and mean GAF scores increased significantly, with no significant change in cognitive function. Psychiatric hospitalization can meaningfully improve function and quality of life even in this very impaired population. Despite these improvements many patients are discharged to more restrictive settings.
Subject(s)
Dementia/therapy , Disability Evaluation , Patient Admission , Quality of Life , Activities of Daily Living/psychology , Aged , Aged, 80 and over , Combined Modality Therapy , Comorbidity , Dementia/diagnosis , Dementia/psychology , Depressive Disorder/diagnosis , Depressive Disorder/psychology , Depressive Disorder/therapy , Female , Hospitals, Psychiatric , Humans , Male , Middle Aged , Neurocognitive Disorders/diagnosis , Neurocognitive Disorders/psychology , Neurocognitive Disorders/therapy , Patient Care Team , Psychomotor Agitation/diagnosis , Psychomotor Agitation/psychology , Psychomotor Agitation/therapy , Treatment OutcomeABSTRACT
The authors examined the effect of hospitalization on cognitive and behavioral symptoms in delirious elderly patients with and without dementia. Forty-four (13%) of the patients admitted to a Veterans Affairs Medical Center geropsychiatric unit were diagnosed with delirium and were administered the Mini-Mental State Examination, the Hamilton Depression Rating Scale, the Brief Psychiatric Rating Scale (BPRS), the Rating Scale for Side Effects, and the Cohen-Mansfield Agitation Inventory. The total sample significantly improved on all measures. When patients with delirium were divided into subgroups with and without dementia, both subgroups improved similarly. Patients discharged to more restrictive environments improved significantly on the BPRS only.
Subject(s)
Delirium/therapy , Dementia/therapy , Hospitalization , Social Environment , Activities of Daily Living/psychology , Aged , Aged, 80 and over , Antipsychotic Agents/administration & dosage , Antipsychotic Agents/adverse effects , Cohort Studies , Combined Modality Therapy , Delirium/diagnosis , Delirium/psychology , Dementia/diagnosis , Dementia/psychology , Depressive Disorder/diagnosis , Depressive Disorder/psychology , Depressive Disorder/therapy , Female , Humans , Length of Stay , Male , Mental Status Schedule , Neurocognitive Disorders/diagnosis , Neurocognitive Disorders/psychology , Neurocognitive Disorders/therapy , Neuropsychological Tests , Patient Care Team , Psychiatric Status Rating Scales , Retrospective StudiesABSTRACT
This pilot study investigated effectiveness and tolerability of risperidone for the treatment of psychosis and agitation in 9 inpatients with Parkinson's disease and dementia. Investigators found risperidone to be effective and safe, without worsening extrapyramidal symptoms or further impairing cognition.
Subject(s)
Antipsychotic Agents/therapeutic use , Dementia/drug therapy , Parkinson Disease/complications , Psychomotor Agitation/drug therapy , Risperidone/therapeutic use , Aged , Antipsychotic Agents/adverse effects , Dementia/complications , Dementia/psychology , Female , Humans , Male , Parkinson Disease/psychology , Pilot Projects , Psychiatric Status Rating Scales , Psychomotor Agitation/etiology , Psychomotor Agitation/psychology , Risperidone/adverse effectsABSTRACT
Several studies have reported an association between aggression and cholesterol levels. The purpose of this study was to investigate the relationship of serum cholesterol and triglyceride levels with aggression and cognitive function in elderly inpatients. One hundred ten patients consecutively admitted to the Geriatric Psychiatry inpatient unit at Houston's Veterans Affairs Hospital received comprehensive evaluations by a multidisciplinary team. Fasting serum cholesterol and triglyceride levels were obtained within 3 days of admission. In addition, two geriatric psychiatrists administered the Mini-Mental State Examination (MMSE) and the Cohen-Mansfield Agitation Inventory (CMAI). Correlation coefficients were calculated between lipid levels, CMAI total and subscale scores, and MMSE scores. Multiple linear-regression analyses were done to further investigate the relation between lipid concentrations and various confounders. We found no significant correlation between serum triglyceride levels and MMSE, CMAI total, and CMAI factor scores. In addition, we found a significant positive correlation between serum cholesterol levels and physical nonaggressive behavior, and a significant negative correlation between serum cholesterol levels and MMSE scores. We found no relationship between aggressive behavior and serum cholesterol or triglyceride levels. However, an association between high cholesterol levels and agitation exists, which may be mediated by the association between high cholesterol levels and impaired cognition.
Subject(s)
Cholesterol/blood , Dementia/blood , Psychomotor Agitation/blood , Triglycerides/blood , Aged , Aggression/physiology , Dementia/diagnosis , Dementia/psychology , Humans , Hypercholesterolemia/blood , Hypercholesterolemia/diagnosis , Hypercholesterolemia/psychology , Male , Mental Status Schedule , Patient Admission , Patient Care Team , Psychomotor Agitation/diagnosis , Psychomotor Agitation/psychology , Risk FactorsABSTRACT
BACKGROUND: The efficacy and tolerability of fluoxetine were examined in 31 patients admitted to a geropsychiatric inpatient unit who were initiated and maintained on a regimen of fluoxetine. METHOD: The Hamilton Rating Scale for Depression, the Brief Psychiatric Rating Scale, the Mini-Mental State Examination, and the Rating Scale for Side Effects were administered at admission and discharge, and scores were compared using paired t tests. Two patients were withdrawn from fluoxetine prior to discharge because of side effects; their data are not included in the analysis. RESULTS: We found significant improvement both in depressive symptoms and in general psychiatric symptoms and nonsignificant improvement in cognitive function. Fluoxetine was well-tolerated, and a significant decrease in the total scores of the Rating Scale for Side Effects was found. Subgroups of older patients (mean age = 75 years), less depressed patients, and demented patients were also examined. In all three groups, we found a statistically significant improvement in depressive symptoms, general psychiatric symptoms, and total side effects. CONCLUSION: Fluoxetine appears to be an effective and well-tolerated antidepressant in elderly inpatients of varying age, levels of depression, and psychiatric diagnoses.
Subject(s)
Fluoxetine/therapeutic use , Hospitalization , Mental Disorders/drug therapy , Age Factors , Aged , Antipsychotic Agents/therapeutic use , Dementia/drug therapy , Dementia/psychology , Depressive Disorder/drug therapy , Depressive Disorder/psychology , Drug Therapy, Combination , Female , Fluoxetine/adverse effects , Geriatric Assessment , Humans , Male , Mental Disorders/psychology , Psychiatric Status Rating Scales , Treatment OutcomeABSTRACT
Temporal lobe epilepsy may present with features similar to those of psychiatric disorders, making diagnosis difficult, especially in an elderly population. The authors present two cases illustrating key points leading to proper diagnosis and treatment.
