Cholinesterase inhibitors. Comparing the options for mild-to-moderate dementia.

Cholinesterase inhibitors can be used as one element of a comprehensive approach to management of mild-to-moderate AD. Benefits include modest cognitive improvement, increased activation, and improved mood and behavior. Patients with other disorders, such as Lewy-body dementia, may also improve. The most common side effects include GI disturbances, insomnia, dizziness, fatigue, and muscle cramps. Adverse effects can be significantly reduced by waiting 4 to 6 weeks before increasing doses. Insomnia may be alleviated by having the patient take the medication early in the day.

Applying Bradford Hill's criteria for causation to neuropsychiatry: challenges and opportunities.

Establishing an argument of causation is an important research activity with major clinical and scientific implications. Sir Austin Bradford Hill proposed criteria to establish such an argument. These criteria include the strength of the association, consistency, specificity, temporal sequence, biological gradient, biologic rationale, coherence, experimental evidence, and analogous evidence. These criteria are reviewed with the goal of facilitating an increase in rigor for establishing arguments of causation in neuropsychiatry. The challenges and opportunities related to these criteria in neuropsychiatry are reviewed, as are two important arguments for causation: one for poststroke depression and one for brain injury as a cause of psychiatric disorders.

Diagnosing and managing delirium in the elderly.

OBJECTIVE: To outline current approaches to diagnosing and managing delirium in the elderly. QUALITY OF EVIDENCE: A literature review was based on a MEDLINE search (1966 to 1998). Selected articles were reviewed and used as the basis for discussion of diagnosis and etiology. We planned to include all published randomized controlled trials regarding management but found only two. Consequently, we also used review articles and recent practice guidelines for delirium published by the American Psychiatric Association. MAIN FINDINGS: Clinical diagnosis of delirium can be aided by using DSM-IV criteria, the Delirium Symptom Interview, or the confusion assessment method. Management must include investigation and treatment of underlying causes and general supportive measures. Providing optimal levels of stimulation, reorienting patients, education, and supporting families are important. Pharmacologic management of delirium should be considered only for specific symptoms or behaviours, e.g., aggression, severe agitation, or psychosis. Only one randomized controlled trial of tranquilizer use for delirium in medically ill people has been published. Findings support the current belief that neuroleptics are superior to benzodiazepines in most cases of delirium. Most authorities still consider haloperidol the neuroleptic of choice. Controlled trials of the new atypical neuroleptics for treating delirium are not yet available. Benzodiazepines with relatively short half-lives, such as lorazepam, are the drugs of choice for withdrawal symptoms. CONCLUSION: Delirium is frequently underdiagnosed in clinical practice. It should be suspected with acute changes in behaviour. Careful investigation of the underlying cause permits appropriate management.

Depression in holocaust survivors: profile and treatment outcome in a geriatric day hospital program.

The profile of depressive symptoms and the outcome of treatment in Holocaust Survivors (HS) versus non-Holocaust Survivors (NS), attending a Psychiatric Day Hospital Program for depression, were evaluated retrospectively using a clinical database. Approximately 24% of the study population were Holocaust Survivors (HS). The HS group was more likely to receive a diagnosis of major depressive disorder or episode as one of their diagnoses. The HS group, in particular those survivors who had been in ghettos or in concentration camps, were more likely to be given a diagnosis of post-traumatic stress disorder. Both groups showed improvement from baseline in their ratings of depression on the Hamilton Depression Rating Scale (HDRS) and Geriatric Depression Scale at the time of discharge (p<0.001). However, there were no significant differences between the groups in terms of their ratings of depression either at admission, at discharge or in their degree of improvement. Likewise, there was no significant difference between the groups in the profile of their depression, as per the sub-scales of the HDRS, with the exception that the HS group displayed more 'insight' than the NS group (p=0.002). The NS group scored higher on the Mattis Dementia Rating Scale compared to the HS group (119.1 versus 125.4, p<0.001), even when level of education was covaried; however, language may be an important confound. In conclusion, there was no significant difference in the profile or outcome of depression between groups. However, the HS group was more likely to receive a diagnosis of post-traumatic stress disorder, displayed more 'insight', and appear to differ in their cognitive profile.

Psychotropic drug utilization in long-term-care facilities for the elderly in Ontario, Canada.

OBJECTIVE: Despite considerable data from a number of countries regarding psychotropic utilization in long-term-care facilities for the elderly, there has been a lack of similar data from Canada. The purpose of this study was to gather prescription data from a series of institutions in Ontario and to compare the results to those of other international studies. METHOD: Single-day surveys were carried out in six homes for the aged, four nursing, homes, two retirement homes, and a veterans' center. The results were compared to those of recent studies from other countries. RESULTS: The data revealed considerable differences in rates of prescription between different classes of institutions and between similarly classified institutions. The prescription rate of neuroleptics ranged from 11.8% (of patients) in retirement homes to 29.8% in nursing homes. Antidepressant use ranged from 12.2% in nursing homes to 24.6% in homes for the aged, and benzodiazepine use ranged from 22.5% in nursing homes to 36.4% in retirement homes. CONCLUSIONS: The overall rate of prescription for psychotropic medications was somewhat lower than in most international studies. The rate of prescription of neuroleptics in nursing homes fell in the midrange of studies, somewhat higher than in recent studies from the United States and an earlier Italian study, but lower than in recent reports from Sweden, Austria, and Australia. The rate of neuroleptic use in homes for the aged was comparable to the rate in the U.S. studies. The overall rate of prescription of antidepressants and benzodiazepines appears to be comparable to that in recent studies from other countries.

Diagnosis and management of late life depression: a guide for the primary care physician.

OBJECTIVE: The purpose of this article is to provide a brief and practical approach for the primary care physician regarding the recognition, diagnosis, and management of depression in elderly patients. METHOD: Empirical evidence and current recommendations regarding the recognition, diagnosis, and treatment of depression are reviewed as the basis for this approach. Appropriate modifications for geriatric depression are added where indicated. RESULTS: The recommendations are listed by category and briefly explained. CONCLUSIONS: It is important to be vigilant for the variety of depressive presentations that occur in older primary care patients. Neurological causes of depression (such as stroke), suicide, and a longer time to recovery are all more frequent concerns in older depressed patients.

Pattern of use of antidepressants in long-term care facilities for the elderly.

Despite some evidence that neuroleptic medication is overused or misused in long-term care facilities for the elderly, there has been virtually no attention paid to the pattern of use of antidepressants in these facilities. All patients in long-term care in a geriatric hospital and a home for the aged who were receiving antidepressants were identified; 10.5% of the patients in the hospital and 12.7% in the home for the aged were receiving an antidepressant. The rate of use of antidepressants on the different units ranged from 0% to 26.8%. The most commonly prescribed antidepressant was doxepin followed by nortriptyline. The mean dose of antidepressant was 34.8 mg. Although depression was the most common reason for the prescription of an antidepressant (69% of patients receiving one), other reasons included pain, agitation, aggression, and insomnia. Patients had been receiving antidepressants for up to 10 years, with a mean duration of 32 months. The majority of patients (60%) had a history of depression predating their institutional admission. Patients receiving antidepressants were compared to a group not receiving antidepressants, who were matched for age, sex, unit, and attending physician. Patients receiving antidepressants were more likely to have a history of stroke (33.8% versus 16.9%). There was no significant difference between the two groups regarding the prevalence of dementia, Parkinson's disease, thyroid disease, malignant tumor, congestive heart failure, or diabetes mellitus. Prospective studies are required to determine the efficacy of antidepressants in this population and to identify factors that can predict a positive response to treatment.

Psychiatric services: a survey of nursing homes and homes for the aged in Ontario.

A survey was conducted to determine perceptions and attitudes of psychiatric services available to nursing homes and homes for the aged across Ontario. A questionnaire was sent by mail to medical and nursing directors separately. Thirty-six point eight percent of responders reported that the nursing home residents never receive psychiatric care, and 88.2% of responders estimated the total psychiatric care received by all of their residents per month was five hours or less. Almost three-quarters of the responders stated that they require more psychiatric services. Significantly more nursing directors than medical directors wanted more psychiatric services. Southwestern Ontario, followed by Northern Ontario, had the least perceived availability of a visiting psychiatrist. Perceived availability was greatest in larger urban areas and least in rural areas. The mean percentage of residents perceived to have psychiatric or behavioural problems was 30.5%, while the mean percentage perceived to require psychotropic medication was 37.4%. Physical aggression, wandering and agitation were identified as the behavioural problems of greatest concern to staff. When a visiting psychiatrist is not available, residents sometimes have to travel long distances for psychiatric evaluation. Planning is required to facilitate and encourage the development of efficient and effective psychiatric services for long term care facilities for the elderly.

Electroconvulsive therapy for poststroke depression.

Of the 193 patients with stroke and depression treated at Massachusetts General Hospital from 1969 to 1981, 14 had electroconvulsive therapy (ECT) for poststroke depression. Among these 14 patients, depression developed less than 1 year after stroke in 9 and more than 1 year after stroke in 5. Except for 2 of the patients in whom depression developed within a year, all had marked improvement in depression after ECT. A transitory cardiac arrhythmia developed in 1 patient, but none of the patients had an exacerbation of stroke or a worsening of neurologic status. These findings indicate that ECT is safe and effective for poststroke depression.