[Key points for the treatment of the elderly with bipolar disorder]. / Aandachtspunten voor de behandeling van ouderen met een bipolaire stoornis.

BACKGROUND: There is a lack of research into the treatment of the elderly with bipolar disorder. The Dutch guidelines for the treatment of older persons with bipolar disorder are based primarily on research relating to younger adults. AIM: To define key points for the treatment of bipolar disorder in later life. METHOD: The working group on the elderly of the Dutch Foundation for Bipolar Disorder defined key points in several consensus meetings based on clinical experience and research literature. RESULTS: Recommendations were drawn up for the treatment of the elderly with bipolar disorder relating to somatic comorbidity, pharmacotherapy, cognitive dysfunctions and psychosocial support. CONCLUSIONS: In general the Dutch Guidelines for the treatment of Bipolar Disorder are applicable for the elderly, provided the key points are taken into consideration.

[Elderly patients, classical monoamine oxidase inhibitors and intercurrent somatic diseases]. / Ouderen, klassieke monoamineoxidaseremmers en intercurrente somatische aandoeningen.

Three patients, a woman aged 70, a man aged 74 and a woman aged 78 years, all using tranylcypromine, a monoamine oxidase inhibitor (MAOI), to prevent the recurrence of severe depressive disorders, developed an intercurrent somatic disease. On admission to a general hospital, the first patient was initially refused her MAOI. The second patient was twice refused anaesthesia and the depression recurred twice when the MAOI was tapered off in connection with his operation. Both recovered after being given tranylcypromine. The third patient received tramadol from her surgeon and read in the directions for use that this drug should not be combined with a MAOI. After discontinuation of the MAOI the depression recurred, her medical condition deteriorated and she died. MAOIs are often a treatment of last resort. Discontinuation of an effective treatment and hence compromising the patient's psychiatric status increases the risk of medical and psychiatric complications and therefore should be avoided. Interdisciplinary consultation is essential in such cases.

[Risk of inducing resistance upon stopping and restarting lithium after long-term usage]. / Het risico van lithiumresistentie na stoppen en herstart na langdurig gebruik.

Three man, aged 66, 60 and 26 years with bipolar disorder and long periods (20-5 years) of effective lithium prophylaxis had relapses on lithium discontinuation. Once the drug was reinstituted, it was no longer effective. Combinations of lithium with a classical MAO inhibitor or a second mood stabilizer (valproic acid and carbamazepine, respectively) ultimately proved to be successful. The risk of refractoriness should be kept in mind before considering to stop lithium therapy. A better compliance can be achieved by informing patients about the risks of discontinuing lithium, by maintaining a minimal maintenance dose and by adequately coping with possible side effects.

Differences in dexamethasone-sensitivity between lymphocytes from patients with Alzheimer's disease and patients with multi-infarct dementia.

Peripheral blood mononuclear cells (PBMC) from 40 consecutive patients entering a screening program on cognitive impairment were studied in vitro with respect to their sensitivity to dexamethasone (DEX). Phytohemagglutinin-induced proliferation by PBMC from patients with senile dementia of the Alzheimer type (SDAT) was less sensitive to the inhibitory effect of DEX, compared to PBMC from patients with multi-infarct dementia (MID) and PBMC from patients with miscellaneous causes of cognitive impairment (MISC). An intermediate sensitivity was found with PBMC from patients with clinical signs of both MID and SDAT (= MIXED). These differences could not be explained by differences in the composition of the CD4(+) T cell population, interleukin (IL)-2 or IL-4 production, or quantitative differences in the expression of glucocorticoid receptors as measured by flowcytometry. However, the expression of bcl-2 was higher in PBMC from SDAT patients than in cells from MID patients or from MISC patients, whereas the MIXED group showed an intermediate expression; a high bcl-2 expression correlated with a low DEX-sensitivity. These findings suggest that characteristics of PBMC reflect related changes in the central nervous system and indicate that PBMC may be a useful and accessible tool to obtain more insight into the pathogenesis of Alzheimer's disease.