Bipolar disorder in late life: a review.

Although there is a broad base of literature on depression among elderly patients and on mania in younger patients, there is a relative paucity of information on bipolar disorder in the elderly population. While the quantities of data reflect the relative prevalences of these illnesses, there is evidence to suggest that classification of mania in the elderly with respect to age of onset, natural course, family history, and pathophysiology may be useful in understanding the heterogeneous etiologies of this syndrome. This paper presents a review of the literature on the incidence and course of illness in late-life bipolar disorder. Further, dilemmas of diagnostic classification in relation to associated risk factors will be discussed.

Assessing competency to make a will.

The finding by a court that the author of a will (the testator) lacked mental capacity or was subject to undue influence at the time the will was executed can invalidate the will. A psychiatrist may be asked to assess the competency of a testator when he or she is planning to create or modify a will or after the death of a testator when the will is challenged. To provide guidelines for such evaluations, the authors reviewed the relevant psychiatric, forensic, and legal literature and drew on their own professional experience as well. They outline a systematic approach to the contemporaneous and retrospective evaluation of the elements that affect decisions about mental capacity and undue influence and offer suggestions for the organization and presentation of expert testimony. Awareness of the relevant legal principles and a systematic clinical approach to the assessment can maximize the quality of the psychiatric consultation and expert testimony.

HLA antigens in depressed, demented, and nondemented elderly.

To identify HLA antigen associations with geriatric depression, the authors typed 36 elderly patients with major depression and, for comparison, 36 patients with Alzheimer-type dementia and 29 nondemented elderly controls. The frequency for antigen Aw32 was significantly higher in the group of patients with major depression (14%) than in the demented (0%) and control (3%) groups. The frequencies for antigens Aw32 (22%) and Bw51 (22%) were significantly higher in the subgroup of 23 patients with endogenous depression than in the demented (Aw32 = 0%; Bw51 = 11%) and the control (Aw32 = 3%; Bw51 = 0%) groups. Although these results were derived from a relatively small sample (n = 101) and become nonsignificant when corrected for multiple comparisons, they suggest that HLA antigen associations may be present for only certain depressive subtypes in geriatric depression.

Desipramine increases circulating growth hormone in elderly depressed patients: a pilot study.

Serial blood samples were collected from 15 elderly depressed inpatients, ages 62 to 95 years, following random assignment to a 50 mg oral test dose of desmethylimipramine (DMI) or amitriptyline (AMI). Nine female and six male subjects began the 210-min study at 0800h. Serum growth hormone (hGH), cortisol, and prolactin (hPRL) were determined by radioimmunoassay. Baseline hormone concentrations were related to self and observer ratings of anxiety and depression. There was a trend for the hGH, cortisol, and hPRL concentrations to decline during the period of study. This trend for all three hormones reversed in those subjects receiving DMI, beginning approximately 90 min after drug ingestion. The DMI-induced increase of hGH reached statistical significance at the very end of the sampling period. There was an apparent latency in the DMI-induced effect for all three hormones. There was no stimulatory effect of AMI on hGH, cortisol, or hPRL. The female subjects had higher baseline hGH levels than the men. In addition, a significant negative correlation was found between baseline hPRL levels and self ratings of anxiety.

Plasma trazodone concentrations in elderly depressed inpatients: cardiac effects and short-term efficacy.

Twenty-three depressed patients with an average age of 78.86 were treated with trazodone in dosages averaging 354.3 mg/day. Despite pretreatment cardiac conduction delay in 30%, no electrocardiographic abnormalities were produced or exaggerated during the study. Plasma steady state levels averaged 1,474.4 ng/ml and significantly correlated with dosage at r = 0.415. In a subgroup of 13 patients, six who sustained good short-term response to trazodone had lower mean steady state plasma levels than seven who did not, suggesting that plasma levels about 1,500 ng/ml may not be therapeutic in the short run.

Electroencephalographic spectra and coherence in the diagnosis of Alzheimer's-type and multi-infarct dementia. A pilot study.

The accurate diagnosis of dementia is difficult because there are no specific physiologic tests. Computer-analyzed electroencephalography (EEG) has shown promise as a tool for the differential diagnosis of dementia, but topographic methods for data collection and analysis have seldom been used. We used these methods to investigate EEG differences among three groups of elderly subjects: those with mild to moderate dementia of the Alzheimer's type (DAT), those with mild to moderate multi-infarct dementia (MID), and age- and sex-matched normal controls. The two groups of demented subjects were distinguished from the control group by a new criterion, the ratio of high-frequency to low-frequency electrical activity in the left temporal region, which was greatly diminished in demented subjects. Using this single variable, all control subjects and 15 of 18 demented subjects were correctly classified (sensitivity 83%, specificity 100%). The three misclassified subjects were among the least impaired subjects with DAT. Examination of coherence, or synchronization of the EEG signal, enabled us to distinguish subjects with DAT from those with MID. Using discriminant analysis of both EEG frequency and coherence, 92% (22/24) of subjects were accurately classified. These results justify further evaluation of topographic, computer-based EEG analysis as a test for the differential diagnosis of dementia.

Clinical tests of memory in dementia, depression, and healthy aging.

In Study 1, carefully screened elderly adults with primary degenerative dementia or major depression were compared to healthy aged control subjects on three tests of learning and memory: the Benton Visual Retention Test, Inglis Paired-Associate Learning Test, and the Fuld Object-Memory Evaluation (OME). The sharpest distinction in performance among the groups was observed on the OME, and discriminant equations based on this test correctly classified a high percentage (greater than or equal to 90%) of participants. Study 2 applied the classification rules derived in the first investigation to an unselected series of geropsychiatry inpatients referred for neuropsychological evaluation. There was agreement between memory test classification and general categories of clinical discharge diagnosis (organic vs. functional) for 21 of 25 patients, and with status at follow-up approximately 18 months later. Predictive value computations suggested that the OME is more accurate in confirming true dementia than in detecting dementia syndromes associated with functional disorders.

The late-onset psychoses. Clinical and diagnostic features.

Psychoses of late onset are poorly understood due to a limited number of inconsistent studies. The authors conducted this study to determine the clinical characteristics of a clearly defined group of patients with onset of psychosis after age 65 years and to test the usefulness of DSM-III criteria in diagnosing the condition of these patients. Late-onset psychosis occurred in 8% of the patients admitted to the geropsychiatry unit during the study period. More than three quarters of these patients suffered from either an organic mental disorder or major affective disorder, the remainder having primary psychotic disorder. The diagnoses of the psychotic patients were much less reliable than those of a comparable group of nonpsychotic patients, with more than 5 times as many patients in the psychosis group changing diagnostic categories between the time of their admission and their discharge. DSM-III diagnostic criteria were not well suited for the categorization of many of these patients. For patients with primary psychotic disorder, the criteria artificially subdivided groups of similar patients. For patients with organic mental disorder, the criteria did not provide sufficient guidance for the diagnosis of psychosis in the presence of dementia. All three groups of patients responded to somatic therapies. A subgroup of patients with affective disorder improved without neuroleptic treatment, and several patients with primary psychotic disorder benefited from antidepressant treatment. These results highlight the difficulty inherent in the treatment of patients with late-onset psychosis. Further research is needed to develop adequate diagnostic criteria and to determine which patients will benefit from neuroleptic and/or antidepressant therapy.

Major depression in the elderly: DSM-III criteria and the dexamethasone suppression test as predictors of treatment response.

Twenty-seven elderly individuals with DSM-III diagnoses of major depression who demonstrated a nonsuppressor response to the dexamethasone suppression test had higher pretreatment levels of mood disturbance, required higher dosages of antidepressant medication, and had poorer responses to treatment than 17 clinically similar individuals with a suppressor response. However, when data on the outcomes of suppressors and nonsuppressors were combined, over half of the entire group sustained significant improvement, which supports the practical value of DSM-III criteria for depression in the elderly.

Dementia in the elderly: the silent epidemic.

The graying of America will be accompanied by an epidemic of major proportions--dementia or intellectual impairment--that will have an impact on all aspects of the helath care system, particularly on the institutional component of the long-term care system. Health professionals; federal, state, and local health planners; families; and others must recognize that many ameliorable or curable physical and emotional diseases in the elderly are associated with intellectual impairment that may be difficult to distinguish from irreversible brain disease of the Alzheimer type. We present information on the cause, physiopathologic mechanism, clinical presentation, appropriate laboratory studies, and anticipated outcomes in the various forms of intellectual impairment found in the elderly. Important new developments will occur in the next decade that will address the cause, pathogenesis, further refinement of laboratory investigation, and specific therapeutic intervention in dementia.

Dementia in the aged.

Dementia can be feature of several distinct pathologic processes, including extracranial and intracranial disease, iatrogenesis, and depression. In approximately 20 per cent of cases, dementia is caused by a potentially reversible disease; in the remaining 80 per cent, it is associated with primary brain disease for which no specific treatment is yet known. In all cases, thorough medical and psychiatric evaluation is indicated. In a large percentage of cases of primary dementia, a multiple therapeutic approach, which includes psychopharmacologic and psychotherapeutic modalities, can arrest and sometimes reverse some of the debilitating complications of the dementing illness.

Hospital treatment of elderly neuropsychiatric patients. II. Statistical profile of the first 122 patients in a new teaching ward.

Data are presented on the first 122 patients admitted to a geropsychiatric teaching ward in a university hospital. A high incidence of medical problems are reflected by abnormal laboratory findings complicated the management of these patients, most of whom had dementia or depression. In all diagnostic categories, the patients appeared to benefit from the intensive inpatient treatment. Difficulties in the areas of diagnosis, treatment, length of hospital stay, discharge placement and program evaluation are discussed.

Hospital treatment of elderly neuropsychiatric patients. I. Initial clinical and administrative experience with a new teaching ward.

Program planning and the initial experience of a new teaching ward for geriatric psychiatry are described. Elderly psychiatric patients, with diagnoses predominantly of depression and dementia, demonstrate more self-centeredness and less group awareness than do younger patients. Ward staff members often experience frustration, sadness and anger in response to working with them. Major problems unique to a geriatric psychiatry service include the paucity of adequate resources for post-discharge care and the necessity to obtain excellent medical-surgical consultation and support.

Bipolar affective disorder in aged patients.

Bipolar affective illness may be a relatively common missed diagnosis in the elderly. Inaccurate historical data, atypical course of illness and atypical clinical presentation are all sources of diagnostic error. Lithium and tricyclic antidepressants are effective agents in this age group but require close monitoring, with particular attention to their interaction with illness and other medications. A high index of suspicion for bipolar illness is suggested when elderly patients present with depression.

The board-and-care home: does it deserve a bad press?

A survey of 46 randomly selected schizophrenic residents of six board-and-care homes in the Los Angeles area found that the schizophrenic who adjusts to the setting experiences a schizoid-compliant pattern of outcome on antipsychotic drugs that is characterized by blunted affect, passivity, and lack of initiative, interest, and spontaneity. The authors conclude that it is those negative symptoms of schizophrenia, mistakenly attributed to the presumed inadequacies of the board-and-care environment, that have given the board-and-care home a bad press both in the newspapers and in the psychiatric literature.