[Diagnosis and treatment of paranoid and schizophrenia-like psychosis in elderly patients].

Research supports theories on valid differences between early-onset schizophrenia (EOS), which persists through life, versus late-onset schizophrenia. We differentiate between schizophrenia, late-onset schizophrenia (LOS), very late-onset schizophrenia-like psychosis (VLOSLP) and paranoid psychosis in the elderly. While LOS may resemble EOS, VLOSLP may resemble neurodegenerative disorders such as Parkinson's disease and Alzheimer's disease. In this review, a treatment guideline is proposed.

Simple scoring of the Clock-Drawing test for dementia screening.

INTRODUCTION: This study assessed five scoring methods of the Clock-Drawing test (CDT). MATERIAL AND METHODS: A total of 72 out-patients and 29 healthy controls were assessed three times. At Visit 1, diagnostic procedure and assessments were performed with the Clinical Global Impressions (CGI) and Global Deterioration Scale (GDS), and the CDT and the Mini Mental State Examination (MMSE) were done blinded by a nurse. At Visit 2, CDT and MMSE were repeated, and at Visit 3 the CDT, CGI and the GDS were repeated. The CDTs were then rated by physicians and nurses using five different methods of scoring. Receiver-operating characteristics curve analyses were used to assess the CDT's suitability as a screening tool. Correlations between the five CDTs, other scales and predictive values were calculated. The extent to which three-word recall could improve the predictive values was analysed. RESULTS: Correlations between the CDTs and the other scales were good. The predictive values were almost identical (positive values: 93-97%; negative values: 70-74%). Three-word recall improved the values. Rates of dementia in general practice and corresponding predictive values were estimated which resulted in markedly lower positive values around 60% for a rate of dementia of 20%, and 40% for a rate of dementia of 10%. CONCLUSION: As predictive values were nearly identical, the shortest scoring manual (0 to 1) seems preferable. FUNDING: The study was partly funded by Novartis Pharma A/S. TRIAL REGISTRATION: Scientific Ethical Committee, 2003-2-17.

[Large differences in treatment of depression between departments of psychiatry]. / Stor forskel i behandling af depression mellem psykiatriske afdelinger.

INTRODUCTION: A large proportion of patients admitted to psychological departments and wards suffer from depression. Knowledge is limited about the clinical aspects and treatment of depression at admission and discharge, as well as about the differences between psychiatric hospitals. The purpose of this study was to develop a database for patients admitted to a psychiatric department comprising registration of central clinical parameters. MATERIAL AND METHODS: A group of senior psychiatrists with research experience selected 12 central clinical and treatment parameters. All five hospitals in the Copenhagen area participated. Centralised training in the use of Hamilton Depression Rating Scale (HDRS) was performed. At discharge the scores on the various parameters were reported to a central database. RESULTS: The educational HDRS ratings for the departments were rather uniform. The HDRS ratings and Beck Depression Inventory (BDI) ratings at admission and discharge were rather uniform between the participating departments. A large proportion of patients had depressive symptoms at discharge. The most prevalent antidepressants were newer selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors. Much variability was found in the use of medical augmentation strategies and in electroconvulsive therapy (ECT). CONCLUSION: The severity of depression at admission and discharge were uniform across the participating departments. Many patients suffered from depressive symptoms at discharge. Much variability was found in the use of medical augmentation strategies and ECT.

The Neuropsychiatric Inventory--NPI. Validation of the Danish version.

Assessment of neuropsychiatric symptoms in dementia has great clinical importance. The aim of the study was validation of the Danish version of the NPI, using assessments of 72 demented and 29 non-demented of age 65+ years and their caregivers at three visits. The NPI was administered by the same psychiatric nurse interviewing the same caregiver. At visits 1 and 3, a psychogeriatrician assessed the participant using the ICD-10, the Geriatric Deterioration Scale (GDS) and the Clinical Global Impression (CGI) as well as the NPI in a visual analogue scale (VAS) version. These scores were blindly converted into scores equalling the frequency and severity of the NPI by one of the investigators. Data analysis comprised inter-rater reliabilities (intra-class coefficients, ICC); NPI scores and corresponding VAS scores were compared using Spearman's correlation coefficients. NPI scores at visits 1 and 2 were used to assess the test-retest reliabilities. The scalability of the NPI was assessed with Mokken and Loevinger coefficients. The ICC for all the NPI domains and the GDS (>0.80) were perfect, the ICC for the NPI-VAS (0.68-0.95) and the CGI (0.69) was satisfactory to perfect. Correlations between NPI and NPI-VAS were high; only two domains had coefficients below 0.60: depression and agitation/aggression. NPI-total scores increase with increasing severity of dementia. The NPI did not fulfil the scalability assessed by the Mokken and Loevinger coefficients. The NPI Danish version is valid and reliable in assessing neuropsychiatric symptoms in dementia but not fully scalable. The use of single item scores and not total sum score is recommended.

[Mini mental state examination. Validation of new Danish version]. / Mini mental state examination. Validering af en ny dansk udgave.

INTRODUCTION: The Mini Mental State Examination (MMSE) is widely used in Denmark, but often in non-validated versions. In 2000 a cross-sectional workgroup decided on a new common version of the MMSE with a corresponding manual, which is validated for the first time in the present study. MATERIALS AND METHODS: The study was performed from April 2003 until August 2005 in four psycho-geriatric departments. The participants (65+ years) were assessed on three consecutive occasions (week 0, 1 and 26) with the MMSE (nurse), and global scales as well as diagnostically with ICD-10 (psycho-geriatrician). RESULTS: 101 persons were included, 29 were healthy, non-demented; 82 participants were assessed at visit two, 90 at visit three, but only 88 ratings were useable. The best cut-off value for the MMSE was > or = 26. Inter-rater and test-retest (r=0.91) correlations of the MMSE were high as were the correlations to the global scales. However, there were considerable variations in mean score (+/-SD) as well as median score and range in relation to CGI and GDS values. The MMSE score is independent of sex and educational level. CONCLUSION: The MMSE also proved to be a robust scale in the present Danish version. It achieved excellent inter-rater and test-retest reliability. A cut-off value of = 26 proved better than 24 which was preferred hitherto. However, the ranges of the MMSE scores are so dispersed within the same global degree of severity that the MMSE should not generally be used to describe the severity of dementia disorders.

Treatment with antiparkinson and antidepressant drugs: a register-based, pharmaco-epidemiological study.

Depressive symptoms and major depression are frequent in patients with Parkinson's disease (PD). However, a systematic knowledge about the treatment with antidepressant drugs among PD patients is missing. We estimated the frequency of antidepressant drug treatment in a national sample of persons treated with antiparkinson drugs (APDs). All persons treated with APDs were identified in the national Danish Prescription database. The subsequent risk of treatment with antidepressants was estimated and compared with the risks for two large control groups. The study period was 5 years. In total, 1,029,737 persons were included. Persons who got APDs had significantly increased rate ratios (RR) of subsequent antidepressant drug treatment compared with an unexposed control group (RR: 2.10 (95% CI: 2.04-2.16)) and with persons who got anti-diabetic drugs [RR: 1.58 (95% CI: 1.51-1.65)]. Persons treated with APDs have higher frequency of antidepressant drug treatment than have controls. With the reservation that data on drug consumption cannot be directly transferred into conclusions about specific diseases, the present study supports results from other population-based studies of an association between PD and depression.

[Depression and neurological disorders]. / Depression og neurologisk sygdom.

Depression frequently accompanies neurological disorders. Depressive symptoms have specific characteristics depending on the type of cerebral lesion, comorbidity and psychosocial impact. Difficulties in distinguishing mental symptoms from those caused by neurological damage partly explain the fact that depression is still under-diagnosed. Depression has a major negative impact on the quality of life and increases patients dependency on relatives. Evidence-based guidelines for treatment are very sparse and there is an urgent need for large-scale controlled trials.

Use of antiparkinsonian drugs in Denmark: results from a nationwide pharmacoepidemiological study.

The objective of the present study was to record the use of antiparkinsonian drugs (APD) in Denmark and discuss estimates of the incidence and prevalence rates of Parkinson's disease (PD). The main indication for treatment with APD is idiopathic PD. The use of APD is, therefore, an indicator of the epidemiology of PD and Parkinsonism. We used a drug tracer design, which previously has been found applicable in estimating the frequency of PD. From a national prescription database, all persons who purchased APD from 1995 to 2002 could be identified on an individual level. Results show an age-standardized prevalence rate for APD purchase of 164.0 persons per 100,000, and an incidence rate of 55.9 persons per 100,000. The total number of persons purchasing APD was 11,656 per year on average. Our results showed higher figures of persons purchasing APD than the estimated prevalence of idiopathic PD in Denmark, which is approximately 100 persons per 100,000, corresponding to 5,000 to 6,000 persons. The differences might in part be explained by other indications for APD prescription in addition to PD and in part by misdiagnosis. However, the possibility of somewhat higher incidence and prevalence rates of PD than hitherto estimated should be considered.

Increased risk of developing diabetes in depressive and bipolar disorders?

A few studies have suggested that the prevalence of diabetes is increased for patients with depression and for patients with bipolar disorder compared with the general population. However, no study has been published comparing the risk of getting a diagnosis of diabetes for patients with affective disorders with the risk for patients with other medical illnesses. It was the aim of the present study to investigate whether patients hospitalised for depressive or bipolar disorders are at increased risk of getting a diagnosis of diabetes at readmission compared to patients previously admitted for osteoarthritis. In a nationwide case register study, all patients who got a discharge diagnosis of depression, mania/bipolar disorder or osteoarthritis at first admission in a period from 1977 to 1997 were identified. The probability of getting readmitted and discharged with a diagnosis of diabetes was estimated with competing risks models in survival analysis. In total, 29,035 patients with a diagnosis of depression at first discharge, 6683 patients with mania/mixed episode and 108,525 patients with a diagnosis of osteoarthritis were identified. The risk of getting readmitted with diabetes was not increased for patients who had previously been admitted with depression or mania/bipolar disorder compared to patients with osteoarthritis. There was no difference in the risks of developing Type 1 and Type 2 diabetes.

No increased risk of developing depression in diabetes compared to other chronic illness.

Several studies have found that the prevalence of depression in patients with diabetes is higher than in the general population but it is unclear whether patients with diabetes have an increased risk of developing depression compared with patients with other chronic illnesses. In a nationwide case register study, all patients who had a discharge diagnosis of diabetes or of osteoarthritis at first admission in a period from 1977 to 1997 were identified. The probability of being readmitted and discharged with a diagnosis of depression was estimated with competing risks models in survival analysis. In total, 91,507 patients with a diagnosis of diabetes at first discharge and 108,487 patients with a diagnosis of osteoarthritis were identified. The median age of the populations was high. No difference in the risk of being readmitted with a diagnosis of depression was found between the two groups of patients. There was no difference in the risk for Type 1 and Type 2 diabetes. It is concluded that older patients with diabetes do not seem to have an increased risk of developing severe depression compared with patients with other chronic illness.

On the increased risk of developing late-onset epilepsy for patients with major affective disorder.

BACKGROUND: Based on register data we wanted to investigate whether patients with a diagnosis of affective disorder are at increased risk of developing epilepsy compared to other medically ill control groups. METHODS: By linkage of public hospital registers covering the whole of Denmark from 1977 to 1993, using ICD-8 diagnoses, three study cohorts were identified: Patients with first affective disorder episodes (mania and depression), patients with first osteoarthritis and patients with first diabetes discharge. Time to first diagnosis of epilepsy was estimated with the use of survival analysis. RESULTS: A total of 164,227 patients entered the study base: 13,748 patients with mania or depression, 81,380 patients with osteoarthritis and 69,149 patients with diabetes. The risk of getting a diagnosis of epilepsy was increased for patients with affective disorder compared with the risk for the control groups. However, the increased risk seemed to be due to the effect of comorbid alcohol or drug abuse and not to the effect of the affective illness itself. LIMITATIONS: The results only apply to hospitalised patients. Diagnoses are not validated for research purposes. CONCLUSION: Patients with a diagnosis of affective disorder have an increased risk of developing epilepsy in later life. In patients with affective disorder, comorbid alcoholism/drug abuse seriously increased the risk of a subsequent diagnosis of epilepsy.

Increased risk of developing dementia in patients with major affective disorders compared to patients with other medical illnesses.

BACKGROUND: The association between affective disorder and subsequent dementia is unclear. Our aim was to investigate whether patients with unipolar or bipolar affective disorder have an increased risk of developing dementia compared to patients with other chronic illnesses. METHOD: By linkage of the psychiatric and somatic nation-wide registers of all hospitalised patients in Denmark, 2007 patients with mania, 11741 patients with depression, 81380 patients with osteoarthritis and 69149 patients with diabetes were identified according to diagnosis at first-ever discharge from a psychiatric or somatic hospital between 1 January 1977 and 31 December 1993. The risk of receiving a diagnosis of dementia on subsequent re-admission was estimated with the use of survival analyses. RESULTS: Patients with unipolar or bipolar affective disorder had a greater risk of receiving a diagnosis of dementia than patients with osteoarthritis or diabetes. Differences in age and gender and the effect of alcohol- or drug-abuse did not explain these associations. CONCLUSION: Patients with unipolar or bipolar affective disorder seem to have an increased risk of developing dementia compared to patients with other illnesses. LIMITATION: The study includes only patients who have been hospitalised at least once. CLINICAL RELEVANCE: Patients with unipolar or bipolar affective disorder may be at increased risk of developing dementia.