Electroconvulsive Therapy in a Patient With a Liver Transplant.

Depression is common in patients after liver transplantation and, when severe, can threaten both viability of the graft and the patient's life. Electroconvulsive therapy (ECT) is a safe and highly effective therapy for severe depression, but there have been very few reports of its use in liver transplant recipients. We describe a patient who had undergone a successful orthotopic liver transplant 26 years previously, who developed severe major depression. The patient tolerated an index course of ECT well and responded robustly. There were no complications pertinent to the graft or otherwise. Liver transplantation is not a contraindication to ECT, and clinicians should not hesitate to proceed when necessary.

Postviral Depression.

A previously healthy 68-year-old man rapidly developed a severe melancholic depression following influenza infection. There is an evolving understanding of the complex and possibly bidirectional relationship between depression and inflammation. We review the literature concerning this relationship in the context of viral infection and discuss possible implications for treatment.

Trazodone Treatment of Bruxism in a Patient With Severe Dementia.

OBJECTIVES: The objective of this study was to report the effectiveness of trazodone for treatment of bruxism in dementia. METHODS: A single case study of a 66-year-old man with severe vascular dementia and awake bruxism was performed. RESULTS: The patient's bruxism responded robustly to titration of trazodone. He tolerated the medication with no untoward sedation or other adverse effects. CONCLUSIONS: Bruxism is occasionally encountered in patients with advanced dementia and raises concerns about nutritional compromise and about potential need for poorly tolerated dental treatment. Trazodone may potentially be effective for bruxism in some patients.

Lithium for Carbamazepine-Induced Syndrome of Inappropriate Antidiuretic Hormone.

OBJECTIVES: To examine the effectiveness of low-dose lithium carbonate for managing carbamazepine-induced hyponatremia. METHODS: Single case study in an 88 year old man with bipolar illness and vascular dementia who had failed to respond to other mood stabilizers. RESULTS: The patient had developed hyponatremia on two separate occasions when treated with carbamazepine. Introduction of low-dose lithium resulted in prompt normalization of serum sodium levels, which was maintained for the subsequent 8 weeks. CONCLUSIONS: Carbamazepine may sometimes be the best or only viable treatment option for patients with bipolar illness or other conditions. When its use is complicated by syndrome of inappropriate ADH, dose reduction and fluid restriction are the simplest options but, if ineffective, addition of lithium may be a feasible, albeit somewhat complicated, alternative.

Chronic Microaspiration and Frailty: A Geriatric Smoking Gun?

Chronic microaspiration and diffuse aspiration bronchiolitis may account for some otherwise unexplained frailty in nursing home patients.

Palliative Care for Dementia: 2020 Update.

Dementia management is complicated by neuropsychiatric symptoms such that the longitudinal care of a psychiatrist or other mental health provider is often an essential part of patient care and a major source of family support. Given the importance of end-of-life continuity of care, the involvement of psychiatry in palliative and hospice services affords an important opportunity for growth. Common challenges involve sharing prognostic information with patients and families to aid in advance planning, and management of persistent pain and nutritional issues. Future research will yield important new insights and guidelines for care.

Aripiprazole and Delusional Disorder.

Delusional disorder is a relatively rare psychotic illness characterized by delusions with contents that are theoretically possible but highly unlikely, and an absence of the disorganized thought and negative symptoms characteristic of schizophrenia. The illness is rarely studied systematically and most guidance with regard to the treatment derives from case reports and small case series. Antipsychotic medications are the mainstay of treatment, but it is not clear whether any particular agent is more effective than others. We report the case of a patient with delusional disorder who had failed to respond to risperidone but improved markedly with aripiprazole. Aripiprazole may show promise as a treatment for delusional disorder, possibly as a result of its effects on both dopaminergic and serotonergic receptors.

A Case of Musical Hallucinations Related to Mirtazapine.

Musical hallucinations (MHs) are relatively uncommon phenomena sometimes encountered in older patients, especially older women. They usually involve popular, overlearned music, either entire songs or repetitive snippets. While MHs are most commonly associated with hearing loss, they may occur in a variety of psychiatric, neurologic, and iatrogenic conditions. We report a 91-year-old man whose MHs were causally related to the antidepressant mirtazapine. Although mirtazapine is generally well tolerated, it may rarely cause MHs or other psychotic symptoms.

Palliative Care for Dementia.

With the growing care needs for the older population at the end of their lives, there has been a substantial increase in attention to the management of the patient with dementia in hospice and palliative care services. This article reviews issues in access to care and the optimal management of the patient with dementia, particularly in the context of neuropsychiatric complexities. Special issues such as delirium, cachexia, behavioral symptoms, and pain management are addressed. Future challenges in research such as the development of better prognostic models are noted as well as the importance of attention to access to care.

Carbamazepine Treatment of Hyperactivity and Intrusiveness in Dementia.

Behavioral problems are seen in most patients with dementia and are often poorly characterized in the literature. We present a 70-year-old man with advanced Alzheimer disease and problematic disinhibited behaviors, including intrusiveness and Witzelsucht (disinhibited humor). These symptoms responded robustly to carbamazepine. Carbamazepine may be a useful adjunct in managing problematic behaviors in dementia, especially when those problems can be framed as behavioral disinhibition.

Swallowing Disorders in Schizophrenia.

Disorders of swallowing are poorly characterized but quite common in schizophrenia. They are a source of considerable morbidity and mortality in this population, generally as a result of either acute asphyxia from airway obstruction or more insidious aspiration and pneumonia. The death rate from acute asphyxia may be as high as one hundred times that of the general population. Most swallowing disorders in schizophrenia seem to fall into one of two categories, changes in eating and swallowing due to the illness itself and changes related to psychotropic medications. Behavioral changes related to the illness are poorly understood and often involve eating too quickly or taking inappropriately large boluses of food. Iatrogenic problems are mostly related to drug-induced extrapyramidal side effects, including drug-induced parkinsonism, dystonia, and tardive dyskinesia, but may also include xerostomia, sialorrhea, and changes related to sedation. This paper will provide an overview of common swallowing problems encountered in patients with schizophrenia, their pathophysiology, and management. While there is a scarcity of quality evidence in the literature, a thorough history and examination will generally elucidate the predominant problem or problems, often leading to effective management strategies.

PEG and Thickeners: A Critical Interaction Between Polyethylene Glycol Laxative and Starch-Based Thickeners.

Clinicians commonly encounter dysphagia and constipation in a skilled nursing population. Increasing the viscosity of liquids, usually with a starch- or xanthan gum-based thickener, serves as a key intervention for patients with dysphagia. We report a newly identified and potentially dangerous interaction between polyethylene glycol 3350 laxative (PEG) and starch-thickened liquids. A patient requiring nectar-thickened liquids became constipated, and medical staff prescribed PEG for constipation. His nurse observed that the thickened apple juice immediately thinned to near-water consistency when PEG was added. She obtained the same results with thickened water and coffee. We quantified this phenomenon by isothermal rotational rheology. Results confirmed a precipitous loss of thickening when PEG was added to starch-based thickeners but not with xanthan gum-based thickeners. Clinicians and front-line staff should be aware of this potentially critical interaction between PEG- and starch-based thickeners. Although confirmatory studies are needed, our preliminary data suggest that PEG may be compatible with xanthan gum-- based thickeners.