Medication-induced dystonias in nine patients with dementia.

Evidence from previous studies of neuroleptic side effects suggests that acute dystonic reactions are rare in elderly patients. The authors report 9 cases of dystonic reactions in patients with dementia following the initiation of antipsychotic medication. The cases are important in documenting that drug-induced dystonias do occur in patients with dementia, that risperidone appears to have contributed to dystonia among elderly patients, and that the categorization of dystonic reactions needs further clarification.

Disagreement in the reporting of depressive symptoms between patients with dementia of the Alzheimer type and their collateral sources.

The authors investigated sources of disagreement on the Geriatric Depression Scale (GDS) between patients and their collateral sources (CSs). There were 198 subjects with possible or probable Alzheimer's disease (DAT) and 64 cognitively intact subjects evaluated at an outpatient geriatric assessment center. The 30-item GDS was completed by the patient and the CS version of the GDS by the CS. A sizable discrepancy was found in the reporting of depressive symptoms by the subjects vs. the CSs. Multiple-regression analyses revealed that both level of insight and level of physical illness in the subjects with DAT significantly influenced the discrepancy. An increased sense of burden in the CSs was associated with a larger symptom gap in both DAT and control subjects. CSs consistently perceived more depressive symptoms than subjects, especially subjects with DAT who had no insight into their cognitive impairment.

Maintenance electroconvulsive therapy for intractable Parkinson's disease.

The authors administered electroconvulsive therapy (ECT) to four patients with intractable Parkinson's disease who were free from depression or dementia. After an initial "acute" phase, subjects received bitemporal maintenance ECT every 3 to 4 weeks for up to 12 months. Serial measures of mood, cognition, and motor function were performed. One subject developed cognitive impairment after seven maintenance treatments, and another developed delusions during the acute phase of the study. The two subjects completing the 12-month maintenance phase noted significant reductions in "off" time without impairment of cognitive functioning.

Donepezil improves symptoms of delirium in dementia: implications for future research.

Delirium is a common complication of dementia and may produce considerable morbidity. In addition to psychotic symptoms such as hallucinations and delusions, delirium may produce considerable agitation, which may be refractory to conventional medications such as antipsychotics and benzodiazepines. The main approach to delirium is to treat any underlying medical problem that could cause the delirium. However, delirium is not always reversible, and there is no specific treatment for persistent delirium. The authors present a case of delirium complicating a preexisting dementia that resolved rapidly following initiation of the cholinesterase inhibitor donepezil, suggesting that cholinergic dysfunction may have played a role in the etiology of this patient's delirium. Future research needs to be directed at the issue of cholinergic activity in delirium through monitoring of serum anticholinergic activity and its response to procholinergic therapy.

The use of selective serotonin reuptake inhibitors for depression and psychosis complicating dementia.

This retrospective chart review examines the impact of selective serotonin reuptake inhibitors on 20 patients with both depression and psychosis complicating dementia of the Alzheimer type (DAT) and other dementias. Fifteen of the 20 patients had moderate to marked improvement in depressive and psychotic symptoms. Eleven of 12 patients with DAT had moderate to marked improvement compared to only four of eight patients with dementia from other causes. The drugs were effective in diminishing or eliminating psychotic symptoms in six patients who had previously not responded to a trial of a neuroleptic. The selective serotonin reuptake inhibitors may have an important role to play in patients with DAT who have coexisting depression and psychosis. These drugs are very well tolerated and may have a place as first-line agents in non-emergent settings where a clinician might otherwise think of instituting a neuroleptic or as a second-line agent when a neuroleptic has proven ineffective.

The reliability and validity of the collateral source version of the Geriatric Depression Rating Scale administered by telephone.

OBJECTIVE: To prospectively evaluate the reliability and validity of the Collateral Source Geriatric Depression Scale (CS-GDS) administered by telephone (T-CS-GDS) in patients undergoing outpatient comprehensive geriatric assessment. SUBJECTS: Eighty-three geriatric patients evaluated in a 1-year period at the outpatient Geriatric Assessment Center of the University of Nebraska Medical Center. METHODS: The 30-item CS-GDS was completed by the collateral source of all patients on three occasions: by telephone several days before their assessment, face-to-face during their assessment visit and several days later, again by phone. During their assessment, all patients were evaluated by one of three geriatric psychiatrists who were blinded to CS-GDS results. The test retest reliability of the T-CS-GDS was measured by comparing the results of the two phone interviews. The construct validity of the T-CS-GDS was estimated by comparing the results of the initial T-CS-GDS with the CS-GDS obtained during the comprehensive assessment. The criterion validity of the T-CS-GDS was estimated by comparing the results of the T-CS-GDS with the clinical diagnosis of depression assigned by the psychiatrists. RESULTS: The individual items of the initial T-CS-GDS showed substantial concordance with the second T-CS-GDS (kappa range 0.41-0.8, mean = 0.61) and with the assessment GDS (kappa range 0.33-0.85, mean = 0.61). Twelve items showed evidence of bias when comparing the two T-CS-GDSs and four items when comparing the initial T-CS-GDS with the CS-GDS done during the assessment. The mean number of symptomatic responses was not significantly different for the T-CS-GDS vs assessment administration but did decline slightly when comparing the two T-CS-GDSs. ROC curve analysis showed good agreement between the clinical diagnosis and the T-CS-GDS. CONCLUSION: The CS-GDS appears to maintain its reliability and validity when administered via telephone and thus may be useful for a variety of epidemiologic and clinical purposes.

The reliability and validity of the Geriatric Depression Rating Scale administered by telephone.

OBJECTIVE: To evaluate prospectively the reliability and validity of the Geriatric Depression Scale administered by telephone (T-GDS) in patients undergoing outpatient comprehensive geriatric assessment. SUBJECTS: A total of 101 geriatric patients were evaluated in a 1-year period at the outpatient Geriatric Assessment Center of the University of Nebraska Medical Center. METHODS: The 30-item GDS was completed by all patients on three occasions: by telephone several days before their assessment, face-to-face during their assessment visit, and several days later, again by phone. During their assessment, all patients were evaluated by one of three geriatric psychiatrists who were blind to all GDS results. The test-retest reliability of the T-GDS was measured by comparing the results of the two phone interviews. The construct validity of the T-GDS was estimated by comparing the results of the initial T-GDS to the GDS obtained during the comprehensive assessment. The criterion validity of the T-GDS was estimated by comparing the results of the T-GDS with the clinical diagnosis of depression assigned by the psychiatrists. RESULTS: The individual items of the initial T-GDS showed substantial concordance with the second T-GDS (kappa range 0.35-0.75, mean = 0.52), and with the assessment GDS (kappa range 0.29-0.75, mean = 0.52). One item showed evidence of bias when comparing the two T-GDSs, and two items when comparing the initial T-GDS to the GDS done during the assessment. The mean number of symptomatic responses was not significantly different for the T-GDS versus assessment administration but did decline slightly when comparing the two T-GDSs. ROC curve analyses showed good agreement between the clinical diagnosis and the T-GDS. CONCLUSION: The GDS appears to maintain its reliability and validity when administered via telephone and thus may be useful for a variety of epidemiological and clinical purposes.

Reliability and validity of the Short Portable Mental Status Questionnaire administered by telephone.

Effective, economical, and reliable means of screening subjects for cognitive impairment when personal contact is not feasible could facilitate epidemiologic studies and longitudinal assessment. The Short Portable Mental Status Questionnaire (SPMSQ) is a 10-item examination that has been found reliable and valid in distinguishing demented subjects from cognitively intact subjects when given face to face. The current study assessed the utility of a telephone version of the SPMSQ in patients evaluated in an outpatient geriatric assessment program. Mean scores for both test versions decreased with dementia severity and correlated significantly. Mean score differences between the two versions were not affected by reports of hearing impairment or the time interval between test administration. Both test versions correlated significantly with the Mini-Mental State Examination. In distinguishing demented from nondemented subjects, sensitivity and specificity were .74 and .79 for the telephone test and .74 and .91 for the face-to-face test, respectively.

L-deprenyl in the treatment of mild dementia of the Alzheimer type: results of a 15-month trial.

OBJECTIVE: To examine the cognitive and behavioral effects of L-deprenyl in persons with mild dementia of the Alzheimer type (DAT) over a 15-month period. DESIGN: A 15-month randomized, double-blind, placebo-controlled trial using a parallel-group design. PARTICIPANTS: 39 subjects with mild DAT (CDR 1) selected using NINCDS-ADRDA criteria. OUTCOME MEASURES: A battery of neuropsychological tests and clinical rating scales. RESULTS: The placebo and L-deprenyl subjects were similar at baseline on the clinical and neuropsychological tests. The total score on the Brief Psychiatric Rating Scale (BPRS) was significantly less after 15 months in subjects taking L-deprenyl. The only individual item of the BPRS which differed between groups was disorientation. There was no evidence of a L-deprenyl effect on any other clinical or neuropsychological measure after 2, 8, or 15 months. CONCLUSION: L-deprenyl did appear to have a slight effect on a single measure of psychopathology, the BPRS. It did not have a measurable impact on any other measure of behavior or cognitive function over a 15-month period in this group of subjects with mild DAT and did not appear to slow the progression of the disease.

L-deprenyl in the treatment of mild dementia of the Alzheimer type: preliminary results.

OBJECTIVE: To examine the short-term cognitive and behavioral effects of L-deprenyl in persons with mild dementia of the Alzheimer type (DAT) over a 2-month period. DESIGN: A 15-month randomized, double-blind, placebo-controlled trial using a parallel-group design. This report deals with the first 2 months of the trial. PARTICIPANTS: 39 subjects with mild DAT (CDR 1) selected using NINCDS-ADRDA criteria. MEASURES: A battery of neuropsychological tests and clinical rating scales. RESULTS: The placebo and L-deprenyl subjects were similar at baseline on the clinical and neuropsychological tests. There was no evidence of a L-deprenyl effect on any clinical or neuropsychological measures after 2 months. CONCLUSION: L-deprenyl did not have a measurable impact on behavior or cognitive function over a 2-month period in this group of subjects with mild DAT.

A prospective evaluation of the Geriatric Depression Scale in an outpatient geriatric assessment center.

OBJECTIVE: To prospectively evaluate the Geriatric Depression Scale (GDS) in cognitively intact and impaired patients undergoing outpatient geriatric assessment. SUBJECTS: One hundred ninety-four geriatric patients evaluated in a 1-year period. SETTING: The outpatient Geriatric Assessment Center of the University of Nebraska Medical Center. MEASUREMENTS: The 30-item GDS was completed by all patients. The patients were then evaluated by one of three geriatric psychiatrists who were blind to the GDS results. The prospective clinical diagnosis of major depression was compared to the GDS results. Patients were categorized as cognitively impaired or intact on the basis of the Mini-Mental State Examination. Data were analyzed using ROC curves. An optimal cutoff was identified which was the total score on the GDS with the highest combined sensitivity and specificity. RESULTS: ROC curve analyses showed good agreement between the clinical diagnosis and the GDS in both cognitively intact and impaired subjects. Cognitively intact, euthymic patients reported a mean of 8.4 symptoms, while cognitively impaired, euthymic patients, reported a mean of 8.7. Cognitively intact, depressed patients reported a mean of 14.7 symptoms, while cognitively impaired, depressed patients reported a mean of 15.0. CONCLUSIONS: This study provides further evidence that the GDS is as accurate a screening test for depression in cognitively impaired as in intact patients.

Validation of a telephone version of the mini-mental state examination.

OBJECTIVE: To assess the construct validity of a telephone-administered version of the Mini-Mental State Examination (MMSE). DESIGN: Validity testing by comparing a telephone version of the MMSE administered first to a face-to-face evaluation done several days later. SETTING: Outpatient geriatric assessment center. SUBJECTS: 100 of 175 consecutive referrals. MAIN OUTCOME MEASURES: MMSE and a brief neuropsychological screening test (BNPS) face-to-face and a telephone version of the MMSE as part of the Adult Lifestyles and Function Interview (ALFI-MMSE). RESULTS: Test scores of the two MMSE versions correlated strongly for all subjects (Pearson's r = 0.85, P = 0.001) and remained significant for the cognitively intact (P = 0.02) and questionably (P = 0.002), mildly (P = 0.0001), and moderately (P = 0.003) demented. Comparison of the two versions' equivalent 22 items revealed no significant difference for scores of all subjects (P = 0.07) but with a trend toward higher scores in the original version. Diminished hearing, reported either by the subject (P = 0.003) or by the collateral source (P = 0.02) was associated with lower scores on the telephone version. Five individual test items were biased by the route of test administration. Sensitivity and specificity relative to the BNPS were 67% and 100% for the ALFI-MMSE and 68% and 100% for the MMSE, respectively. CONCLUSION: The scores on the ALFI-MMSE correlated strongly with the scores of the original version given face-to-face in subjects undergoing geriatric assessment. The results indicate that the ALFI-MMSE could be a useful and economical tool to screen for cognitive impairment.

The short form of the Geriatric Depression Scale: a comparison with the 30-item form.

The Geriatric Depression Scale (GDS) exists in both short and long forms. The original 30-item form of the GDS has been shown to be an effective screening test for depression in a variety of settings. However, its utility in patients with dementia of the Alzheimer type (DAT) is questionable. The short, 15-item version of the GDS was developed primarily for brevity and, in particular, for use in populations such as the medically ill or those with dementia, where the longer form might be burdensome. How well this short form works in these populations, however, is largely undetermined. In this paper, the sensitivity and specificity of the 15- and 30-item GDS are compared in a group of patients who were either cognitively intact or had mild DAT. The findings suggest that the short version of the GDS, like its longer predecessor, is an effective screening tool in the cognitively intact. However, in a population of subjects with mild DAT, it does not appear to retain its validity.

Musical hallucinations. The sounds of silence?

Hallucinations may occur in any sensory modality. Auditory hallucinations, usually ascribed to psychiatric illness, take various forms including the perception of voices, cries, noises, or rarely, music. Formed musical hallucinations, (ie, the perception of either vocal or instrumental melodies), reported in the English literature to date have typically been associated with marked hearing loss, advanced age (average 67.8 years), female sex (71%), lack of response to treatment, and general lack of associated psychopathology. We have collected data on seven additional patients with musical hallucinations. The average age of these patients was 72.9 years; all were women. Six had significant hearing problems. All reported onset of musical hallucinations after the age of 60. Interestingly, all seven had major psychiatric illnesses. Four had major depression, two had late-onset schizophrenia, and one had multi-infarct dementia. Of the five who had CT scans, one was normal and the rest demonstrated varying degrees of brain pathology. Neuroleptics were used with varying results in three cases; antidepressants were used in two depressed patients and were temporally related to the onset of musical hallucinations in one patient. Electroconvulsive therapy (ECT) was very effective in treating depression and musical hallucinations in the three patients for whom it was used, usually providing relief from hallucinations after only two treatments. Our collection of cases demonstrates that musical hallucinations can occur in association with psychiatric illness, and perhaps unlike the hallucinations associated with isolated hearing loss, may respond to conventional treatments for the underlying psychiatric disorder. Hearing loss is neither a necessary nor sufficient condition for the occurrence of musical hallucinations.

Characteristics of elderly patients admitted for the first time to a psychiatric facility.

There has been little investigation of patients admitted to a psychiatric facility for the first time late in life. We therefore examined characteristics of a group of 100 consecutive patients over the age of 65, admitted for the first time to the psychiatric service of a private, university-affiliated hospital. Almost two thirds of these patients received a primary discharge diagnosis of major depression, while another one fourth received a diagnosis of dementia. Patients with dementia were significantly older and more likely to be men. The frequency of dementia climbed with each decile affecting 15% of those less than 75 years, 39% of those 75 to 84, and 47% of those over age 85. Thirty-six percent of all patients were psychotic on admission, including 28% of those with major depression and 48% of those with dementia. Visual hallucinations were significantly more common in the group with dementia. In turn, eye disease was significantly more common in those with visual hallucinations. Nine patients were admitted with a history of recent assaultive behavior. Four of these were psychotic and eight of nine were demented. Five patients had attempted suicide prior to their admission. All were diagnosed as having major depression.