Ana Hategan

Heart transplant, social support, and psychiatric sequelae: a 10-year follow-up clinical case review.

The authors document a case of a 65-year-old heart transplant recipient at 10-year follow-up, with particular reference to his psychiatric recovery. This case illustrates the importance of social support as both an acute intervention and for long-term maintenance in the heart-transplant patient with psychiatric and multiple medical conditions. It was found that the influence of social support on transplant recovery may be affected by critical periods, including initial postoperative stabilization and convalescence, and then again with longer-term changes in social roles. Enhanced collaboration between cardiac transplant teams and mental health professionals is warranted.

Competency-based medical education and scholarship: Creating an active academic culture during residency

The competency-based medical education movement has been adopted in several medical education systems across the world. This has the potential to result in a more active involvement of residents in the educational process, inasmuch as scholarship is regarded as a major area of competency. Substantial scholarly activities are well within the reach of motivated residents, especially when faculty members provide sufficient mentoring. These academically empowered residents have the advantage of early experience in the areas of scholarly discovery, integration, application, and teaching. Herein, the authors review the importance of instituting the germinal stages of scholarly productivity in the creation of an active scholarly culture during residency. Clear and consistent institutional and departmental strategies to promote scholarly development during residency are highly encouraged.

The Role of Nutrient-Based Epigenetic Changes in Buffering Against Stress, Aging, and Alzheimer’s Disease

Converging evidence identifies stress-related disorders as putative risk factors for Alzheimer Disease (AD). This article reviews evidence on the complex interplay of stress, aging, and genes-epigenetics interactions. The recent classification of AD into preclinical, mild cognitive impairment, and AD offers a window for intervention to prevent, delay, or modify the course of AD. Evidence in support of the cognitive effects of epigenetics-diet, and nutraceuticals is reviewed. A proactive epigenetics diet and nutraceuticals program holds promise as potential buffer against the negative impact of aging and stress responses on cognition, and can optimize vascular, metabolic, and brain health in the community.

Donepezil-associated manic episode with psychotic features: a case report and review of the literature☆

OBJECTIVE Reports of manic episodes associated with the use of cholinesterase inhibitors (including donepezil) are limited. Despite the previous notion of procholinergic drugs potentially inducing depression, the contemporary evidence for cholinesterase inhibitors appears to also indicate a trend for elevated mood (in patients with or without a history of depressive disorder). METHOD Case report. RESULTS The authors report a case of a manic episode with psychotic features associated with the up-titration of donepezil in a patient with Alzheimers disease and a distant history of major depression but without a preexisting bipolar disorder. CONCLUSION Pathophysiology of donepezil-induced mania appears to contradict the traditional cholinergic-adrenergic hypothesis. Donepezil-associated mania should be suspected after donepezil initiation/dose up-titration when correlated to new onset of mania. Donepezil should be used more cautiously in patients with current or previous mood episodes or in those who are otherwise at high risk for manic episodes (e.g., cerebrovascular disease). Although this requires further investigation in different patient populations, there may be subtypes of older patients with neurocognitive disorders who are particularly vulnerable to activation effects of cholinesterase inhibitors.

The Chief Psychiatric Complaints

In this chapter, we review the chief psychiatric complaints encountered in geriatric patients in crisis and the initial intervention relevant to on-call and crisis situations. We hope to familiarize medical students, residents, practicing physicians, and allied mental health professionals with some of the high-risk clinical scenarios that they are likely to encounter while on call and on out-of-hours duties, in the provision of safe and effective patient care in the geriatric psychiatric population.

Harnessing neuroplasticity in Diogenes syndrome: A proposed mechanism to explain clinical improvement☆

Extreme neglect of ones living space and self-care is a perplexing condition termed Diogenes syndrome, where outcomes of intervention are often poor, with high relapse and mortality rates. Relatively little has been reported regarding management approaches. We present a case of Diogenes syndrome responsive to a structured behavioral paradigm during a hospital admission and speculate on the mechanism of neuroplasticity-based behavioral treatment in facilitating clinical improvement.

Neuropsychiatric Symptoms in Scleroderma

Systemic sclerosis (SSc; scleroderma), a rare disorder of connective tissue characterized by widespread organ dysfunction due to fibrosis and ischemia, is marked by the overproduction and abnormal deposition of collagen. The brain parenchyma itself is largely collagen-free and, thus, primary central nervous system (CNS) involvement in SSc is believed to be rare, although peripheral neuropathy is common. However, SSc is known to cause widespread microvascular damage, which may be a plausible mechanism for the neuropsychiatric symptoms of mood, anxiety, and cognitive disorders that have been documented in SSc patients. Thus, SSc may be a systemic cause of vascular cognitive impairment and should be considered in the diagnosis of vascular dementia. The current case report illustrates a potential vascular connection between SSc and neuropsychiatric symptoms. The classification of SSc includes limited and diffuse forms. The limited form includes the CREST variant, an acronym for Calcinosis, Raynaud phenomena, Esophageal dysmotility, Sclerodactyly, and Telangiectasias. The diffuse form features widespread collagen deposition resulting in dermatological thickening and fibrosis in the lungs, heart, kidneys, and gastrointestinal tract. However, CNS involvement has been less often documented. Although microangiopathy is the principal pathogenic marker of the disease, more recently some attention has also been paid to macrovascular abnormalities. Therefore, CNS manifestations in SSc may be due to primary cerebrovascular changes or hypertension. It is known that vascular dementia is a frequent consequence of small and/or large vessel disease. Many subtypes of vascular dementia have been described; however, regardless of the subtype, hypertension is the most common cause. Less common causes include hypoperfusion due to large vessel and/or cardiac disease and other systemic vasculopathic syndromes (e.g., polyarteritis nodosa) leading to multiple infarcts that can lead to vascular dementia. SSc, although perhaps even less common cause, may also manifest clinically as vascular cognitive impairment.

Hypovitaminosis D in Delirium: a Retrospective Cross-sectional Study

Background As vitamin D may have a neuroprotective effect, the authors studied the association of biomarkers of vitamin D status and delirium to see if low vitamin D status was common in delirium cases. Methods Biochemical measures of vitamin D (25-hydroxyvitamin D [25-OHD]) and calcium metabolism were used in this retrospective cross-sectional analysis of adult in-patients with delirium, admitted at three Canadian academic hospitals from January 2011 to July 2012. Primary outcome was to determine estimates of the prevalence of hypovitaminosis D in this group in whom vitamin D was checked. Results Seventy-one (5.8%) out of 1,232 delirium inpatients had their vitamin D measured. Thirty-nine (55%) showed vitamin D insufficiency (25-OHD of 25-75 nmol/L) and 8 (11%) showed vitamin D deficiency (25-OHD < 25 nmol/L). Mean serum 25-OHD levels were lower in males (57.1±7.7 nmol/L) than in females (78.2±6.1 nmol/L), p = .01, even when controlled for age and season. Men were younger than the women (74.4±2.3 vs. 82.4±1.7, p = .005). Mean age was 78.7±1.5 years, and 33 (47%) were male. Conclusions Although vitamin D is rarely checked during delirium workup and/or management, high rates of hypovitaminosis D were found to be common in the delirium in-patients in whom it was checked. Larger studies would be needed to estimate the prevalence of hypovitaminosis D in delirium and whether hypovitaminosis D plays a role in the pathogenesis of delirium.

Sexuality and Sexual Dysfunction in Later Life

There has been a positive correlation between sexual activity and physical health, mental health, and overall quality of life. Sexual needs in later life appear to be similar to those in adult life with variations in frequency, intensity, and mode of expression. There are a number of societal, ideological, institutional, and physiological factors that can create barriers for adults in later life to achieve sexual expression. It is therefore important to acknowledge the changing nature of sexuality as one ages and not to pathologize it. A sexual dysfunction relates to any issue that arises during one of the stages of the sexual response cycle, which can be a common issue for both males and females especially during the aging process. Inappropriate sexual behaviors in institutionalized settings are more likely to occur in patients with major neurocognitive disorders. Because there is a need to balance autonomy rights of older patients while avoiding paternalism in institutionalized settings, ensuring the safety of patients and other sexual partners is paramount. Clinicians and other healthcare personnel working with older adults need to remain well-informed of legal and ethical issues related to the right to consensual sexual activity, which are discussed in this chapter.

Ethics, Mental Health Law, and Aging

The number of older adults has been steadily increasing globally over the past few decades. At the same time, there has been an increasing population of older individuals who suffer from psychiatric illness. This chapter provides some insights and strategies for clinicians who work with this vulnerable population from the perspective of mental health law and ethical theories, principles, and frameworks. While the theory of “therapeutic jurisprudence” has been applied to mental health law, some have suggested that an analogous term “geriatric jurisprudence” has emerged to address the legal and ethical challenges facing this vulnerable group. The issues canvassed in this chapter are non-exhaustive and intended to highlight common ethical themes around how to balance competing rights and ethical dilemmas, including autonomy, self-determination, and liberty with the need for societal values, such as public safety and protection of vulnerable persons. Specific topics include decisional capacity assessments, informed consent, advance directives, guardianship, involuntary commitment, elder abuse, and end-of-life decision-making. The chapter further explores ethical factors related to the use of technology in clinical practice with a geriatric population.