Daniel D. Sewell

Anxiety, depression and disability across the lifespan

The authors examined the relationship between anxiety, depression and physical disability, after controlling for demographic and health variables, in a sample of 374 adults aged 18–94. Results indicate that anxiety, depression and comorbid anxiety and depression are associated with higher levels of disability, after controlling for factors such as age, gender, income, self-rated health, number of medical conditions and number of physician visits in the past year. Furthermore, anxiety, depression and comorbid anxiety and depression have a differential effect on disability according to age, with older adults with any of these symptoms reporting higher levels of disability than younger adults. These findings suggest that physicians working with older adults should assess for and treat anxiety as well as depressive symptoms.

Older adults are less accurate than younger adults at identifying symptoms of anxiety and depression.

The present study examined age differences in the identification of anxiety and depressive symptoms in a community sample of 374 adults, ages 18 to 93. Older adults were less accurate and more likely than younger adults to label symptoms as neither anxiety nor depression. Both older and younger adults were more accurate in their classification of depressive than anxiety symptoms. These findings suggest that additional efforts are needed to educate the general public, particularly older adults, about anxiety and its symptoms.

Neuroleptic treatment of HIV-associated psychosis

The aim of this rater-blinded randomized study was to evaluate the efficacy and side effects of haloperidol and thioridazine in the treatment of new-onset psychosis in HIV-positive individuals. Participants were 13 men who had no history of psychosis prior to infection with HIV, and whose psychosis was not attributable to delirium or to non-HIV-related organic factors. Participants were evaluated at baseline after at least one month without neuroleptic treatment and then weekly for six weeks of the experimental treatment using several rating scales. The mean daily dose in chlorpromazine equivalents was 124 mg. Both neuroleptics produced modest but significant reduction in overall level of psychosis and in positive symptoms, but not in negative symptoms. All the haloperidol-treated patients developed extrapyramidal side effects and required treatment with anticholinergic medication, whereas three of the five thioridazine-treated patients had noticeable side effects. We make recommendations for the treatment of HIV-associated psychosis with neuroleptics.

Metoclopramide and Tardive Dyskinesia

Metoclopramide (MCP) is a D-2 receptor blocker (Kebabian and Calne 1979), which has been available by prescription in the United States since 1979 for use as an antiemetic in a wide range of situations. One of the common indications for MCP is the e Woerner et al1993). There have been case reports but few systematic studies of MCP-associated TD (Sewell et al 1992; Sewell and Jeste 1992; Ganzini et a1 1993). We present hkre preliminary results of a clinical study of MCPassociated TD. We wished to study the frequency of dy&esia in patients with a history of exposure to MCP compared to a non MCP-treated comparison group. We also wished to study localization and course of MCP-associated TD, as well as factors such as the diagnosis of diabetes mellitus which might be associated with an increased risk of TD.

Unrecognized Medical Disorders in Older Psychiatric Inpatients in a Senior Behavioral Health Unit in a University Hospital

Medical disorders may cause psychiatric symptoms. This study investigated the frequency and nature of previously unrecognized medical disorders associated with behavioral disturbances in acute geriatric psychiatry inpatients. Data came from a chart review of 79 consecutive admissions to the University of California, San Diego, Senior Behavioral Health Unit from May 1999 to October 1999. The most common Axis I admission diagnoses were depression and psychosis. At admission, 27 of 79 cases (34%) had unrecognized medical disorders. Comparison of these cases with the cases that did not have unrecognized medical disorders found no differences in age, education, gender, or cognitive abilities. The group with unrecognized medical disorders had more medical disorders (mean 5.0 vs 3.6; P = .002). Unrecognized conditions (n) included constipation (7), urinary infection (7), and hypothyroidism (5). Elderly psychiatric patients are more likely to have physical comorbidity. A large number of medical disorders should alert clinicians to look carefully for unrecognized medical disorders. (J Geriatr Psychiatry Neurol 2003; 16:121-125)

Factors Associated With Frequent Admissions to an Acute Geriatric Psychiatric Inpatient Unit

As a first step toward developing strategies to reduce the frequency of psychiatric hospitalizations, the authors retrospectively collected and analyzed demographic and clinical variables from 424 consecutive admissions to a university-based geriatric psychiatry inpatient unit over a 20-month period. The study sample was dichotomized into patients who were admitted more than one time (35.6%) versus those with a single admission. Factors associated with rehospitalization were examined with multivariate logistic regression analysis. The great majority of readmissions (81%) occurred in the first 3 months after discharge. The logistic regression model indicated that significant predictors of rehospitalization were single relationship status, male gender, and bipolar disorder diagnosis. Our findings overlap with findings from previous similar studies and suggest that information readily obtainable on admission to an acute geriatric psychiatry inpatient unit may provide a useful indication of risk for frequent psychiatric hospitalizations and may contribute to readmission prevention strategies.

Lamotrigine for agitation in older patients with dementia.

Although not approved by the Food and Drug Administration (FDA) for behavioral disturbances, the largest number of antipsychotic prescriptions in older adults is for this indication associated with dementia (Sultzer et al ., 2008). In 2005, the FDA determined that atypical antipsychotic medications were associated with a 1.6 to 1.7 greater risk of mortality compared with placebo when administered to older patients with dementia (De-Deyn et al ., 2005). Psychosis and agitation symptoms in patients with dementia are common, disruptive, and costly but there are no well-established, evidenced-based effective treatment alternatives (Jeste et al ., (2008). A limited amount of mostly anecdotal scientific data suggests that anticonvulsant medications, including some of the newer agents like lamotrigine, may be helpful for agitation and psychosis in older patients with dementia (DeLeon, 2004). Lamotrigine is an anti-epileptic drug whose mechanism of action is thought to be linked to voltage-sensitive sodium channel blockade in the neuronal membrane and inhibition of presynaptic glutamate and aspartate release (Baumann et al ., 2007). Lamotrigine has a safe profile and has documented efficacy in delaying recurrence of mood episodes in patients with bipolar disorder in trials conducted for up to 18 months.

Reduction of suboptimal prescribing and clinical outcome for dementia patients in a senior behavioral health inpatient unit

BACKGROUND Suboptimal prescribing in older psychiatric patients causes iatrogenic morbidity. The objectives of this study were to compare the prevalence of suboptimal prescribing before and after admission to a geropsychiatry inpatient unit and to evaluate a possible correlation between optimal medication use and functional improvement in patients with dementia. METHODS The study sample comprised 118 consecutively admitted patients to a 14-bed university hospital-based geropsychiatry inpatient unit over a period of 20 months who met the DSM-IVTR criteria for an Axis I psychiatric illness and co-morbid dementia. At admission demographic information, Mini-mental State Examination (MMSE) Score, Mattis Dementia Rating Scale Score (DRS), and number of active medical illnesses were recorded. At admission and discharge the number and type of medications, number of Revised Beers Criteria (RBC) medications (a published list of potentially inappropriate medications in older adults independent of diagnoses or conditions), Global Assessment of Functioning (GAF) scores, and Scale of Functioning (SOF) scores were tabulated. chi2 tests, paired t-tests and Pearson correlations were used to test the medication prevalence and associations between measures of clinical function and other variables. RESULTS The mean age (standard deviation) of the sample was 81.5 (6.2) years. The mean scores on the MMSE and DRS were 22.1 (6.2) and 116.6 (18.7), respectively. From admission to discharge, the mean number of RBC medications per patient decreased significantly from 0.8 (1.1) to 0.4 (0.6). There was also a significant correlation between reduction in Beers criteria medications and improved SOF score from time of admission to time of discharge. CONCLUSION Suboptimal medication use is a potential source of decreased function in older patients with dementia.

The Clock Drawing Test as a Measure of Executive Dysfunction in Elderly Depressed Patients

The aims of this research were to determine whether performance on the Clock Drawing Test (CDT) could accurately distinguish between older patients with depression and older patients with depression and previously undocumented executive dysfunction and to determine if there was a correlation between CDT and depression severity. The authors studied 52 patients consecutively admitted to a geriatric psychiatry inpatient unit of a university hospital who met DSM-IVcriteria for major depression or depression not otherwise specified but had no concurrent diagnosis of dementia. All the subjects completed the Mini-Mental State Examination (MMSE), Mattis Dementia Rating Scale (DRS), and the CDT, as well as the Geriatric Depression Scale (GDS). The patients were divided into 2 subgroups based on the DRS score: <129 (cognitive impairment) versus = 129. Results indicated that the depressed patients with a score of DRS <129 had significantly lower CDT scores than did patients with DRS = 129 and normal comparison subjects (P< .01). The results support the hypothesis that CDT score is lower in elderly depressed patients with executive dysfunction versus nondepressed seniors as well as depressed patients without executive dysfunction.

The Mental Health of Older LGBT Adults

There are approximately one million older lesbian, gay, bisexual, and transgender (LGBT) adults in the USA. Their mental health issues result from interactions between genetic factors and stress associated with membership in a sexual minority group. Although advancements in acceptance and equal treatment of LGBT individuals have been occurring, sexual minority status remains associated with risks to physical and mental well-being. Older LGBT adults are more likely to have experienced mistreatment and discrimination due to living a majority of their lives prior to recent advancements in acceptance and equal treatment. All LGBT adults experience one common developmental challenge: deciding if, when, and how to reveal to others their gender identity and/or sexual orientation. LGBT individuals have higher rates of anxiety, depression, and substance use disorders and also are at increased risk for certain medical conditions like obesity, breast cancer, and human immunodeficiency virus (HIV). Improved education and training of clinicians, coupled with clinical research efforts, holds the promise of improved overall health and life quality for older LGBT adults.