David A. Casey

Schizophrenia: medical illness, mortality, and aging.

Objective: Schizophrenia is a devastating and common psychiatric disorder which is associated with a high degree of medical morbidity and reduced life span in addition to psychosis. In this article, these problems will be discussed in the context of schizophrenia and aging. Method: The recent literature was reviewed using Pubmed, Medline, and Google scholar with the search terms “schizophrenia, aging, medical problems.” Results: Schizophrenia is associated with significant medical morbidity and mortality. Diabetes and cardiovascular disease, along with smoking and obesity, are over-represented and contribute to reduced quality of life and life span. Schizophrenics often receive poor medical care. Conclusions: The impacts of schizophrenia on physical health and successful aging have been underestimated. Psychiatrists and primary care physicians need to address the overlapping medical and psychiatric aspects of the disorder while the medical care system for these patients requires a much higher degree of coordination than is currently available.

Electroconvulsive therapy in the very old.

At least one study has questioned the safety of electroconvulsive therapy (ECT) in the very old. In this study, the authors reviewed a 5-year experience with ECT at two university psychiatric services for patients 75 years of age or older. Both outcomes and complications were reviewed. Nineteen of 22 patients (86.3%) were ECT responders. Five patients (22.7%) suffered complications which varied from minor to substantial. ECT was found to be an effective and reasonably safe treatment for depression in the very old.

Axis II diagnoses in geriatric inpatients.

Little is known about personality disorders in the elderly. Review of 100 consecutive inpatient admissions revealed that 70% received an Axis II diagnosis of personality disorder. Sixteen percent received a diagnosis of personality disorder trait. (J Geriatr Psychiatry Neurol 1989;2:87-88).

Depression in the elderly: A review and update

Depression is a major source of suffering and disability among the elderly. It may be overlooked among elders because of its co‐occurrence with the aging process, grief, dementia, and medical illness. The author reviewed the field in 1994, and in this paper describes important developments of the past two decades. These include evolving concepts in diagnosis such as minor depression, vascular depression, and the depression of Alzheimers disease. Complex inter‐relationships among depression and medical diseases have been explored, especially cardiovascular and cerebrovascular disease. During this period selective serotonin reuptake inhibitors and serotonin/norepinephrine reuptake inhibitors have largely replaced tricyclic antidepressants and monoamine oxidase inhibitors, while electroconvulsive therapy has continued to be utilized. Repetitive transcranial stimulation is in its infancy and its role in geriatric depression is being defined. Developments in psychotherapy have solidified its place in the treatment of geriatric depression, particularly cognitive behavioral therapy.

Utilizing cognitive therapy on the short-term psychiatric inpatient unit

Cognitive therapy as applied to the short-term psychiatric inpatient unit is explored. The authors provide an overview of the cognitive model and the utilization of cognitive-behavioral therapies for a variety of diagnostic categories. Adaptations of cognitive techniques to the inpatient unit are described and illustrated through case presentations.

Geriatric Psychiatry: Evolution of an Inpatient Unit

The development of geropsychiatry inpatient units is a relatively new phenomena, spanning only the last quarter century (Spar, Ford, & Liston, 1980). In this article we describe such a unit, founded on a biopsychosocial (Engel, 1977) view of psychiatric illness, and organized around a cognitive behavioral treatment (CBT) milieu (Casey & Grant, 1993). The biopsychosocial model is necessary because nearly all of these patients have some medical difficulties, and their medical and psychiatric difficulties result in many social changes for both the patient and their families or caretakers. Adapting cognitive behavioral therapy to the needs of elders in an important goal of the unit. The development of such a comprehensive CBT milieu is described elsewhere (Wright, Thase, Ludgate, & Beck, 1993). Many psychiatric hospitals do not segregate patients by age. One reason

Senile Macular Degeneration and Psychosis

Two cases are reported in which visual hallucinations occurred in elderly patients after the development of senile macular degeneration, a condition that causes gradual loss of visual acuity with preservation of peripheral vision. The hallucinatory experiences are interpreted as delusional explanations for pathologically altered vision, rather than as psychological or phys iological consequences of sensory deprivation. Ocular pathology should be considered in the evaluation of psychotic states in the elderly. (J Geriatr Psychiatry Neurol 1988;1:108-109).

Outcomes of a Two-Component Intervention on Behavioral Symptoms in Persons With Dementia and Symptom Response in Their Caregivers

Purpose: This study evaluated the longitudinal influence of an individualized evidence-based psychoeducational intervention for caregivers on frequency of behavioral symptoms in persons with dementia (PWD) and caregiver reaction to these symptoms. The intervention included information about the disease process using Progressively Lowered Stress Threshold (PLST) content and a family meeting based on Mittelman’s New York University Intervention. Method: A quasi-experimental study design was implemented. The Revised Memory and Behavior Problems Checklist was administered to N = 127 caregiver/care recipient dyads at baseline, 6, 12, and 18 months follow-up. All caregivers were enrolled in the intervention at baseline and followed over 18 months. Linear mixed models were developed to evaluate effects on frequency of behavioral symptoms in PWD and caregiver response. Results: The most frequently occurring behavior was memory problems, although depressive behaviors produced the most negative caregiver responses. Between baseline and 6-month follow-up, there was a significant decrease in frequency of behavioral symptoms. Overall, there was a significant decrease in caregiver’s reaction to behavioral symptoms from baseline to 18-month follow-up.

ERP as a biomarker for Alzheimer's disease: The cognision system

Background: Biomarker research has led to development of promising markers (e.g., amyloid imaging, cerebrospinal fluid analysis). However, the causal link between the pathologic process and cognitive decline remains unclear, contributing to uncertainty in early AD diagnosis as well as monitoring progression. Recent consensus statements suggest that AD diagnosis should involve evidence of pathological biochemical process as well as cognitive malfunction, with progressive cognitive decline as the core criterion. The FDA has stated that a treatment must not only show the desired pharmacodynamic effect (as demonstrated by biomarkers) but also prove efficacy in a cognitive domain. This requires the development of a reliable cognitive biomarker. The limitations of psychometric testing are well known. Event-related potentials (ERP) have potential as a cognitive biomarker for early AD as well as evaluating drug efficacy. Methods: ERP studies demonstrate its utility in diagnosis. Our portable, easy-to-use ERP system enables standardized data collection in outpatient settings. This device is being used in a multi-center trial (100 well-characterized AD and 100 age-matched controls to validate ERP as a cognitive biomarker). Results: ERP and other biomarker data will be analyzed to address following specific aims: 1) To train an ensemble-of-classifiers neural network system with time and frequency based features of ERP and to determine whether the sensitivity, specificity, and positive likelihood ratio (PLR) in detecting early AD can meet the performance of community clinic physicians. 2) To test, within the dementia cohort, how well ERP biomarkers correlate with CSF biomarkers and test whether combining ERP data with MRI data in a decision-fusion classifier boosts the classification accuracy of differential diagnosis (AD vs. non-AD dementia). 3) To compare statistically, within the dementia cohort, ERP biomarkers with ADAS-Cog scores to assess the utility of ERP biomarkers in monitoring efficacy of AD drugs. Conclusions: Clinical trials are currently underway and preliminary results will be presented.