Dhiren Singh

Development of an Australian version of the Alcohol-Related Problems Survey: A comprehensive computerised screening tool for older adults

The Alcohol‐Related Problems Survey (ARPS) reliably classifies drinking as non‐hazardous, hazardous or harmful using scoring algorithms that consider quantity and frequency of alcohol use alone and in combination with health conditions, medication‐use and functional status. Because it has been developed using a 14‐g US standard drink, it is not valid in Australia where a standard drink contains 10 g of ethanol.

Efficacy and safety of risperidone long-acting injection in elderly people with schizophrenia

Antipsychotic medication is the mainstay of treatment in elderly patients with psychosis. In recent years, second generation antipsychotics have come to be preferred. Long-acting risperidone is the first such antipsychotic available for use in this vulnerable group of patients and offers an attractive alternative to traditional medications. The available literature revealed that long-acting risperidone is generally well tolerated and is effective in treating both the positive and negative symptoms of schizophrenia. Despite a lack of randomized trials and head-to-head studies, it appears to be a useful addition to the treatment armory for patients with chronic psychosis who require a depot preparation. Further research into its endocrine and metabolic side effects is needed.

The Clinical and Service Outcomes of Unilateral and Bilateral ECT Electrode Placements in Australian Aged Psychiatry Services

Objective The aim of the study was to determine whether depressed aged inpatients treated with brief pulse unilateral electroconvulsive therapy (ECT) differed from those treated with bilateral (bitemporal or bifrontal) ECT with respect to numbers of treatments, length of hospital admission, changes in scores on depression and cognitive scales, and serious adverse effects. Methods An audit of routinely collected data regarding 221 acute ECT courses in 7 public aged psychiatry services in Victoria, Australia. Results Patients given unilateral, bifrontal, and bitemporal treatments were similar with respect to personal, clinical, and treatment characteristics. Most treatments were administered in line with local clinical guidelines and were rated as effective. Psychiatrists preferred unilateral ECT in the first instance with stimulus dosing based on patients’ seizure thresholds. Approximately a quarter of unilateral courses were switched later to bitemporal placement, most probably because of insufficient progress. Bilateral treatments were associated with a larger number of treatments, less improvement in scores on mood and cognitive scales, and more refusals to continue treatment than unilateral-only ECT. Discussion Brief pulse unilateral ECT proved more effective than bitemporal and bifrontal ECT for most aged patients, especially when coupled with stimulus dosing based on seizure threshold.

Follow up of post-traumatic stress disorder symptoms in Australian servicemen hospitalized in 1942-1952

Juan I. Garcia and Richard Mullen, Department of Psychological Medicine, University of Otago, Dunedin School of Medicine, Dunedin, New Zealand: In their paper Drs Burgess Watson and Daniels conclude, on the basis of interviews with 12 servicemen who responded to a newspaper advertisement, that eight had ‘symptoms satisfying a diagnosis of PTSD at the time of the study’ [1]. They then deduce that post-traumatic stress disorder (PTSD) symptoms were probably common and underreported during and after World War II. The study design and sample size call for caution in interpretation of their data. The criteria used for diagnosing PTSD relied on participants’ endorsement of symptoms from the Impact of Events Scale (Revised; IES). The presence of these symptoms is not sufficient to satisfy the criteria for a diagnosis of PTSD because this requires not only the presence of these symptoms but also the presence of clinically significant distress or impairment: the F criterion of DSM-IV-TR. The authors give no evidence that this was the case. In fact all the men had held steady jobs. Several retrospective studies have shown high incidences of PTSD in combat veterans. The incidences are routinely revised downward when the requirement of presence of ‘significant impairment’ is imposed. Also, the severity and prevalence seem to grow with time. People who seemed minimally affected at the time of the traumatic event may become more distressed as their environment becomes more favourable or changes its expectations about how people should feel, think or react about things. The issue is an important one. The concept of PTSD is still subject to controversy. If the symptoms are understood as the normal response expected from a healthy person who is exposed to terrifying and severe experiences, then we should explain why it is that some people seem immune to it and why different people seem to react in different ways to the same stressor. In contrast, if it constitutes a pathological reaction to stress then the diagnostic emphasis should be steered away from the nature and identity of the stressor, and the emphasis placed instead on the predisposing factors present in the afflicted. It is therefore particularly important for researchers in PTSD to adhere to strict diagnostic guidelines.

Depot risperidone in elderly patients: the experience of an Australian aged psychiatry service.

Antipsychotic medications form the mainstay of both the acute and maintenance treatment of schizophrenia. In recent years, atypical antipsychotics like risperidone, olanzapine and clozapine have come to be preferred because of their lower incidence of extra-pyramidal, anti-cholinergic and cardiac side-effects and a possible greater efficacy in reducing negative and neuro-cognitive symptoms (Ritchie et al ., 2006).

Quality indicators of psychotropic prescribing to people with dementia in aged psychiatry inpatient units

ABSTRACT Objectives: To develop indicators of safe psychotropic prescribing practices for people with dementia and to test them in a convenience sample of six aged mental health services in Victoria, Australia. Method: The clinical records of 115 acute inpatients were checked by four trained auditors against indicators derived from three Australian health care quality and safety standards or guidelines. Indicators addressed psychotropic medication history taking; the prescribing of regular and ‘as needed’ psychotropics; the documentation of psychotropic adverse reactions, and discharge medication plans. Results: The most problematic areas concerned the gathering of information about patients’ psychotropic prescribing histories at the point of entry to the ward and, later, the handing over on discharge of information concerning newly prescribed treatments and the reasons for ceasing medications, including adverse reactions. There were wide variations between services. Conclusion: The indicators, while drawn from current Australian guidelines, were entirely consistent with current prescribing frameworks and provide useful measures of prescribing practice for use in benchmarking and other quality improvement activities.

Catatonia, major depression and Takotsubo cardiomyopathy in an elderly patient.

181 daytime sleepiness was obvious after any shortfall in CPAP, often due to mask leaks. Rehabilitation staff engaged Patient A with motivational counselling and programmed activities. The test battery was repeated at three and six months after commencing his treatment. Patient A was regularly reviewed by the clinical team, he adhered to the clozapinemonitoring regimen and had appropriate diabetic-integrated care (medical review, podiatry review and eye review).

Neuroleptic sensitivity in the elderly: lesson from clinical practice

Anti-psychotic medications are commonly used in aged psychiatry. Elderly patients are more sensitive to adverse effects especially cardiac complications, anti-cholinergic and extra-pyramidal side effects due to changes in receptors, volume distribution and increased number of concomitant medications [1]. We describe a case where an elderly man developed marked neuroleptic sensitivity despite the use of low dose atypical antipsychotics. A 74 year old man with a history of depression was referred to an acute psychogeriatric inpatient unit with a one month history of confusion, depressed mood, poor appe tite, insomnia, delusions of poverty and agitation. His medical co-morbidity included diabetes mellitus, as well as prostate and throat cancer which were in remission. Physical examination and organic workup was unremarkable apart from neuroimaging evidence of moderate ischaemia. A provisional diagnosis of psychotic depression was entertained and 15 mg of mirtazapine and 2.5 mg olanzapine was initiated. After three days, these medications were increased to 30 mg and 2.5 mg twice daily, respectively. The following day he developed increased agitation, confusion, bradykinesia, increased tone and tachycardia. Creatinine kinase (CK) was found to be elevated at 1739. Psychotropic medication was ceased. Following neurological review, drug-induced Parkinsonism was diagnosed with the raised CK thought to be related to the rigidity. His CK returned to normal and the Parkinsonism improved; however, his mental state continued to fl uctuate with ongoing psychotic symptoms, including now, visual and auditory hallucinations. On transfer back to the acute aged psychiatry unit, queti apine 25 mg twice daily was commenced. However, within 48 h he developed increased confusion, rigidity and a low grade fever. The CK rose to over 3000 and we diagnosed neuroleptic malignant syndrome (NMS). Quetiapine was ceased. He was transferred to an acute medical ward where following intravenous hydration and supportive management the CK returned to normal and the pyrexia and brady kinesia improved over the next week. Following transfer to the psychogeriatric inpatient unit, we reviewed the history, diagnosis and management. Given the marked neuroleptic sensitivity, fl uctuating cognition and visual hallucinations in particular, a clinical diagnosis of dementia with Lewy bodies (DLB) was considered. Donepezil 5 mg was prescribed and regular lorazepam added to assist with management of agitation. There was global improvement. However, ten days later he complained of headache, was drowsy and more confused. A CT scan revealed a large left parietal haemorrhage. He was transferred to a medical ward and died two weeks later. This case highlights a number of issues related to use of anti-psychotics in general and in the elderly in particular. NMS, although historically a rare but serious side effect of typical anti-psychotic medication, occurs with atypical anti-psychotics as well and manifests in a similar way, the exception being clozapine which is less likely to manifest with prominent extra pyramidal symptoms [2]. One needs to be particularly vigilant with the elderly, given their increased sensitivity to adverse effects [1]. Neuroleptic sensitivity in DLB to typical and high potency atypical anti-psychotics has been reported including the potential to alter the course of the illness [3]. Low potency atypical anti-psychotics such as quetiapine are reported as being preferable in patients with DLB [4]. In this case, although the diagnosis of DLB was unable to be supported by neu ropsychological assessment or functional neuroimaging, the marked neuroleptic sensitivity even on low dose queti apine was striking. Another contentious issue raised is the association with risperidone and olanzapine and increased vascular risk when used to treat the behavioural symptoms of dementia. Some have concluded that there is a two-fold increase in stroke and therefore should not be used in dementia [5]. Others have found no difference in stroke between typical and atypical anti-psychotics used in the treatment of dementia [6]. This case adds to the uncertainty. Overall our case demonstrates the need for caution and an awareness of adverse effects even when following the prin ciple ‘ start low and go slow ’ in this vulnerable patient population.

Guidelines for alcohol consumption for older Australians

Peninsula Health’s Older Wiser Lifestyles (OWL) program is Australia’s first older adult-specific alcohol and other drugs service. We were pleased to see McLaughlin et al.’s [1] recommendation for national guidelines for non-hazardous alcohol consumption by older Australians. This recommendation was based on evidence indicating that changes in physiology associated with the natural ageing process affect the pharmacokinetics of alcohol [2,3], as well as McLaughlin et al.’s findings regarding sex differences and the benefits of alcohol-free days [1].