Dov Aizenberg

Anticholinergic burden and the risk of falls among elderly psychiatric inpatients: a 4-year case-control study.

OBJECTIVE Falls are an everyday risk for the elderly and their etiology is multifactorial. Because there are little data focusing on falls among elderly psychiatric inpatients, we aimed to retrospectively assess the characteristics of inpatients that had sustained a fall during hospitalization. METHODS Over 4 years, all adverse-event reports of falls were reviewed. Inclusion criteria were age >65 years and intact cognition. The control group consisted of the previous and next admission of an elderly patient to the same ward. Anticholinergic score was calculated for each patient. RESULTS Of 414 admissions of elderly patients, 34 (8.2%) patients had had a fall. The control group (n = 68) did not differ in mean age, distribution of diagnoses, or use of benzodiazepines, antidepressants, or antipsychotics. Two variables were significantly associated with falls: female gender (68% vs. 39%, p < .05) and anticholinergic burden score (ABS) (mean: 3.7 vs. 2.1, p < .05). CONCLUSIONS Our results support reported findings of higher rates of falls among elderly women and suggest that ABS may be a risk factor for falls.

Sexual Dysfunction in Male Posttraumatic Stress Disorder Patients

Background: Previous studies have suggested that sexual dysfunction may be associated with posttraumatic stress disorder (PTSD). Yet such studies have not examined a full range of sexual functioning and have not accounted for the possibility that medication used to treat PTSD may contribute to sexual dysfunction. Objective: The current study compares the various components of sexual functioning among three groups of males: (1) untreated PTSD patients (n = 15), (2) PTSD patients currently treated with selective serotonin reuptake inhibitor (SSRI) agents (n = 27) and (3) a group of normal controls (n = 49). Methods: All participants completed an 18-item questionnaire for assessment of sexual functioning. Those with PTSD also completed the Impact of Events Scale and the Symptom Check List-90 (SCL-90). Results: Untreated and treated PTSD patients had significantly poorer sexual functioning in all domains (desire, arousal, orgasm, activity and satisfaction) as compared to normal controls. Those treated with SSRI had greater impairment in desire, arousal and frequency of sexual activity with a partner. There was a high correlation between sexual dysfunction among the PTSD group and the anger-hostility subscale of the SCL-90. Conclusions: PTSD appears to be associated with pervasive sexual dysfunction that is exacerbated by treatment with SSRIs. PTSD may represent a heterogeneous syndrome. Patients with PTSD have a high rate of comorbid panic disorder, major depression and anxiety, and it could thus be argued that these comorbid disorders, rather than PTSD, accounted for the observed result. Future research aimed at understanding comorbidity and heterogeneity should help to illuminate the psychobiology of PTSD and eventually guide both medication and psychosocial treatments.

Cyproheptadine treatment of sexual dysfunction induced by serotonin reuptake inhibitors.

Treatment of serotonin reuptake inhibitors (SRIs) is associated with sexual dysfunction. The cause of this dysfunction is unclear but may be related to stimulation of the serotonergic system. In the present article, we describe seven patients in whom iatrogenic sexual dysfunction induced by SRIs was treated with cyproheptadine, a 5HT-2 antagonist with antihistaminergic and adrenolytic properties. Seven obsessive-compulsive male patients, aged 29-54 years, who developed sexual dysfunction following treatment with SRIs (fluoxetine, fluvoxamine, and clomipramine) were instructed to take cyproheptadine (4-12 mg) 1-2 h before commencing sexual activity. Five of the seven patients displayed improvement in sexual function, although the improvement was transitory in two. The two remaining patients did not respond. All patients exhibited sedation on the day following cyproheptadine administration. Our preliminary observation suggests that some patients with sexual dysfunction associated with SRI treatment, mainly decreased libido and anorgasmia, may benefit from cyproheptadine administration. The role of 5HT-2 antagonists in SRI-induced sexual dysfunction merits further investigation.

Differences in audiovisual integration, as measured by McGurk phenomenon, among adult and adolescent patients with schizophrenia and age-matched healthy control groups.

BACKGROUND McGurk effect is a perceptual phenomenon that reflects the integration of visual and auditory information during speech perception. Using McGurk effect, the authors examined the audiovisual integration in adolescents and adults with schizophrenia as compared with healthy volunteers. SAMPLING AND METHODS Thirty hospitalized patients with schizophrenia and 20 age-matched healthy controls were examined for perception of ambiguous audiovisual stimuli. RESULTS The mean of McGurk-positive responses was significantly lower in adolescent patients with schizophrenia than in healthy adolescents (3.13 +/- 2.09 vs 5.60 +/- 0.7, respectively; t = 3.591, P = .001). The McGurk-positive responses were significantly higher in healthy adolescents than in healthy adults (5.60 +/- 0.7 vs 3.60 +/- 1.43, respectively; t = 3.974, P = .001). No significant difference in McGurk-positive responses was found between adults with schizophrenia and healthy adult individuals, or between adolescent and adults with schizophrenia. Duration of schizophrenia, soft sign status, type of symptoms, and type of antipsychotic medication showed no influence on the audiovisual integration ability. CONCLUSIONS (I) Age effect: It seems that the audiovisual integrative function increases from childhood to adolescence and decreases from adolescence to early adulthood. (II) Schizophrenia: Audiovisual integration is poor in adolescent and adult patients with schizophrenia. Thus, it seems that schizophrenia is associated with early and persistent impairment in the development of the audiovisual integration ability. (III) Reliance on visual cue stimuli: Although several previous investigations concluded that patients with schizophrenia rely less on visual cue stimuli than healthy controls, our data suggest that this is true only for specific types of visual cue stimuli.

Suicide amongst Alzheimer’s Disease Patients: A 10-Year Survey

Suicide is a major public health problem with advancing age being one of the factors associated with increased risk. It has been suggested that most DSM axis-I disorders contribute to increased suicidal risk while dementia is one of the few exceptions. We conducted a 10-year retrospective analysis of all elderly patients suffering from dementia admitted to a large urban mental health center. Between 1991 and 2000 there were 1,551 admissions to our center who were 65 years or older. Of these, 341 were diagnosed (DSM-IV criteria) as suffering from dementia and 215/341 as suffering from Alzheimer’s disease (AD). Sixteen AD patients (7.4% of all AD patients) were admitted immediately following a suicide attempt. The control group consisted of the next admission of an elderly AD patient matched for age and gender. The index group (suicidal patients) differed from controls in Clinical Dementia Rating scores (p = 0.017) and higher frequency of previous suicide attempts (p = 0.022). Lifetime psychopathology was not associated with higher rates of suicide attempts (p = 0.068). Physicians should be aware that suicide attempts are not rare in elderly AD patients. Higher level of daily functioning and previous suicide attempts are associated with increased suicidal risk.

Cyproheptadine versus propranolol for the treatment of acute neuroleptic-induced akathisia: a comparative double-blind study.

The purpose of this study was to investigate the efficacy of cyproheptadine, an antiserotonergic agent, in the treatment of neuroleptic-induced akathisia (NIA), as compared with propranolol, the current gold standard. In a double-blind trial, 30 patients with schizophrenia and NIA received either cyproheptadine 16 mg/day (N = 18) or propranolol 80 mg/day (N = 12) for 4 days, followed by 3 days without any anti-NIA treatment. The Barnes Akahisia Scale, Simpson-Angus Extrapyramidal Effects Rating Scale, and Brief Psychiatric Rating Scale were used to assess the severity of NIA, parkinsonism, and psychosis, respectively. In both groups, the severity of NIA decreased significantly over time (cyproheptadine, −46%; propranolol, −42%), with no significant intergroup difference. The NIA symptoms worsened significantly when cyproheptadine and propranolol were discontinued. We conclude that cyproheptadine 16 mg/day is as effective as propranolol for the treatment of acute NIA. The antiakathisic effect of cyproheptadine may be mostly attributable to its serotonin antagonistic activity.

Mianserin, a 5-HT2a/2c and α2 antagonist, in the treatment of sexual dysfunction induced by serotonin reuptake inhibitors

Sexual dysfunction is commonly encountered in patients treated with antidepressants. The exact mechanism responsible for the sexual impairment is as yet unclear, although activation of the serotonergic system has been implicated. In the present study, we examined the effect of the 5-HT2a/2c and alpha 2 antagonist mianserin in the treatment of patients with sexual dysfunction induced by serotonin reuptake inhibitors (SRIs). Mianserin 15 mg was coadministered to 15 male subjects with new-onset sexual dysfunction who were under treatment with SRIs. Four major domains of sexual activity-desire, erection, orgasm, and satisfaction-were assessed once weekly for 4 weeks. At the end of the study, 9 of the 15 subjects reported a marked improvement in their sexual functioning, 2 reported partial improvement, and only 4 subjects showed no improvement at all. The beneficial effects were prominent in the areas of orgasm and satisfaction and were usually noted within the first and second week of mianserin treatment. The addition of mianserin to the treatment regimen was not associated with either improvement or worsening of the basic psychiatric clinical status. It appears that the coadministration of low-dose mianserin may be an additional option in the treatment of sexual dysfunction induced by SRIs.

Attitudes Toward Sexuality Among Nursing Home Residents

There is a paucity of data regarding sexuality among nursing home residents. The aim of the present study was to evaluate sexual attitudes in a group of independent residents in a large urban nursing home. Ten items covering different aspects of sexual attitude were scored by two board certified psychiatrists following a semistructured interview. The study was undertaken at a large 1,200-bed nursing home providing services to both healthy independent elderly as well as geriatric patients. Subjects were 31 volunteers: 15 men and 16 women (mean age: 82.4 and 74.1 years, respectively), who consented to participate. Participants were cognitively intact and living independently at the nursing home. Exclusion criteria were: a) current major psychiatric morbidity, b) drug or alcohol abuse, c) Geriatric Depression Scale (short version) score ≥5, and d) Clinical Dementia Rating >0. A hierarchy of basic functions was constructed wherein each function was graded on a 5-point Likert-like scale reflecting its endorsed importance. The majority (23/31) felt that sexuality should be openly discussed with the elderly by health professionals. Twenty-one of 31 expressed willingness to receive medical consultation and treatment for sexual dysfunction as needed and 20/31 expressed a similar attitude if their partner so needed. The hierarchy of needs was rated by the participants (men and women, respectively) as follows: Mood (4.4; 4.3), Memory (4.2; 4.2), Sleep (3.8; 3.9), Sex (3.5; 2.8), and Appetite (2.8; 2.6). Sex is graded as “moderately important” among nursing home residents, more so in males. The majority of residents expressed positive attitudes towards open discussion of sexual matters and willingness to accept therapeutic interventions when needed.

Switching to Aripiprazole as a Strategy for Weight Reduction: A Meta-Analysis in Patients Suffering from Schizophrenia

Weight gain is one of the major drawbacks associated with the pharmacological treatment of schizophrenia. Existing strategies for the prevention and treatment of obesity amongst these patients are disappointing. Switching the current antipsychotic to another that may favorably affect weight is not yet fully established in the psychiatric literature. This meta-analysis focused on switching to aripiprazole as it has a pharmacological and clinical profile that may result in an improved weight control. Nine publications from seven countries worldwide were analyzed. These encompassed 784 schizophrenia and schizoaffective patients, 473 (60%) men and 311 (40%) women, mean age 39.4 ± 7.0 years. The major significant finding was a mean weight reduction by −2.55 ± 1.5 kgs following the switch to aripiprazole (P < .001). Switching to an antipsychotic with a lower propensity to induce weight gain needs be explored as a strategy. Our analysis suggests aripiprazole as a candidate for such a treatment strategy.

Lithium and Male Sexual Function in Affective Patients

The aim of the present study was to evaluate sexual function and behaviour in male patients who take lithium. Participants included 35 bipolar and schizoaffective men, aged 43.3 +/- 9.6 years, who were in euthymic state and were receiving lithium as the sole medical treatment. Eleven patients (31.4%) reported sexual dysfunction on at least two items of the sexual function questionnaire. Notable results were reduction in frequency of sexual thoughts and loss of erection during sex in 23 and 20% of patients, respectively. Difficulties in achieving and maintaining erections (ease of arousal) were reported in 14% of patients. Nevertheless, almost all patients reported preserved pleasure during sexual activity and were satisfied with their sexual performance. There was no difference in serum lithium levels in patients with and without sexual dysfunction. No statistical correlation was found between sexual function scores and serum lithium levels. Lithium therapy may impair desire and arousal, yet it does not appear to have a major impact on patient self-satisfaction or subjective sense of pleasure during sexual activity. The degree of sexual dysfunction as reported in the present study was not a source of distress to patients and did not cause noncompliance.