Giuseppe Ferrari

Occurrence of Cognitive Impairment and Dementia after the Age of 60: A Population-Based Study from Northern Italy

Objective: To evaluate the age, gender and education distribution of both cognitive impairment and dementia in the whole old age range of the elderly (from 61 years of age and over). Subjects and Methods: The study population consisted of all subjects born in 1930 or before, living in the municipality of Faenza and Granarolo, Italy (n = 7,930). A two-phase study design was implemented, by using the Mini-Mental State Examination and Global Deterioration Scale as screening instruments. The DSM-III-R diagnostic criteria were used for the clinical diagnosis of dementia. A subject was classified as affected by cognitive impairment, no dementia (CIND) if he/she scored 2 or more standard deviations lower than the corrected mean MMSE score. Results: The prevalences of dementia and CIND were 6.5 per 100 (95% CI 5.9–7.0) and 5.1 per 100 (95% CI 4.6–5.6), respectively. The prevalence of CIND was higher than that of dementia in the youngest old groups (61–74 years), both in men and women, whereas the opposite pattern was present among the older old (75+). In the older age groups, dementia prevalence increased exponentially with age, while CIND prevalence was more stable. There was not a substantial gender difference in CIND prevalence in all ages. Only in the subpopulation of higher educated subjects, women had a higher prevalence of both dementia and CIND than men. Lower educated subjects had a higher prevalence of both dementia and CIND. When compared to higher educated persons, subjects without any schooling had odds ratios of 10.9 (CI 7.0–16.7) and 16.7 (CI 11.2–25.0) for dementia and CIND, respectively. Conclusions: Cognitive impairment is very common in the younger old ages (under 70 years of age), whereas dementia becomes predominant after 75 years of age. Both conditions are strongly related to the educational level.

Mental, physical and functional status in primary care attenders.

Objective: The purpose of the present study was to analyze the association, in primary care attenders, between psychiatric disorders, medical comorbidity, and impairment in mental and physical function status. Methods: The study had a two-stage design. The GHQ-12 was used to screen 1647 patients, and 323 of them were then interviewed using the CIDI-PHC to obtain ICD-10 diagnoses. Severity of mental illness was assessed using the Hamilton scales for anxiety and depression. The DUSOI was used to evaluate the severity of physical illness. The MOS SF-36 was used to assess health related quality of life. Results: The estimated prevalence of ICD-10 psychiatric disorders and subthreshold disorders was 12.4 percent and 18 percent respectively. The most common psychiatric disorders were generalized anxiety, major depression, and neurasthenia. The severity of physical illness did not vary across diagnostic status categories. Significant impairment, both in physical and mental functioning was seen in patients suffering from ICD-10 full-fledged and subthreshold disorders. Severity of impairment increased from subthreshold cases to full-fledged cases, and among the latter according to the severity of depressive and anxious symptoms, assessed using Hamilton scales. The most frequent psychiatric disorders were associated with significant worsening in health related quality of life, with relevant differences between psychiatric diagnoses regarding the domains affected. Impairment associated with mental disorders was greater than that associated with physical illness. Conclusions: The results of the present study confirm that ICD-10 psychiatric disorders are common in general practice and are associated with relevant impairment in physical and mental functional status. Psychiatric morbidity is not related to severity of physical illness rated by general practitioner.

Long-term treatment of geropsychiatric depressed patients with venlafaxine

Twenty-eight psychiatric patients older than 65 years with major depression with high probability of recurrence were enrolled in a 24-month open label clinical trial aimed at evaluating the long-term efficacy and safety of venlafaxine. All patients completed the acute phase of the study; 21 were responders and entered the follow-up period. During the continuation phase no relapse was observed. During the maintenance period, 20% of the patients had a single new recurrence. No significant side effects were observed. The results demonstrate that venlafaxine is both effective and safe in the long-term treatment of major depression in geropsychiatric patients.

Can Breast-Feeding Protect against Schizophrenia?

Background: Human milk, unlike formula feeds, contains long-chain polyunsatured fatty acids, such as docosahexaenoic acid and arachidonic acid which are essential in the development of the central nervous system. If human milk is the optimal food for brain development, and if schizophrenia is a neurodevelopment disorder, might people who become schizophrenic in adult life be less likely to have been breast-fed? Aims: To compare the incidence and length of breast-feeding in patients, siblings and normal controls and to examine the relationship between the duration of breast-feeding and age at onset of schizophrenia. Method: 113 schizophrenic patients were recruited, as were 140 siblings of the patients and 113 nonschizophrenic controls. The breast-feeding history of the patients, their siblings and controls was obtained through interviews with the mothers of the patients and controls. Results: There were no significant differences between groups in the incidence of breast- feeding. The duration of breast-feeding was positively correlated with the age at onset of illness (r = +0.25, p < 0.02). Conclusion: Breast-feeding is no less common in those who develop schizophrenia in later life. However, breast milk might postpone the onset of the illness in schizophrenic patients.

Different Classification Systems Yield Different Dementia Occurrence among Nonagenarians and Centenarians

Literature data consistently show different prevalence estimates of dementia when different classification systems are used in the same population. Very few data are available for the oldest old of the elderly. We investigated the occurrence of dementia among 34 nonagenarians and centenarians according to four classification systems: the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, third edition revised (DSM-III-R) and fourth edition (DSM-IV), the World Health Organization’s International Classification of Diseases, 10th revision (ICD-10), and the Cambridge Examination for Mental Disorders of the Elderly (CAMDEX). Cognitive functioning, work, social function and independence in activities of daily living were evaluated by using an extensive neuropsychological examination. The prevalence (95% CI) of dementia was the following: 47.1% (95% CI 30.3–63.8) with the DSM-III-R criteria, 41.2% (95% CI 24.6–57.7) with the DSM-IV criteria, 29.4% (95% CI 14.1–44.7) with the ICD-10 criteria and 38.2% (95% CI 21.9–54.6) with the CAMDEX. The factors that best predicted disagreement between DSM-III-R and DSM-IV were calculation impairment and the presence or absence of personality changes. DSM-III-R and ICD-10 were differentiated by the weight given to executive functions that all have to be impaired according to ICD-10, whereas progressive deterioration differentiated CAMDEX from DSM-III-R. It should be noted that although the DSM-III-R diagnoses differ by a factor of 1.6 times from the ICD-10 and 1.2 times from the CAMDEX diagnoses, we are speaking about dementia, which is very frequent in nonagenarians and centenarians. Moreover, with regard to public health, an estimation of the number of subjects who will lose their autonomy is rather more useful and informative than simple prevalence figures of dementia by itself. In this light, classification systems, such as the ICD-10, that do not include impairment of social function as a criterion for assessing dementia become less adequate.

Short-term and long-term evaluation of selective serotonin reuptake inhibitors in the treatment of panic disorder: fluoxetine vs citalopram

This double‐blind study evaluates the efficacy and tolerability of fluoxetine and citalopram in the acute and long‐term treatment of panic disorder in 42 patients meeting DSM‐IV criteria for panic disorder with or without agoraphobia. Fluoxetine and citalopram showed similar efficacy in the treatment of panic disorder patients. On the basis of HRSA and PASS mean score evaluation, fluoxetine was more rapid than citalopram in reducing generalized anxiety symptoms, spontaneous panic attacks and anticipatory anxiety. Fluoxetine appeared to be effective at a dosage of 10 mg/day, while citalopram reached the same efficacy at a dosage of 30 mg/day. Long‐term evaluation has demonstrated high rates of persistent full remission with both drugs. Copyright

The Bologna Primary Care Liaison Service: First Year Evaluation

Primary care and mental health were recently integrated by the Italian health authorities. The Bologna Primary Care Liaison Service (PCLS) is ideally suited to the Italian National Health Care System, because most primary care physicians practice individually and mental health services provide first level care. The distinctive features of the program are: 1) location within a mental health center; 2) comprehensive mental health assessment and intervention; 3) collaboration between primary care physicians and mental health services which is facilitated through committees and communication. First year results met expectations. Integrating a PCLS program within a mental health center can be a viable means of implementing national policy.

PANIC DISORDER. A LONG-TERM TREATMENT STUDY : FLUOXETINE VS IMIPRAMINE

This double‐blind study evaluates the efficacy and tolerability of fluoxetine and imipramine in the acute and long‐term treatment of panic disorder in 38 patients meeting DSM‐IV criteria for panic disorder with or without agoraphobia. On the basis of HRSA mean scores evaluation, fluoxetine was found to be quicker than imipramine in reducing generalized anxiety at the end of the first week of treatment. However, through PASS and CGI mean scores evaluation, no statistically significant differences were found at any time in the efficacy of fluoxetine and imipramine on the total number of panic attacks, anticipatory anxiety or phobia severity. Fluoxetine has also turned out to be better tolerated than imipramine and to be effective at dosages low enough to avoid the event of an activation syndrome. Long‐term evaluation has shown high rates of persistent remission with both drugs. Copyright

Extrapyramidal symptoms and residual psychopathology with low-dose neuroleptics

Residual psychopathology associated with EPS has been mainly assessed in experimental studies where neuroleptics were administered at standard, fixed dosages. The present study evaluates residual psychopathology in 69 schizophrenic patients treated with moderate, flexible doses of neuroleptics (430 mg eq. CPZ) at the out‐patient Community Mental Health Services (CMHSs) in Bologna. Akathisia was present in 27·5 per cent of patients and parkinsonism in 27·5 per cent. A more severe psychopathological state was associated with both side‐effects, as seen by significantly higher BPRS global scores. This severity was due to tension and anxiety–depression symptoms in patients with akathisia and to negative symptomatology in patients with parkinsonism, as shown by significant associations with BPRS subscales ANS‐DEP and NEG, respectively. In conclusion, the present study underlines that EPS are frequent even in an out‐patient setting where moderate neuroleptic doses are employed, and more importantly shows that in these conditions, the residual psychopathology resulting from EPS is clinically very significant. Copyright

The prevalence of dementia in a population-based study carried out in Granarolo, Ravenna

OBJECTIVE To evaluate the prevalence of dementia among persons born in the year 1930 or before, who were living in Granarolo, Ravenna province, on December 31, 1991. DESIGN Population study, carried out in two phases: in the first was phase all persons were administered two screening tests for dementia. In the second phase, persons who screened positive underwent detailed clinical and cognitive assessments. MAIN OUTCOME MEASURES The Mini Mental State Examination (MMSE) and the Global Deterioration Scale (GDS) were administered as screening tests. In the second phase the screened-positive subjects underwent a general and neurological examination, and a detailed neuropsychological assessment. RESULTS Of the 557 participants, 56 were clinically diagnosed as demented. Twenty-nine persons were diagnosed as affected by Alzheimers disease (AD) and 14 patients by vascular dementia (VaD). The crude prevalence ratios for dementia were 9.1% (95% C.I. = 5.29-12.89) for men and 12.7% (95% C.I. = 8.84-16.6) for women. The prevalence of all dementias, as well as AD, increased steeply every five years of age for both men and women up to 90 years of age. Women had higher prevalence of all dementias and AD than men, more evident in the advanced ages. CONCLUSIONS Our findings are in agreement with similar studies carried out in European populations, showing that prevalence of dementia increases with increasing age. If we consider that in Italy the oldest (those 80 years and older) are the fastest growing part of the elderly population, we can expect that dementia will be a major emerging public health problem, as it is one of the most common diseases in the very elderly and a major cause of disability and mortality.