Howard H. Fenn

Factors associated with prospective long-term treatment adherence among individuals with bipolar disorder.

OBJECTIVE Clinical characteristics, adverse effects of medication, and treatment attitudes have been associated with adherence in bipolar populations in cross-sectional studies. The aim of this secondary analysis from a larger study was to identify the association between baseline variables and average treatment adherence over a subsequent three-year period. METHODS Veterans with bipolar disorder were evaluated on self-reported adherence status at baseline and every six months over a three-year period. The sample was dichotomized into two clinically relevant categories: those who were primarily adherent and those who were primarily nonadherent. Demographic and clinical variables were examined for the two groups of patients in relation to their average adherence over the three-year period. RESULTS The study recruited a sample of 306 persons with severe bipolar disorder. The sample was predominantly male (278 men, or 91%), with a mean+/-SD age of 46.6+/-10.1 years. A total of 240 individuals (78%) were largely adherent to treatment, and 37 individuals (12%) were largely nonadherent to treatment. Nonadherent individuals were less likely to be on intensive somatotherapy regimens (p=.001); experienced more barriers to care, including lack of telephone access (p<.05) and life obligations and commitments (p<.05); and had more prior suicide attempts (p=.003). CONCLUSIONS Nonadherent individuals with bipolar disorder received less intensive pharmacologic treatments, had more suicide attempts, and experienced more barriers to care than adherent individuals. Nonadherence may have system as well as patient components. Consideration of nonadherence as a function of both patient factors and system factors will enhance our ability to understand nonadherence and intervene more effectively.

Review of topiramate for the treatment of epilepsy in elderly patients

Individuals over 65 years of age experience the new onset of seizures at a prevalence rate of roughly twice that of younger adults. Differences in physiology, need of concomitant medications, and liability for cognitive deficits in this population, make the choice of anticonvulsant drugs especially important. This paper reviews topiramate (TPM), a treatment for many types of seizures, with the above risks in mind. In particular, we discuss efficacy and pharmacokinetics with emphasis on the older patient, and adverse events in both the younger and older adult. With most studies of TPM-induced cognitive deficits having been performed in younger adults and volunteers, we discuss the implications for the older adult. Even in studies of younger individuals, up to 50% discontinue TPM because of intolerable cognitive deficits. Most studies find specific declines in working memory and verbal fluency. In conclusion, we give recommendations for use of this antiepileptic drug in this population.

Safety and efficacy of anticonvulsants in elderly patients with psychiatric disorders: oxcarbazepine, topiramate and gabapentin

Few controlled studies are available to guide the clinician in treating potentially assaultive elderly individuals with psychiatric disorders. Safety concerns limit the use of benzodiazepines and antipsychotic medications in the elderly individual, making anticonvulsants an attractive alternative. This paper reviews three specific anticonvulsants for this purpose: gabapentin, oxcarbazepine and topiramate, describing safety and efficacy in elderly patients with severe agitation from psychosis or dementia. Gabapentin, renally excreted, with a half-life of 6.5 – 10.5 h, may cause ataxia. Oxcarbazapine, hepatically reduced, may cause hyponatremia, and topiramate may cause significant cognitive impairment. Nonetheless, these are important medications to consider in the treatment of agitation.

Safety of antidepressants in the elderly

Until the 1980s, the two major classes of antidepressants, the tricyclics and the monoamine oxidase inhibitors (MAOIs), were effective but had severe side effects, requiring monitoring by psychiatrists. The past several years have brought new classes of antidepressants that are safer for the patient to take and far easier for the non-psychiatrist to prescribe. Whilst this is of enormous value, it leaves the physician with the dilemma of which one to prescribe. These new antidepressants cannot safely be used interchangeably. This paper will discuss each of the antidepressants presently available, with particular emphasis on safety in the elderly. Drug interactions, side effects and particular challenges to the older patient will be described. The authors will then advise a general strategy for prescribing antidepressants.

A prospective study of the impact of comorbid medical disease on bipolar disorder outcomes

BACKGROUND Several studies suggest that medical comorbidity is associated with worse clinical status in bipolar disorder. It is unclear which aspect of medical comorbidity is responsible: simple disease count, risk for future morbidity, or current physical burden. METHODS We analyzed three years of prospective data from a randomized clinical trial of collaborative care in 306 bipolar veterans. We examined the association of clinical outcome with baseline medical comorbidity defined as: (1) simple active disease count, (2) diseases with risk for future morbidity measured with the Charlson Comorbidity Index, and (3) current physical burden measured with the SF-36 Physical Component Summary score (PCS). Bipolar outcomes were weeks in episode, mean depression score, and change in mental health burden measured by the SF-36 Mental Component Summary score (MCS). RESULTS The three medical comorbidity measures were not highly correlated, indicating that each conveyed novel information. Controlling for potential confounders, worse baseline PCS predicted significantly higher mean depression scores (p=0.011) and less improvement in MCS scores (p=0.0099) over three years. Simple disease count and risk for future risk did not predict worse bipolar outcomes. LIMITATIONS Some potential limitations include not accounting for all confounding factors, selection bias for participants, increased the likelihood of Type I error due to multiple comparisons and having a predominantly male population. CONCLUSIONS This long-term prospective study extends cross-sectional and retrospective research on the link between medical illness and bipolar outcomes. It is the current experience of burden of physical illness, rather than an unweighted or weighted disease count, that leads to worse bipolar outcomes.

PAIN ASSESSMENT IN THE ALZHEIMER'S PATIENT

To the Editor: A 96-year-old woman presented with a syncopal episode. She was not on medication and had a permanent ventricular-demand pacemaker. Except for a heart rate of 40, the examination was unremarkable. Electrocardiogram demonstrated underlying atrial fibrillation with a noncapturing pacemaker, a slow ventricular response, and a prolonged QT interval (Figure 1). Serum potassium was 3.6 mM/L, and serum magnesium was 1.6 mg per dL. The patient received intravenous potassium chloride and magnesium sulphate. Recurrent episodes of tachyarrhythmias were recorded, consistent with torsades de pointes (Figure 2). An emergent temporary transvenous pacemaker was inserted. There were no further tachyarrhythmias, and there was no evidence of acute myocardial infarction. The permanent pacemaker was subsequently reprogrammed.

Safety and tolerability of mood-stabilising anticonvulsants in the elderly

The authors review current research on the safety and tolerability of anticonvulsant medications used for individuals over the age of 60 years with affective disorders, agitation and other psychiatric disorders. Three anticonvulsants currently approved in the US for treatment of bipolar affective disorder are reviewed: valproate, lamotrigine and extended-release carbamazepine. The authors discuss the pharmacokinetics, pharmacodynamics, drug–drug interactions and the impact of ageing for each drug. There are few studies of anticonvulsant medications in elderly patients with bipolar disorder or other psychiatric conditions. Therefore, the authors summarise adverse events of greatest prevalence and/or greatest severity based on data derived predominately from studies of geriatric patients with epilepsy and/or other non-psychiatric indications. Guidelines are offered for the safe use of these medications in the elderly, based on research literature.

Treatment of bipolarity + medical comorbidity = costability

This issue of the Acta Psychiatrica Scandinavica reports from an open-label follow-up of 3766 research subjects of the STEP-Bipolar project. At least one medical comorbid condition was found in 58.8%. Baseline data from subjects with bipolarspectrum disorder and schizoaffective disorder, bipolar type, were analyzed retrospectively to determine the association of historical variables with medical comorbidity (1). A strong linear-by-linear association was noted between the following historical variables and prevalence of any medical comorbidity:

ERYTHROCYTE SEDIMENTATION RATE IN ALZHEIMER'S DEMENTIA

made it difficult for him to follow serial programs on television. He said that his wife accused him of being snappy. His wife reported that his behavior had changed dramatically during the last 6 years. He behaved disgracefully, and he was shunned in the home where they lived; his memory had gone. On examination he was cooperative but a bit slow, and, except for the date, fully orientated in time. Assessment of the mental status showed failures only on memory tasks. Although the available information was strongly suggestive for dementia (DSM-111-R) his wife also mentioned that she had never been happy with him. Aggravation was suspected. Information from the team at the day center based on several months’ observations indicated that he behaved more like a volunteer than a patient in that setting. He was not demented, in their opinion, and he was kind and helpful to others. It became obvious that his personality had not altered but that his wife was tired of him. His diagnosis was then changed from Dementia to a mild Amnestic Syndrome

Acute Inpatient Psychiatric Settings

The term coverage does not capture the range of responsibilities one accepts while on call for inpatient psychiatry nor the complexity of clinical issues one may confront when the patient is geriatric. Patients are often admitted with behaviors which disrupt their milieu or treatment or for actions which are potentially dangerous to self and/or others. They cannot be easily treated at home, in nursing homes, or in inpatient medical units. Although these problems happen in other settings, they are more common in inpatient psychiatry. In the geriatric patient, symptoms and behavioral expressions of psychotic, manic, depressive, anxiety, and neurocognitive disorders are often complicated by systemic medical comorbidities. The challenge is to treat the psychiatric symptomatology which initiated the admission while identifying and ameliorating the effect of drug-drug interactions, comorbid systemic medical conditions, disruption to sleep, chronic pain, and medication adverse effects. This chapter offers an overview of common situations encountered with geriatric patients in the psychiatric inpatient unit, along with recommendations which emphasize collaboration with the inpatient staff.