Ira R. Katz

The Psychiatric Symptoms of Alzheimer's Disease

The authors used a semistructured interview administered to primary family caregivers to assess the prevalence and nature of psychiatric pathology in 175 well‐diagnosed community‐residing Alzheimers disease patients. Symptoms that are indicative of depression in the cognitively intact were virtually ubiquitous in this demented population. A variety of psychotic features were also regularly reported. The implications of these findings for the recognition and treatment of reversible psychiatric impairment are discussed.

Anxiety and Its Association With Depression Among Institutionalized Elderly

The authors assessed anxiety and depression among nursing home and congregate housing residents at yearly intervals. At baseline, modified DSM-III-R criteria yielded a 3.5% prevalence rate for anxiety or panic disorders. Another 13.2% reported milder symptoms not meeting diagnostic criteria. Anxiety was strongly associated with depression and with physical health, functional disability, and cognitive status. Follow-up data yielded an overall incidence rate of 2.3% for possible anxiety disorders; the majority of these cases were among those with mild anxiety at baseline. Change in anxiety was strongly associated with depression and, less consistently, with functional disability and cognitive status. Results are interpreted as indicating the indistinguishability of anxiety from depression in this frail elderly population.

Clinical Features of Depression in the Nursing Home

The prevalence of depression among nursing home residents was estimated by screening a group of residents selected from a random sample on the basis of cognitive status; it ranged from 18-20% for major depression to 27-44% for other dysphoric states. Though individual patients were observed to change over a 6-month period, depression as assessed with the Geriatric Depression Scale was, in general, persistent. Major depression was clinically confirmed in 8 of 10 patients identified at screening. It was characterized by medical disorders that complicated diagnosis and treatment, and by increased mortality relative to the rest of the population.

Failure To Thrive in the Elderly: Exploration of the Concept and Delineation of Psychiatric Components:

Findings from an exploratory study of the relationships between routine clinical laboratory tests and the clinical status of elderly patients living in a nursing home or congregate housing facility demonstrate that low albumin and anemia are associated with decreased survival and with self-care deficits, cognitive impairment, depression, and summary measures of the severity of medical illness. The interrelationships observed among these variables support the usefulness of the concept of failure to thrive. Although albumin can serve as a nutritional marker, findings on its relationship with sedimentation rate, triiodothyronine uptake, fasting plasma amino acids, and retinol-binding protein levels suggest that the low albumin related to failure to thrive is not a simple reflection of steady-state deficits in protein-calorie nutrition; it appears to be sensitive to more direct effects of disease and inflammation or to the interactions between nutrition and illness.

Psychometric properties of the Geriatric Depression Scale among the institutionalized aged.

Validity and reliability of the Geriatric Depression Scale (GDS) were examined among 806 nursing home and congregate apartment residents (mean age 84 years)

Association of Antidepressants and Other Medications with Mortality in the Residential-Care Elderly

To explore the extent to which treatment of depression affects survival, we evaluated the association between use of antidepressant medications and death rates among the residents of a large residential-care facility for the elderly using a retrospective record-review study (N=624). One year survival, among those taking antidepressants (10.9%), was 11.8% compared to 11.1% among the remainder of the population. A second study followed a group of 32 patients in the same institution who had participated in a therapeutic trial of nortriptyline treatment for major depression. Patients who experienced adverse medical events during treatment exhibited significantly increased mortality; among treatment completers, there was no significant relationship between mortality and therapeutic response. These findings suggest that the inability to tolerate treatment with an antidepressant can be considered a manifestation of physiologic frailty and increased vulnerability to mortality from disease. The previously reported decrease in survival among residential-care patients with major depression is not paralleled by a similar effect in those taking antidepressants. This may reflect selection factors with respect to the ability to tolerate antidepressants, rather an effect of treatment.

Detecting Subclinical Change in Cognitive Functioning in Older Adults: Part I: Explication of the Method

This research reports on the practicality of performing repeated measures of cognitive functioning in older adults. The detection of acute or subacute changes in cognitive functioning in the clinical setting could be facilitated by the development of an objective screening tool. Such a tool would not depend on the observation of symptoms only in pathological states, but rather, would depend on monitoring the cognitive functioning of patients over time. These repeated assessments allow us to define the magnitude of normal fluctuations in performance, thereby allowing us to define the magnitude of change in performance that represents a significant decrement or improvement in functioning. The findings reveal that routine monitoring of cognitive performance could allow identification of acute or subacute cognitive change in older adults.

Toxic and Metabolic Encephalopathies in Long-Term Care Patients

Evaluation of the change in performance on the Blessed Memory Information Concentration Test over a one-year period was used as a probe for the prevalence of reversible cognitive disorders among patients living in a residential care facility. Of 157 patients with cognitive impairment at the initial assessment, 10 (6.4%) improved by 6 points or more, 19 (12.1%) improved by 5 points or more, and 15 (9.6%) had a reduction in the number of errors by 33% or more. Thus, using improvement over time as an indicator, we estimate that 6% to 12% of the elderly patients in our sample had a reversible component to their cognitive impairment at the initial assessment. Retrospective review of medical records identified (one or more) possible causes for impairment at baseline in each of the ten patients who showed the greatest improvement: adverse drug effects in seven patients, depression in two, and metabolic encephalopathies in three.

Bedside clinical and electrophysiological assessment: assessment of change in vulnerable patients.

Current approaches to the diagnosis of delirium are based upon the recognition of symptoms that emerge in the pathological state. As an alternative, we propose an approach to case identification for research purposes based on the recognition of significant changes in the cognitive or cerebral state of the individual patient. Categorical change can be defined using prediction intervals calculated from repeated measures on a population of medically stable subjects. Data from subjects enrolled in a prospective study of delirium in a long-term care population were utilized to calculate prediction intervals for the Mini-Mental Status Examination and for measures of the electroencephalographic background frequency as obtained with a two-channel microprocessor-based EEG device. Preliminary findings support the validity of this quantitative approach for defining changes in brain state. Future research should evaluate both cognitive and electrophysiological techniques for monitoring vulnerable patients.

Detecting Subclinical Change in Cognitive Functioning in Older Adults: Part II: Initial Validation of the Method

Repeated measures of cognitive functioning may provide a clinically feasible supplement to standard operational criteria for the diagnosis of delirium or toxic or metabolic encephalopathies in older adults. This research reports on the feasibility of detecting change in cognitive functioning through repeated assessments. The findings demonstrate that the method of identifying excessive cognitive changes through repeated assessments is not compromised by fatigue or practice effects. Further, a controlled drug trial validated this method for detecting change in a situation in which investigators would expect mild cognitive change to occur. Significant change in memory functioning was detected after administration of 50 mg of diphenhydramine. The results suggest that repeated monitoring of cognitive functioning may be an objective tool for measuring cognitive change that may facilitate the identification of subclinical toxic and metabolic encephalopathies.