Jonathan T. Stewart

Dysphagia associated with risperidone therapy.

Dysphagia is occasionally reported in patients taking neuroleptic agents, although the newer, “atypical” neuroleptics are generally believed to be associated with fewer neurologic side effects. We report a 76-year-old man who developed radiographically confirmed dysphagia when treated with risperidone; the dysphagia resolved when risperidone was withdrawn. Clinicians should be aware of the potential for this dangerous but highly reversible problem.

REVERSIBLE DYSPHAGIA ASSOCIATED WITH NEUROLEPTIC TREATMENT

wide spectrum of activity. With intense quinolone use in LTCFs, resistance has increased.” 1 Chen et al. reported increasing pneumococcal resistance to fluoroquinolones, highest in older patients associated with higher rates of use. No pneumococci with reduced susceptibility were noted in children, where quinolone use was negligible. 2 Lee et al. reported low but increasing rates of colonization with ciprofloxacin-resistant Gram-negative bacilli in a skilled nursing facility where quinolones were the most commonly prescribed antibiotics. 8 Withdrawal of antibiotic pressure has been suggested to reduce resistance. Examples of successful hospital-based cephalosporin intervention programs have been reported. 3,4 During a course of antibiotics, the selection of resistant bacteria is inevitable. Sensitivity is likely to be restored if the resident bacteria are given time to reclaim their territory on an even playing field. Unfortunately, resistant bacteria are constantly being selected in the 6% to 8% of nursing home residents being treated with antibiotics. 1 Direct transmission probably occurs continuously between socializing, hygiene-challenged residents or on the hands of staff racing to meet the needs of dependent residents. 9 The emergence of antibiotic resistance seems inevitable. We anticipate that every switch from an empiric quinolone or cephalosporin to a narrow spectrum agent will extend the efficacy of these useful agents as empiric therapy.

Involuntary weight loss associated with cholinesterase inhibitors in dementia

talized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377–384. 3. Oliver D, Hopper A, Seed P. Do hospital fall prevention programs work? A systematic review. J Am Geriatr Soc 2000;48:1679–1689. 4. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guidelines for the prevention of falls in older persons. J Am Geriatr Soc 2001;49:664–672. 5. Oliver D, Daly F, Martin FC et al. Risk factors and risk assessment tools for falls in hospital in-patients: A systematic review. Age Ageing 2004;33:122–130. 6. Renteln-Kruse von W, Krause T. [Fall events in geriatric hospital in-patients. Results of prospective recording over a 3 year period]. Z Gerontol Geriatr 2004;37:9–14. German. 7. Lübke N, Meinck M, von Renteln-Kruse W. [The Barthel Index in geriatrics. A context analysis for the Hamburg Classification Manual.]. Z Gerontol Geriatr 2004;37:316–326. German.

Treatment of catatonia with amantadine.

Catatonia is an episodic syndrome characterized by specific affective, behavioral, and motor symptoms and thought to result from regional abnormalities in neurotransmitter function. Although generally thought to represent a manifestation of schizophrenia or depression, there is strong evidence that it may represent a distinct entity, caused by a number of psychogenic, infectious, iatrogenic, and neurological conditions. The morbidity associated with catatonia is significant, and, in some cases, the condition may be life threatening.

Frégoli syndrome associated with levodopa treatment

Acknowledgments: The authors thank the patient and her mother for their commitment to furthering our understanding of this condition and other disorders affecting the cerebellum. We also thank Richard Johnson, MD for his contribution to the care of this patient. This work was supported in part by the Doris Duke Charitable Foundation and Harvard Medical School (RCG) and the Birmingham Foundation (JDS).

Treatment of clozapine-induced constipation with bethanechol.

To the Editors: C lozapine is often dramatically effective for otherwise refractory patients with schizophrenia and other psychiatric illnesses, but its use may be limited by serious adverse effects. Agranulocytosis is perhaps most familiar, but constipation is far more common, reported in at least 21% of patients. Clozapine-induced constipation can be severe, leading to serious or fatal bowel obstruction, ischemic colitis, or intestinal perforation. Deaths related to vomiting and aspiration have been reported as well. In a review of 102 cases of serious clozapine-induced gastrointestinal hypomotility, Palmer et al noted a mortality rate of 27.5%. We report a patient with refractory schizophrenia for whom clozapine was the only reasonable treatment. He developed severe constipation and a bowel obstruction that was not preventable with conventional laxatives but was able to continue clozapine when bethanechol, a muscarinic agonist, was added.

Managing the care of patients with dementia. How to maximize level of functioning and minimize behavior problems.

Effective treatment of patients with dementia involves supporting and educating the primary caregiver, uncovering and correcting the underlying cause of any decompensation that may occur, and deciding when drug therapy is appropriate. Caregivers must be taught how to cope with the patients denial and how to modify the patients environment so that it is safe and easy to understand. Pharmacologic therapy for depression accompanying dementia can improve a patients quality of life and independence considerably; drugs may also be of help in dealing with patients who resist care. Psychotic symptoms usually do not require pharmacologic treatment, and hypnotics should, if possible, be avoided as a solution to sleep problems.

Dronabinol Treatment of Refractory Nausea and Vomiting Related to Peritoneal Carcinomatosis

Nausea and vomiting are common and often highly distressing symptoms in advanced cancer and in hospice and palliative medicine practice. Nausea and vomiting generally respond well to correction of the underlying etiology (when possible) and appropriate selection of antiemetic medication, but up to 7% of patients will have refractory symptoms. Dronabinol is extensively studied for chemotherapy-related nausea and vomiting, but there are only a few case reports of its use in nausea and vomiting unrelated to chemotherapy. We report a patient with end-stage ovarian cancer with peritoneal carcinomatosis and refractory nausea and vomiting who responded dramatically to addition of dronabinol. Dronabinol is usually well tolerated and may have several novel mechanisms of antiemetic action; further study of its scope of efficacy is warranted.

Swallowing Disorders in Schizophrenia.

Disorders of swallowing are poorly characterized but quite common in schizophrenia. They are a source of considerable morbidity and mortality in this population, generally as a result of either acute asphyxia from airway obstruction or more insidious aspiration and pneumonia. The death rate from acute asphyxia may be as high as one hundred times that of the general population. Most swallowing disorders in schizophrenia seem to fall into one of two categories, changes in eating and swallowing due to the illness itself and changes related to psychotropic medications. Behavioral changes related to the illness are poorly understood and often involve eating too quickly or taking inappropriately large boluses of food. Iatrogenic problems are mostly related to drug-induced extrapyramidal side effects, including drug-induced parkinsonism, dystonia, and tardive dyskinesia, but may also include xerostomia, sialorrhea, and changes related to sedation. This paper will provide an overview of common swallowing problems encountered in patients with schizophrenia, their pathophysiology, and management. While there is a scarcity of quality evidence in the literature, a thorough history and examination will generally elucidate the predominant problem or problems, often leading to effective management strategies.

Why don't physicians consider depression in the elderly? Age-related bias, atypical symptoms, and ineffective screening approaches may be at play

In 1990, as authorized and requested by Congress, President George H. W. Bush proclaimed the 1990s the Decade of the Brain. 1 It was an extraordinary decade: advances in the basic neurosciences and in diagnosis and treatment of neurologic and psychiatric illnesses during that period are unparalleled. Sadly, though, one of the most common, most morbid, and yet most treatable of all brain illnesses still goes undiagnosed with frightening frequency.