Jothika Manepalli

Alcoholism and Prescription Drug Abuse in the Elderly: St. Louis University Grand Rounds

This Grand Rounds will review the problem of alcoholism and prescription drug abuse in the elderly. Several case vignettes will be presented. The pharmacology of alcohol and potentially addictive prescription medications will be reviewed. The clinical presentation of and psychiatric symptoms associated with these disorders will be discussed. The process of addiction and issues regarding the clinical evaluation of the elderly addict will be discussed. The medical complications of these disorders will be reviewed, followed by a discussion of guidelines for the appropriate use of these drugs in the elderly. The grand rounds will conclude with a discussion of the treatment of patients with these disorders.

Prevalence of Delirium and Urinary Tract Infection in a Psychogeriatric Unit

A retrospective study involving 407 patients discharged over a 2-year period from a psychogeriatric unit found that 83 (20.4%) had urinary tract infection (UTI) and 54 (13.3%) had delirium diagnoses at admission. Of the 54 with delirium, 14 (25.9%) had UTI. Of these 14 patients, delirium cleared in nine (64.3%) after appropriate treatment of UTI, two (14.3%) improved with treatment of concomitant medical disorders, and three (21.4%) did not improve. Only six of the 14 (42.8%) showed symptoms of UTI, with only one of the 14 (7.1%) showing fever and leukocytosis. Urine analyses were abnormal in all cases with 13/14 (92.8%) having positive cultures. Dementia was an associated risk factor in 71.4% of the 14 patients with UTI and delirium. Clinicians need to have a high index of suspicion relative to the presence of UTI in the elderly, especially with pre- existing cognitive impairment, since it can precipitate delirium. Early recognition and appropriate treatment decreases morbidity. (J Geriatr Psychiatry Neurol 1990;3:198-202).

Electroconvulsive Therapy in the Presence of a Metallic Skull Plate After Meningioma Resection

Electroconvulsive therapy (ECT) is an effective and safe treatment even in the frail and in the medically ill. A case report of ECT being administered to a patient with a history of a recently resected meningioma and the presence of a metallic skull plate is presented here. The patient has a history of bipolar disorder in remission but had an acute manic episode with psychotic features after resection of suprasellar meningioma. He presented with superimposed delirium that complicated the presentation. Because there was no effective resolution with medications, ECT was administered. This case documents the safe administration of ECT in complicated situations such as these. This case also demonstrates that ECT can be successfully administered in the presence of superimposed delirium and after a recent meningioma resection. Clinical skills and expertise are required to safely and effectively administer ECT in such cases.

Anxiety Disorders in Older Adults

Late life anxiety disorders are the most prevalent psychiatric conditions among older adults and they often present at a sub-threshold level. Specific phobias (SP) are particularly frequent and fear of falling is increasingly being recognized as a class of phobias typically seen in older adults. Generalized anxiety disorder (GAD), although recognized as a chronic disorder with early onset, has been found to have an onset late in life as well. Social phobia (SoP) has been found to not necessarily have a chronic course in this population. Post-traumatic stress disorder (PTSD) manifests in older adults often as an exacerbation of symptoms from a trauma earlier in life. Cognitive behavior therapy (CBT) augmented with learning and memory aids, and a combination of CBT and medication, has had good outcomes in the management of anxiety disorders in older adults.

Recent Advances in Neuromodulatory Therapies in Psychogeriatrics: From TMS to ECT to VNS to Both Surgical and Magnetic DBS

Neuromodulation therapies also known as brain stimulation therapies or techniques are used to treat various neuropsychiatric illnesses in adult and geriatric patients. Electroconvulsive therapy (ECT) was the first such treatment availed to be used for mood disorders and psychotic disorders. Since then, transcranial magnetic stimulation (rTMS) was also found to be effective with fewer side effects than ECT. Similarly, vagal nerve stimulation (VNS) and deep brain stimulation (DBS), used for seizure and movement disorders, respectively, have been found useful in the treatment of depression and other psychiatric disorders. These neuromodulation therapies are becoming more refined, and we are learning more about their uses in other neuropsychiatric disorders. In the last decade, there has been tremendous growth of knowledge and research in the use of these therapies, but more needs to be evaluated before such treatments become as familiar as ECT.