Ling Han

The Course of Delirium in Older Medical Inpatients: A Prospective Study

AbstractOBJECTIVES: To describe the clinical course and outcomes of delirium up to 12 months after diagnosis, the relationship between the in-hospital clinical course and post-discharge outcomes, and the role of dementia in both the clinical course and outcomes of delirium.n DESIGN: Prospective cohort study.n SETTING: Medical wards of a 400-bed, university-affiliated, primary acute care hospital in Montreal.n PATIENTS: Cohort of 193 medical inpatients aged 65 and over with delirium diagnosed at admission or during the first week in hospital, who were discharged alive from hospital.n MEASUREMENTS AND MAIN RESULTS: Study outcomes included cognitive impairment and activities of daily living (standardized, face-to-face clinical instruments at 1-, 2-, 6-, and 12-month follow-up), and mortality. Dementia, severity of illness, comorbidity, and sociodemographic variables were measured at time of diagnosis. Several measures of the inhospital course of delirium were constructed. The mean numbers of symptoms of delirium at diagnosis and 12-month follow-up, respectively, were 4.5 and 3.5 in the subgroup of patients with dementia and 3.4 and 2.2 among those without dementia. Inattention, disorientation, and impaired memory were the most persistent symptoms in both subgroups. In multivariate analyses, pre-morbid and admission level of function, nursing home residence, and slower recovery during the initial hospitalization were associated with worse cognitive and functional outcomes but not mortality.n CONCLUSIONS: Among patients with and without dementia, symptoms of delirium persist up to 12 months after diagnosis. Quicker in-hospital recovery is associated with better outcomes.

Tracking Cognitive Decline in Alzheimer's Disease Using the Mini-Mental State Examination: A Meta-Analysis

OBJECTIVESnTo estimate the annual rate of change scores (ARC) on the Mini-Mental State Examination (MMSE) in Alzheimers disease (AD) and to identify study or population characteristics that may affect the ARC estimation.nnnMETHODSnMEDLINE was searched for articles published from January 1981 to November 1997 using the following keywords: AD and longitudinal study or prognosis or cognitive decline. The bibliographies of review articles and relevant papers were searched for additional references. All retrieved articles were screened to meet the following inclusion criteria: (a) original study; (b) addressed cognitive decline or prognosis or course of AD; (c) published in English; (d) study population included AD patients with ascertainable sample size; (e) used either clinical or pathological diagnostic criteria; (f) longitudinal study design; and (g) used the MMSE as one of the outcome measures. Data were systematically abstracted from the included studies, and a random effects regression model was employed to synthesize relevant data across studies and to evaluate the effects of study methodology on ARC estimation and its effect size.nnnRESULTSnOf the 439 studies screened, 43 met all the inclusion criteria. After 6 studies with inadequate or overlapping data were excluded, 37 studies involving 3,492 AD patients followed over an average of 2 years were included in the meta-analysis. The pooled estimate of ARC was 3.3 (95% confidence interval [CI]: 2.9-3.7). The observed variability in ARC across studies could not be explained with the covariates we studied, whereas part of the variability in the effect size of ARC could be explained by the minimum MMSE score at entry and number of assessments.nnnCONCLUSIONSnA pooled average estimate of ARC in AD patients was 3.3 points (95% CI: 2.9-3.7) on the MMSE. Significant heterogeneity of ARC estimates existed across the studies and cannot be explained by the study or population characteristics investigated. Effect size of ARC was related to the initial MMSE score of the study population and the number of assessments.

Environmental Risk Factors for Delirium in Hospitalized Older People

To evaluate the relationship of environmental risk factors in hospitals to changes over time in delirium symptom severity scores.

No coding variant of the tryptophan hydroxylase gene detected in seasonal affective disorder, obsessive–compulsive disorder, anorexia nervosa, and alcoholism

BACKGROUNDnThe goal of this study was to evaluate the role of genetic variation in the coding sequence of tryptophan hydroxylase (TPH) in the pathogenesis of several psychiatric diseases in which altered serotonin function has been implicated: bipolar affective disorder (BP), obsessive-compulsive disorder (OCD), anorexia nervosa (AN), seasonal affective disorder (SAD), panic disorder (PD), and alcoholism (Alc).nnnMETHODSnNinety-three percent of the TPH coding sequence was screened by polymerase chain reaction single-strand conformation polymorphism (SSCP) for DNA sequence variations in 128 AN, 88 OCD, 72 SAD, 45 PD, and 36 BP patients and 142 normal volunteers. Also included in the screening were 61 Alc randomly selected from a Finnish alcoholic population in which an association of a TPH intron 7 polymorphism with suicidality was previously observed. Polymorphisms detected by SSCP were characterized by DNA sequencing and by allele-specific restriction enzyme digestion. Genotyping was then performed in 34 Finnish alcoholic suicide attempters.nnnRESULTSnA rare silent mutation was identified in exon 10 and is designated T1095C. The C1095 allele was found in 1 OCD and in 2 AN subjects; all 3 individuals were heterozygous (C1095/T1095) for the variant allele. No association was observed between this TPH T1095C variant with either OCD, AN, Alc, or suicidality.nnnCONCLUSIONnThese results suggest that the coding sequence of the TPH gene does not contain abundant variants, and may not play a major role in vulnerability to several psychopathologies in which reduced serotonin turnover has been implicated.

Monorhinal odor identification and depression scores in patients with seasonal affective disorder

BACKGROUNDnVisual and olfactory pathways are interconnected. Olfactory deafferentation unmasks photoperiodic responsiveness in some nonphotoperiodic animals such as laboratory rats. By analogy, we hypothesized that olfactory deficits may unmask seasonal rhythms in certain individuals, namely those with seasonal affective disorder (SAD). Since previous studies suggest lateralized hemispheric dysfunction in SAD, and since olfactory neurons primary projections are largely ipsilateral, we assessed olfactory identification performance on both the right and left side of the nose.nnnMETHODSnTwenty-four patients with SAD and 24 matched controls were studied using a phenyl ethyl alcohol detection threshold test bilaterally and the University of Pennsylvania Smell Identification Test unilaterally. Subjects rated their mood using the Self Assessment Mood Scale for SAD. Patients testing was done in both depressed and improved on light states.nnnRESULTSnNo difference in olfactory performance was found between patients and controls or between patients before and after light treatment. However, right-side identification scores were negatively correlated with typical depression scores (r = -0.56, P = 0.006), while left-side olfactory scores were not. Atypical depression scores were unrelated to olfactory performance. Similar correlations emerged between the olfactory identification laterality quotient (Right - Left)/(Right + Left) and typical depressive scores (r = - 0.64, P < 0.001) and total depression scores (r = - 0.59, P < 0.004).nnnLIMITATIONSnWe studied a demographically heterogeneous sample and did not control for menstrual factors.nnnDISCUSSIONnOur results add to previous evidence of lateralized hemispheric involvement in SAD and suggest that olfaction may be related to seasonal emotional rhythms in humans.

Summer and winter patterns of seasonality in Chinese college students: a replication.

The goal of this study is to replicate an earlier epidemiological finding of seasonal changes in mood and behavior among Chinese medical students using an independent study population. Three hundred nineteen college students were surveyed with a Chinese version of the Seasonal Pattern Assessment Questionnaire (SPAQ) and the Beck Depression Inventory (BDI) in Jining, China, during March of 1996. The frequency of seasonal patterns and prevalence rates of seasonal affective disorder (SAD) were estimated and compared with data from the medical student survey conducted in the same city. The mean Global Seasonality Score (GSS) of this college student sample was 9.9 +/- 4.9; 84% of the subjects reported some problems with the changing seasons. Summer difficulties were more prevalent than winter difficulties by a ratio of 1.9 to 1 (38.9% v 20.1%). The estimated rates of summer SAD and subsyndromal-SAD (s-SAD) were 7.5% and 11.9%, respectively, as compared with the corresponding winter figures of 5.6% and 6.3%. In addition, the prevalence estimates of winter pattern or winter SADs were higher in males than in females, but the corresponding summer figures showed no gender difference. Compared with the data from the medical student survey, this college student sample had a higher GSS (P < .01) but comparable summer to winter and female to male ratios for the prevalence of SADs (P > .05). These results replicate our previous findings that seasonal problems are common in China, but the predominant problems are summer difficulties rather than winter difficulties, and there is no female preponderance in the prevalence estimates of such problems. Both findings stand in contrast to most Western studies but are consistent with the only other published study performed in the Orient.

Antidepressant Use and Cognitive Functioning in Older Medical Patients with Major or Minor Depression–a prospective cohort study with database linkage

Objective: The long-term cognitive effect of antidepressant medications in older persons is not well understood, especially in those with minor depression and complex medical conditions. The objective of this study is to examine this relationship in older medical patients with different depression diagnoses. Methods: 281 medical inpatients aged 65 years and older from 2 acute care hospitals in Montreal, Canada, were diagnosed as with major or minor depression or without depression according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. They were followed up with the Mini-Mental State Examination for cognitive function and the Hamilton Depression Rating Scale for depressive symptoms at baseline and 3, 6, and 12 months after discharge. Antidepressant medication was ascertained from a provincial prescription database and quantified as cumulative exposures over each follow-up interval. Results: During the 12-month follow-up period, 1027 antidepressant prescriptions were filled. The most frequently prescribed antidepressant agents were citalopram (0.81 prescriptions per person), sertraline (0.76), and paroxetine (0.66). Antidepressant use was not associated with cognitive changes among patients with major depression or without depression but was associated with an increased Mini-Mental State Examination score in patients with minor depression (1.4 points; 95% confidence interval, 0.1-2.6), independent of change in the severity of depression symptoms, concomitant benzodiazepine or psychotropic drug use, and other potentially important confounders. Conclusions: In this cohort of older medical patients, antidepressant use for 12 months did not lead to significant cognitive impairment. The small cognitive improvement among minor depression associated with antidepressant use deserves further investigation.