Melinda S. Lantz

St. John's Wort and Antidepressant Drug Interactions in the Elderly

There is increasing interest in and use of the herbal preparation St. Johns wort. Hypericin, the major active ingre dient, has many psychoactive properties. The agent is sold in the US as a nutritional supplement and is recommended for numerous conditions, including depression, anxiety, insomnia, and inflammation. We report a series of five cases of clinically diagnosed central serotonergic syndrome among elderly patients who combined prescription antide pressants with St. Johns wort. Older adults are large consumers of both over-the-counter and prescription medications. They are particularly vulnerable to interactions between medications and products sold as nutritional or herbal supplements. St. Johns wort requires further evaluation due to potential for drug interactions with central ner vous system agents and for more definitive therapeutic indications. (J Geriatr Psychiatry Neurol 1999; 12:7-10).

The Effect of a Social Work Intervention to Enhance Advance Care Planning Documentation in the Nursing Home

Objectives: To assess the effect of a multicomponent advance care planning intervention directed at nursing home social workers on identification and documentation of preferences for medical treatments and on patient outcomes.

The relationship between apolipoprotein E, dementia, and vascular illness

The purpose of this study was to concurrently assess the relationship of Apolipoprotein E (APOE) with both dementias and vascular illnesses in the very old. Nine hundred and fifty nine subjects (mean age 85 years) in a long-term care facility were genotyped and cognitively tested with the Mini Mental State Exam. All subjects were studied for the relationship of APOE with atherosclerotic heart disease, hypertension, or stroke without concomitant dementia. Four hundred fifty individuals met criteria for inclusion into one of the following groups: Alzheimers disease (n = 318), vascular dementia (n = 49), or not demented controls (n = 83) and were investigated for the relationship between APOE and these diagnostic categories. APOE epsilon4 was not associated with atherosclerotic heart disease, hypertension, or stroke without concomitant dementia. The APOE epsilon3 allele was more common in men with atherosclerotic heart disease. In contrast, the APOE epsilon4 allele was more common in patients with Alzheimers disease (22%) and vascular dementia (26%) than in not demented controls (7%). APOE epsilon4 is associated with dementias in the very old, whereas its relationship with either peripheral or central nervous system vascular disease without dementia is not as robust.

Screening for Depression in Nursing Home Palliative Care Patients

The purpose of the this study was to evaluate the existing tools for assessing depression in nursing home patients referred to palliative care services. The patients referred to palliative care were assessed for depression by a geriatric fellow and a psychiatrist (gold standard). The questions asked by the fellow were derived from the existing validated screening scales and diagnostic tools. The psychiatrist’s assessment had a strong agreement with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV;. = 0.400) and Geriatric Depression Scale (GDS;. = 0.462) and least agreement with the Cornell Scale for Depression in Dementia (CDS). However, depression in the most severe dementia patients (Mini-Mental State Examination = 0) was able to be assessed only by the CDS. Thus, although items from the DSM-IV and GDS may be used to ascertain depression in geriatric patients, to date there is no scale valid and reliable enough to effectively ascertain depression in the most severely demented patients.

Apolipoprotein E-η4 allele and familial risk in Alzheimer's disease

Recent studies have found an association between presence of apolipoprotein E (APOE) η4 allele and Alzheimers disease (AD). The present study compared the cumulative risk of primary progressive dementia (PPD) in relatives of AD probands carrying at least one copy of the η4 allele with the relatives of AD probands not carrying η4 and with relatives of non‐demented controls. Our aim was to determine whether the familial aggregation of PPD in relatives of AD probands is primarily due to those carrying η4. Seventy‐seven neuropathologically diagnosed AD patients were obtained as probands through our Alzheimers Disease Research Center Brain Bank. AD probands were genotyped for APOE. As a comparison group, 198 non‐demented probands were also included. Through family informants, demographic and diagnostic data were collected on 382 first‐degree relatives (age ≥ 45 years) of AD probands and 848 relatives of the controls. We found that the cumulative risk of PPD in both relatives of AD probands with and without the η4 allele was significantly higher than that in the relatives of non‐demented controls. However, the increased risk in the relatives of AD probands with the η4 allele was marginally, but not significantly, lower than the risk in the relatives of probands without η4. A greater likelihood of death by heart diseases over developing PPD in relatives of AD probands with η4 (3.1‐fold increase) was found compared to relatives of probands without η4 (1.7‐fold increase), especially prior to age 70, although the difference was not statistically significant. The increased familial risk for PPD in the relatives of AD probands with the APOE‐η4 allele relative to controls suggests that familial factors in addition to APOE‐η4 are risk factors for AD. Differential censorship from increased mortality of heart diseases may have prevented a higher incidence of PPD among the relatives of probands with η4.

Pharmacologic Treatment of Agitation in Dementia: A Comprehensive Review

Agitated behaviors are a common and nearly universal occurrence among patients suffering from dementing illnesses. The pharmacologic treatments available for this troubling syndrome are varied, but treatment studies are limited. Clinicians are frequently faced with the challenging management of patients with disruptive behavior who fail to respond to trials with multiple agents. This review summarizes available treatment studies of agitation in dementia and offers a guide to therapy and management. Reports of therapies for agitation in dementia are limited by lack of controlled studies, variability of diagnostic criteria and outcome measures, and small sample size. The need for carefully designed, well-controlled studies of outcome in this growing population is formidable. It is imperative to identify effective and well-tolerated treatment strategies to reduce the morbidity of these distressing and burdensome symptoms.

Has familial aggregation in Alzheimer's disease been overestimated ?

Studies of the familial aggregation of Alzheimers disease have primarily used samples ascertained from tertiary care clinics which may not be representative of many AD patients, for example those residing at geriatric nursing homes. Survival analysis was used to investigate whether estimates of familial aggregation of AD based on a clinic‐based AD proband (C‐AD) sample (probands: N=544; first degree relatives; N=4267) differ from one ascertained at a nursing home (NH‐AD; probands: N=225; first degree relatives; N=1772). The cumulative survival from AD was significantly worse in relatives of the C‐AD probands and the overall relative risk (RR) of AD in this group was greater than twice that of relatives of the NH‐AD probands. However, age at onset in C‐AD probands was significantly earlier than in the NH‐AD group and in both groups this factor was negatively associated with familial aggregation. When, for this reason, the proband samples were matched one‐to‐one by age at onset, dropping those probands with no match, the two curves were close to identical and the RR for the C‐AD group of relatives was 1.0 The results suggest that estimates of familial risk of AD based on C‐AD samples are not applicable and overestimate the extent of increased risk for relatives of more prevalent, later onset AD probands. However, the overestimate can be explained by the typically earlier age at onset in C‐AD samples as opposed to a sampling bias related to the probands family history status per se. The relationship between onset age and familial aggregation suggests that no single estimate of the age‐dependent risk (survival curve) is uniformly appropriate for relatives of AD probands. Copyright

Treatment of Late-Life Psychosis

Purpose of reviewPsychosis in late life is a cause of significant distress, suffering, and decline in the quality of life for patients, caregivers, and family members. While psychotic symptoms in later life may be related to long-standing, chronic conditions, the new onset of delusions and hallucinations often presents a diagnostic dilemma to the clinician. This paper seeks to review the overall causes and conditions related to psychosis in later life and discuss available treatment options.Recent findingsThe paucity of new research in the areas of psychosis in late-life and the near absences of clinical drug trials in this area is a source of great frustration to the practicing clinician. The need to abstract and modify drug dosing and treatment regimes for frail, elderly patients based on available data is typically required. The minimal availability of psychotherapy research in the area of psychosis in late life is troubling.SummaryAntipsychotic medications may be safely and effectively utilized for the treatment of psychosis in late life. Side effect monitoring is vital, and agents for the treatment of tardive dyskinesia may be required.