Richard H. Workman

The efficacy and tolerability of divalproex sodium in elderly demented patients with behavioral disturbances

Behavioral disturbances are commonly encountered in elderly demented patients. The records of all patients admitted to a geropsychiatric inpatient unit within a 2‐year period who had a primary diagnosis of dementia and an accompanying behavioral disturbance treated with divalproex sodium were reviewed. Of the 13 patients identified, all tolerated divalproex sodium without significant side‐effects. General psychiatric symptoms, overall agitation, physical aggression and non‐aggressive physical agitation decreased significantly, but verbal agitation did not. Divalproex sodium is well tolerated and may be effective in ameliorating certain behavioral disturbances in elderly demented patients with agitation.

Tolerability of Divalproex Sodium in Elderly Psychiatric Patients with Mixed Diagnoses

This study addresses the tolerability of divalproex sodium in elderly psychiatric inpatients with various Axis I diagnoses, using structured assessments. A chart review for a 7-month period on a geropsychiatry inpatient unit identified 13 patients who had been treated with divalproex sodium. All 13 patients received standardized ratings on the Cohen-Mansfield Agitation Inventory (CMAI), Brief Psychiatric Rating Scale (BPRS), Rating Scale for Side Effects (RSSE), and Mini-Mental State Examination (MMSE) on admission and discharge, which were compared using paired f-tests for 12 of the 13 patients. The thirteenth patient was withdrawn from valproate prior to discharge after developing a delirium thought to be secondary to a divalproex-phenytoin interaction. All of the remaining 12 patients tolerated divalproex sodium well with no significant change in MMSE scores (P = .486), CMAI scores (P = .0546), or RSSE scores (P = .124). The change in BPRS score was found to be significant (P = .004). Based on the present study and previously reported case series, divalproex sodium appears to be well tolerated in an elderly psychiatric population.

Persistence of Combat-Related Posttraumatic Stress Symptoms for 75 Years

Investigations of the duration of combat-related posttraumatic stress symptoms have focused mainly on survivors of World War II and the Vietnam War, with little attention to surviving veterans of World War I. The authors describe a case in which posttraumatic stress symptoms persisted for 75 years in a World War I combat veteran and increased in frequency toward the end of his life accompanied by advancing dementia and hospitalization. The case illustrates that posttraumatic stress symptoms may be lifelong and exacerbated by various consequences of aging, even if they are not disabling.

The Benefits of Psychiatric Hospitalization for Older Nursing Home Residents

To examine the demographic characteristics and treatment outcomes of nursing home residents admitted to a geropsychiatric inpatient unit.

TOLERABILITY OF CLONAZEPAM IN DEMENTED AND NON-DEMENTED GEROPSYCHIATRIC PATIENTS

Objective. The tolerability of clonazepam in geropsychiatric inpatients was examined in patients with and without a diagnosis of dementia.

Association of serum cholesterol and triglyceride levels with agitation and cognitive function in a geropsychiatry unit

Several studies have reported an association between aggression and cholesterol levels. The purpose of this study was to investigate the relationship of serum cholesterol and triglyceride levels with aggression and cognitive function in elderly inpatients. One hundred ten patients consecutively admitted to the Geriatric Psychiatry inpatient unit at Houstons Veterans Affairs Hospital received comprehensive evaluations by a multidisciplinary team. Fasting serum cholesterol and triglyceride levels were obtained within 3 days of admission. In addition, two geriatric psychiatrists administered the Mini-Mental State Examination (MMSE) and the Cohen-Mansfield Agitation Inventory (CMAI). Correlation coefficients were calculated between lipid levels, CMAI total and subscale scores, and MMSE scores. Multiple linear-regression analyses were done to further investigate the relation between lipid concentrations and various confounders. We found no significant correlation between serum triglyceride levels and MMSE, CMAI total, and CMAI factor scores. In addition, we found a significant positive correlation between serum cholesterol levels and physical nonaggressive behavior, and a significant negative correlation between serum cholesterol levels and MMSE scores. We found no relationship between aggressive behavior and serum cholesterol or triglyceride levels. However, an association between high cholesterol levels and agitation exists, which may be mediated by the association between high cholesterol levels and impaired cognition.

Principles and practice of geriatric assent

Geriatric assent involves health care professionals’ active collaboration with cognitively impaired patients that takes account of their longstanding values in any major health care decisions. The main purpose of this paper is to assist geriatric health practitioners ‘in the field’ to understand how to apply geriatric assent in a variety of clinical situations to maximize incapacitated older adults’ input into decision-making. A case example and algorithm are presented to illustrate the basic principles of implementing geriatric assent. Practice informed by the principles of geriatric assent will preserve respect for the current and future autonomy of patients across diverse cultural backgrounds.

Psychosis in geropsychiatric inpatients with and without dementia

Psychotic symptoms are commonly encountered in elderly patients both with and without dementia. The authors compared presentation and treatment response between these two groups. Of 206 consecutive admissions to an inpatient geropsychiatry unit, 52 (26%) had psychotic symptoms. Thirteen of these had dementia and 22 had a primary Axis I psychotic disorder without dementia. Both groups presented similarly, improved significantly from admission to discharge and demonstrated equivalent medication side‐effect profiles. Elderly psychotic patients with and without dementia improve significantly on antipsychotics and tolerate their side‐effects; however, those with dementia receive lower dosages of medication to treat their symptoms.

The Contribution of Cognitive Impairment, Medical Burden, and Psychopathology to the Functional Status of Geriatric Psychiatric Inpatients

In order to define the contributions of cognitive impairment, medical burden, and psychopathology to the functional status of geriatric psychiatric patients, a forward-looking, retrospective study of 106 consecutive admissions to a geriatric psychiatric unit at the Houston Veterans Affairs Medical Center Hospital was done. It was found that psychopathology and cognitive status, but not medical burden, contributed to the variance in functional status of geriatric psychiatric inpatients for both admission scores and for changes in scores during hospitalization. Improvements in cognitive state and psychopathology were associated with improvements in functional status during hospitalization.

Outcome of Psychiatric Hospitalization for Very Low-Functioning Demented Patients

The authors determined the outcome of geropsychiatric hospitalization for 73 very low-functioning demented patients (GAF score < 21). General psychiatric symptoms, depression, and agitation decreased significantly, and mean GAF scores increased significantly, with no significant change in cognitive function. Psychiatric hospitalization can meaningfully improve function and quality of life even in this very impaired population. Despite these improvements many patients are discharged to more restrictive settings.