Susan W. Lehmann

Prevalence of anxiety disorders and anxiety subtypes in patients with Parkinson's disease

Anxiety disorders are common in Parkinsons disease (PD), but are not well characterized. This study determined the prevalence and clinical correlates of all DSM‐IV‐TR anxiety disorder diagnoses in a sample of 127 subjects with idiopathic PD who underwent comprehensive assessments administered by a psychiatrist and neurologist. A panel of six psychiatrists with expertise in geriatric psychiatry and/or movement disorders established by consensus all psychiatric diagnoses. Current and lifetime prevalence of at least one anxiety disorder diagnosis was 43% (n = 55) and 49% (n = 63), respectively. Anxiety disorder not otherwise specified, a DSM diagnosis used for anxiety disturbances not meeting criteria for defined subtypes, was the most common diagnosis (30% lifetime prevalence, n = 38). Compared with nonanxious subjects, panic disorder (n = 13) was associated with earlier age of PD onset [50.3 (12.2) vs. 61.0 (13.7) years, P < 0.01], higher rates of motor fluctuations [77% (10/13) vs. 39% (25/64), P = 0.01] and morning dystonia [38% (5/13) vs. 13% (8/62), P < 0.03]. This high prevalence of anxiety disorders, including disturbances often not meeting conventional diagnostic criteria, suggests that anxiety in PD is likely underdiagnosed and undertreated and refined characterization of anxiety disorders in PD is needed. In addition, certain anxiety subtypes may be clinically useful markers associated with disease impact in PD.

Prevalence of Psychotic Symptoms in a Community-Based Parkinson Disease Sample

OBJECTIVES : To determine the prevalence of psychotic phenomena, including minor symptoms, in a Parkinson disease (PD) sample and compare the clinical correlates associated with the various psychotic phenomena. To evaluate the extent to which cases met National Institute of Neurological Diseases and Stroke (NINDS)/National Institute of Mental Health (NIMH)-proposed criteria for PD-associated psychosis. METHODS : A total of 250 patients with idiopathic PD and Mini Mental State Exam scores greater than 23 from three community-based movement disorder clinics underwent comprehensive research diagnostic evaluations by a geriatric psychiatrist as part of a study on mood disorders in PD. Psychotic symptoms were categorized using a checklist, which included a breakdown of hallucinations, delusions, and minor symptoms. Clinical characteristics of groups with minor and other psychotic symptoms were compared. The NINDS/NIMH criteria for PD-psychosis were retrospectively applied. RESULTS : Of the total sample, 26% of patients were found to have any current psychotic symptoms, with 47.7% of those having isolated minor symptoms, and 52.3% having hallucinations and/or delusions. Compared to those with no current psychiatric symptoms, minor symptoms were associated with more depressive symptoms and worse quality of life, and 90.8% of those with psychotic symptoms fulfilled the NINDS/NIMH proposed criteria. CONCLUSIONS : Psychotic symptoms are common in PD patients, with minor psychotic phenomena present in nearly half of affected patients in a community-based sample. Psychotic symptoms, including minor phenomena, were clinically significant. The NINDS/NIMH PD-psychosis criteria captured the clinical characteristics of psychosis as it relates to PD. Longitudinal studies are needed to determine whether minor psychotic symptoms represent a precursor to hallucinations and delusions, and to further validate diagnostic criteria.

Depression in assisted living is common and related to physical burden

OBJECTIVE The objective of this study was to obtain a direct estimate of the prevalence of depression, its associated factors, and rates of treatment among residents of assisted living (AL) facilities in central Maryland. METHOD One hundred ninety-six AL residents were recruited from 22 (10 large and 12 small) randomly selected AL facilities in the city of Baltimore and seven Maryland counties. Chart review, staff and family history, comprehensive in-person resident evaluation, and the Cornell Scale for Depression in Dementia (CSDD) were administered by an experienced team of geriatric psychiatry clinicians. Those scoring >7 on the CSDD, a cut point repeatedly associated with poor outcomes, were considered clinically depressed. RESULTS Participants had an average age of 86 years, most were female and widowed, and 68% met consensus criteria for dementia. Twenty-four percent (47 of 196) of the sample was depressed. In bivariate analyses, depression was significantly related to medical comorbidity, need for activities of daily living (ADLs) assistance, more days spent in bed, and less participation in organized activities. After controlling for pertinent covariates in a regression model, only need for ADL assistance remained significantly associated with depression. Forty-three percent of those currently depressed were receiving antidepressants and were more likely to receive them if they lived in a large AL facility. Sixty percent of depressed residents had no regular source of psychiatric care. CONCLUSIONS In the first clinical study implemented by geriatric psychiatry professionals in AL, depression was found to be common, undertreated, and related to physical burden. AL is a rapidly growing segment of long-term care and represents an important setting in which to find and treat serious depression.

Lithium-associated hypercalcemia and hyperparathyroidism in the elderly: what do we know?

BACKGROUND Lithium has been reported to induce hypercalcemia and hyperparathyroidism, yet few studies have examined the impact on older patients. We therefore undertook this review and report our findings. METHOD We undertook a systematic review of articles on lithium-associated hypercalcemia and/or hyperparathyroidism that were identified via electronic English language database searches through PubMed. RESULTS Among reported cases and case series of lithium-associated hyperparathyroidism in which ages of specific subjects were provided, 40% of affected individuals were over age 60. Mean serum calcium levels are reported to be higher in lithium treated patients over age 60 compared with younger patients. While many patients who develop lithium-associated hypercalcemia and hyperparathyroidism are asymptomatic, symptomatic complications may be more of a concern in older patients, especially in those with co-morbid renal disease. LIMITATIONS To date, all cross-sectional studies of lithium-associated hypercalcemia and hyperparathyroidism are of mixed age group cohorts and more specific studies focused on older patients have yet to be performed. CONCLUSIONS Lithium-induced hypercalcemia and hyperparathyroidism are under-recognized potential complications of lithium therapy which may occur more frequently in older patients. Psychiatrists should be vigilant in screening for hypercalcemia and hyperparathyroidism in their older patients receiving lithium, both prior to starting treatment and at least annually thereafter.

Anxiety and self-perceived health status in Parkinson’s disease ☆

Both anxiety and depression are associated with lower self-perceived health status (HS) in persons with Parkinsons disease (PD). Given the high co-morbidity with depression and other non-motor symptoms, it is unclear whether anxiety disorders, in general, versus specific anxiety subtypes have an independent effect on HS in PD. To examine this question, comprehensive assessments of motor and non-motor symptoms from 249 subjects with idiopathic PD followed in three community-based movement disorders neurology practices were analyzed. HS was measured using the 8-item PD Questionnaire (PDQ-8). Psychiatric diagnoses were established by consensus using a panel of six psychiatrists with expertise in geriatric psychiatry and movement disorders. Stepwise multiple regression analyses were used, with the PDQ-8 score as the dependent variable, to identify independent predictors of HS among motor, psychiatric, and other non-motor variables. Among the anxiety disorders, only anxiety associated with motor fluctuations was an independent predictor of HS after accounting for co-morbid depression and other clinical features. In addition, depressive disorders were also an independent predictor of lower HS. Prevention or treatment of state-dependent anxiety may improve HS in persons with PD.

Effects of Depression Diagnosis and Antidepressant Treatment on Mortality in Medicare Beneficiaries with Chronic Obstructive Pulmonary Disease

To estimate the effects of depression diagnosis and antidepressant treatment on 2‐year all‐cause mortality in Medicare beneficiaries with chronic obstructive pulmonary disease (COPD) and determine whether Social Security Disability Insurance (SSDI) eligibility modifies these relationships.

Association between depression and maintenance medication adherence among Medicare beneficiaries with chronic obstructive pulmonary disease

Depression is a significant comorbidity in patients with chronic obstructive pulmonary disease (COPD). Although comorbid depression is associated with low use and poor adherence to medications treating other chronic conditions, evidence of the relationship between depression and COPD management is limited. This study estimated the association between depression and COPD maintenance medication (MM) adherence among patients with COPD.

Psychiatric disorders in older women.

With increased longevity and an aging ‘baby boomer‘ population, the numbers of women in older age groups in the United States will be increasing significantly over the coming years. Older women with schizophrenia and mood disorders that began in early adult life continue to need psychiatric treatment, although treatment considerations may require modification with age. In addition, late-onset depressive disorders are more common among older women than older men and may undermine physical and psychosocial well-being if inadequately treated. Late-onset schizophrenia and bipolar disorder are less common, but also affect older women more often than older men. Moreover, psychiatric concerns related to Alzheimer‘s disease and care giving are pertinent to this older population. Clinicians need to be knowledgeable about differences in epidemiology and clinical presentation that distinguish psychiatric disorders in older women from both men and from younger cohorts.

Pharmacologic Treatment of Anxiety Disorders in Parkinson Disease

OBJECTIVE Neither best practices nor an evidence base for the pharmacologic treatment of anxiety in Parkinson disease (PD) has been established. This study investigated pharmacologic treatment of anxiety disorders in idiopathic PD and the associated clinical features. DESIGN Cross-sectional. SETTING Three community-based movement disorder neurology practices. PARTICIPANTS 250 subjects with PD. MEASUREMENTS Anxiety disorder diagnoses were established by consensus using a panel of six psychiatrists with expertise in geriatric psychiatry and movement disorders. Current medications were provided by the treating neurologists at the time of interview. RESULTS Among subjects with anxiety disorders only, 53% were untreated with medications. When anxious subjects with comorbid depressive disorders were included, 70.8% were on medications effective for treatment of anxiety. Subjects with anxiety and comorbid depressive disorders were more likely to be treated for their psychiatric disturbances than subjects with anxiety disorders alone (odds ratio: 8.33), as were subjects with comorbid motor fluctuations (odds ratio: 3.65). There were no differences in the types of anti-anxiety medications used in regard to the presence of depression or motor fluctuations. CONCLUSIONS These findings suggest that over half of nondepressed PD patients with clinically significant anxiety are untreated with medication. A better understanding of the role of clinical features associated with anxiety in PD, such as depression and motor fluctuations, may improve the recognition and treatment of anxiety disorders in this population.

Association between Depression and Maintenance Medication Adherence among Medicare Beneficiaries with COPD

Depression is a significant comorbidity in patients with chronic obstructive pulmonary disease (COPD). Although comorbid depression is associated with low use and poor adherence to medications treating other chronic conditions, evidence of the relationship between depression and COPD management is limited. This study estimated the association between depression and COPD maintenance medication (MM) adherence among patients with COPD.