Suzanne Holroyd

Depression is associated with impairment of ADL, not motor function in Parkinson disease

Depression was diagnosed in 15% of 100 consecutive patients with Parkinson disease (PD). Depression was associated with lower cognition, history of depression, and a higher Unified Parkinson’s Disease Rating Scale score. The latter was due to differences in the activities of daily living (ADL) subscale (17 ± 7 vs 12 ± 6; p = 0.004) rather than the motor subscale (30 ± 13 vs 26 ± 13; p = 0.27). These results suggest that ADL impairment may in part be due to depression. Patients with PD with poor function should be closely evaluated for depression.

Substance use disorders in a geriatric psychiatry outpatient clinic: prevalence and epidemiologic characteristics.

This study was conducted to determine the prevalence of substance use disorders in a geriatric psychiatry outpatient clinic. The overall prevalence for any substance use disorder was 20% (N = 28). The prevalence of benzodiazepine dependence was 11.4% (N = 16); the prevalence of alcohol dependence was 8.6% (N = 12); and the prevalence of prescription narcotic dependence was 1.4% (N = 2). These findings suggest that substance use disorders in the geriatric psychiatry outpatient population exist to a significantly greater extent than previously reported. Descriptive statistics were used to characterize patients with benzodiazepine dependence, alcohol dependence, and no substance use disorder. These groups were compared on demographic and clinical variables using one-way analysis of variance (ANOVA) and chi-squared statistical techniques. Clinicians working in comparable outpatient settings may be in a better position to prevent, detect, and treat substance use disorders in their patients as a result of increased awareness of its epidemiologic characteristics in this population.

Attitudes of elderly subjects toward "truth telling" for the diagnosis of Alzheimer's disease.

This study expands on previous research regarding attitudes of older adults toward disclosure of the diagnosis of Alzheimers disease (AD). Two hundred patients 65 years or older completed a questionnaire assessing opinions about being told the diagnosis of AD versus cancer. Most responded they wanted to be told if they had AD or terminal cancer (92% for AD, 86.5% for cancer, P = .06). Those with personal experience with AD were significantly less likely to want to know themselves if they had AD than were those without personal experience (P <.0001). A variety of reasons were given for wanting to be told the diagnosis of AD, including a small minority (1.7%) who would consider suicide. Although these results appear to support recent American Medical Association guidelines favoring disclosure of a dementia diagnosis, complex issues remain. Further research is needed to develop guidelines for physicians in disclosing dementia diagnoses that includes outcome studies of disclosure to patients. (J Geriatr Psychiatry Neurol 2003; 16:90-93)

Differences in geriatric psychiatry outpatients with early- vs late-onset depression.

This study assessed clinical and demographic differences between 74 geriatric psychiatry outpatients with early‐onset vs late‐onset depression. The following data were considered: age, gender, marital status, years of education, number of prescription medications and active medical diagnoses (including presence of various categories of medical disorder), presence of any comorbid dementia or other psychiatric disorder, age of depression onset, number of depressive episodes and MMSE score. Fifteen patients (20.3%) had an early onset of depression (before age 60 years) and 59 (79.7%) had a late onset of depression. Early‐onset patients had significantly more episodes of depression than late‐onset patients (4.2 vs 1.9, t=4.74, p<0.001). Patients with early‐onset depression also had a higher mean number of prescribed medications (5.3 vs 3.5, t=2.29, p=0.025) and active medical disorders (4.6 vs 3.1, t=2.89, p=0.005). Specifically, early onset of depression was associated with an elevated prevalence of cardiac disease (53.3% vs 23.7%, χ2=5.0, df=1, p=0.025), diabetes (46.7% vs 16.9%, χ2=6.0, df=1, p=0.015), gastrointestinal disorder (40.0% vs 12.0%, χ2=6.5, df=1, p=0.011) and arthritis (26.7% vs 6.8%, χ2=4.9, df=1, p=0.027). These findings support previous reports that people with a history of depression experience greater medical morbidity than those without a history of depression. The study groups did not differ with respect to MMSE score or presence of a concurrent dementia disorder. These results were unexpected given previous studies that indicate greater cognitive impairment in late‐ vs early‐onset depression. The potential contribution of increased vascular risk factors among the early‐onset depression group may have partly contributed to the finding of no difference in cognition between groups in the present study.

MRI findings differentiate between late-onset schizophrenia and late-life mood disorder.

Objectives

Correlates of psychotic symptoms among elderly outpatients

Psychotic symptoms presenting in late life can offer a diagnostic challenge to the clinician. In this study, 140 geriatric outpatients were prospectively examined for psychotic symptoms and assessed on a number of demographic and clinical variables. Cognition was assessed using the Mini‐Mental State Exam. Psychiatric diagnoses were made by DSM‐III‐R criteria. Twenty‐seven per cent (N=38) had psychotic symptoms, delusions being the most common type. Patients with psychosis were significantly more likely to have a previous history of psychosis, to have a lower MMSE and to live in a nursing home. Four diagnoses accounted for 79.5% of all psychotic patients. In order of frequency, these were dementia, major depression, delirium and organic psychosis (organic hallucinosis, organic delusional disorder). Psychotic patients were significantly more likely to have a diagnosis of dementia, delirium or organic psychosis than non‐psychotics, but depression was significantly more likely to occur in patients without psychosis. Although psychotic symptoms occur in a variety of illnesses, elderly patients with psychosis should be carefully evaluated for these disorders. Copyright

Visual Hallucinations in a Geriatric Psychiatry Clinic: Prevalence and Associated Diagnoses

Visual hallucinations are associated with a variety of psychiatric, medical, neurologic, and ophthalmologic disorders. One hundred forty outpatients presenting to a geriatric psychiatric clinic were screened for visual hallucinations and assessed on a number of descriptive variables, medical history, ophthalmologic history, psychiatric diagnosis, and cognitive score. The data revealed that 14 patients (10%) experienced visual hallucinations. Presence of visual hallucinations was significantly associated with diagnoses of dementia or delirium, living in a nursing home, lower cognitive score, and presence of auditory hallucinations and delusions. There was no association to number of medications, age, gender, or presence of eye disease. No patient had ‘insight’ into their visual hallucinations. Despite the numerous disorders that are associated with visual hallucinations, the most common causes in a geriatric psychiatry clinic are dementia and delirium. Clinicians assessing older patients with visual hallucinations should first carefully evaluate for these disorders.

Disabling Parkinsonism Due to Lithium: A Case Report

Two cases of disabling parkinsonism have been previously reported in association with lithium treatment and only one occurred without other signs of lithium toxicity. We report a case of an elderly female who suddenly developed disabling parkinsonism, apparently as a side effect from treatment with lithium carbonate without other signs of lithium toxicity. All neurologic symptoms completely resolved on discontinuation of lithium. Resuming lithium at serum levels below 0.7 mmol/L resulted in no further neurologic side effects, but serum levels of 0.7 to 0.9 mmol/L resulted in the return of mild Parkinsons symptoms. Older age, longer duration of lithium treatment, and high therapeutic levels of lithium may be risk factors for this side effect. Implications for clinicians are discussed.

Psychotropic drugs in acute intermittent porphyria

Acute intermittent porphyria is one of a group of metabolic diseases called the porphyrias that may lead to symptoms of the central nervous system during an acute exacerbation. Certain drugs such as barbiturates are known to precipitate attacks of acute intermittent porphyria, but unfortunately there is little information regarding the safety of many psychotropic drugs in this disorder, especially the newer antidepressants and atypical antipsychotics. We report a case of an elderly patient with acute intermittent porphyria who was treated with a variety of psychotropic agents for a severe depression with psychotic features. Although many of the agents did not improve the psychiatric status of the patient, all the drugs were tolerated without precipitating an episode of acute intermittent porphyria. To our knowledge, this is the first report of the safe use of sertraline, venlafaxine, olanzapine, risperidone, clozapine, buspirone, trazodone, lorazepam, and clonazepam in a patient with documented acute intermittent porphyria. Our report also supports the safety of trifluoperazine. Although response and sensitivity to drugs may vary greatly among patients with this disorder, clinicians may want to consider the possibility of the above drugs to treat psychiatric symptoms in patients with acute intermittent porphyria.

Abnormal thyroid stimulating hormone (TSH) in psychiatric long-term care patients

The objective of the study was to find the prevalence of thyroid dysfunction in long-term care patients referred to psychiatry. We reviewed 868 charts of long-term care residents referred for psychiatric consultation to the university-based psychiatry outreach service. Data obtained were demographics, psychiatric and thyroid diagnoses, and TSH data. Of 868 patients, 10.8% had elevated TSH, 8% in those with a prior diagnosis of hypothyroidism. TSH was low in 0.07%. Elevated TSH was associated with female gender (p<0.001) and a trend with psychosis (p=0.056). No association was found with depression or behavioral disturbance in this study.