Theodore A. Stern

Cognitive Impairment Associated With Atrial Fibrillation: A Meta-analysis

BACKGROUND Atrial fibrillation (AF) has been linked with an increased risk for cognitive impairment and dementia. PURPOSE To complete a meta-analysis of studies examining the association between AF and cognitive impairment. DATA SOURCES Search of MEDLINE, PsycINFO, Cochrane Library, CINAHL, and EMBASE databases and hand search of article references. STUDY SELECTION Prospective and nonprospective studies reporting adjusted risk estimates for the association between AF and cognitive impairment. DATA EXTRACTION Two abstracters independently extracted data on study characteristics, risk estimates, methods of AF and outcome ascertainment, and methodological quality. DATA SYNTHESIS Twenty-one studies were included in the meta-analysis. Atrial fibrillation was significantly associated with a higher risk for cognitive impairment in patients with first-ever or recurrent stroke (relative risk [RR], 2.70 [95% CI, 1.82 to 4.00]) and in a broader population including patients with or without a history of stroke (RR, 1.40 [CI, 1.19 to 1.64]). The association in the latter group remained significant independent proof of clinical stroke history (RR, 1.34 [CI, 1.13 to 1.58]). However, there was significant heterogeneity among studies of the broader population (I2 = 69.4%). Limiting the analysis to prospective studies yielded similar results (RR, 1.36 [CI, 1.12 to 1.65]). Restricting the analysis to studies of dementia eliminated the significant heterogeneity (P = 0.137) but did not alter the pooled estimate substantially (RR, 1.38 [CI, 1.22 to 1.56]). LIMITATIONS There is an inherent bias because of confounding variables in observational studies. There was significant heterogeneity among included studies. CONCLUSION Evidence suggests that AF is associated with a higher risk for cognitive impairment and dementia, with or without a history of clinical stroke. Further studies are required to elucidate the association between AF and subtypes of dementia as well as the cause of cognitive impairment.

The Association Between Intravenous Haloperidol and Torsades de Pointes: Three Cases and a Literature Review

Torsades de Pointes (TDP) is a potentially malignant ventricular arrhythmia that often has a drug-induced origin. Oral, but not intravenous, haloperidol has been generally associated with this arrhythmia. The authors detail three patient cases of TDP that occurred while the patients were receiving intravenous haloperidol. The authors discuss the known risk factors for the development of TDP and review the literature on ventricular arrhythmias associated with haloperidol use.

The Impact of Serious Mental Illness on Health and Healthcare

Background Patients with serious mental illness (SMI; e.g., psychotic disorders and major mood disorders) die earlier, have more medical illnesses, and receive worse medical care than those in the general population. Objective The aims of this article are to review the data on medical morbidity and mortality in those with SMI, to highlight the factors that lead to such disparities, and to discuss potential solutions to the problem. Method The authors reviewed the literature on medical morbidity and mortality in those with SMI. Results Adults with SMI in the United States die 25 years earlier than those in the general population; cardiovascular disease is responsible for the majority of this excess mortality, accounting for roughly 50%–60% of the deaths due to medical illness. Patient, provider, and system-level factors interact to contribute to poor health outcomes in people with SMI. Conclusion Patients with SMI are losing many years of life to preventable and treatable medical illnesses. Solutions to the problem will require attention to patient, provider, and system-level factors.

Falls in the General Hospital: Association With Delirium, Advanced Age, and Specific Surgical Procedures

BACKGROUND Falls and delirium in general-hospital inpatients are related to increases in morbidity, mortality, and healthcare costs. Patients fall despite safeguards and programs to reduce falling. OBJECTIVE The authors sought to determine the prevalence of diagnosed and undiagnosed delirium in patients who fell during their hospital stay. METHOD The authors performed a retrospective electronic chart review of 252 patients who fell during their hospital stay. Falls were categorized by their severity (i.e., minor, moderate, and major). Demographic information, patient outcomes, and diagnostic criteria for delirium (per DSM-IV) were collected on the day of admission, the day of the fall, and the 2 days preceding the patients fall. RESULTS Falls in the general hospital were associated with delirium (both diagnosed and undiagnosed), advanced age, and specific surgical procedures. CONCLUSION Improving the recognition of undiagnosed delirium may lead to sustainable and successful fall prevention programs. Detection of impairments in mental status can assist staff to create individualized patient care plans. Knowledge about which patients are at risk for injury from delirium and falls can lead to improvements in patient safety, functioning, and quality of life.

The Academy of Psychosomatic Medicine Practice Guidelines for Psychiatric Consultation in the General Medical Setting

This practice guideline seeks to provide guidance to psychiatrists who regularly evaluate and manage patients with medical illnesses. The guideline is intended to delineate the knowledge base, professional expertise, and integrated clinical approach necessary to effectively manage this complex and diverse patient population. This guideline was drafted by a work group consisting of psychiatrists with clinical and research expertise in the field, who undertook a comprehensive review of the literature. The guideline was reviewed by the executive council of the Academy of Psychosomatic Medicine and revised prior to final approval. Some of the topics discussed include qualifications of C-L consultants, patient assessment, psychiatric interventions (e.g., psychotherapy, pharmacotherapy), medicolegal issues, and child and adolescent consultations.

Dizziness and Panic Disorder: a Review of the Association Between Vestibular Dysfunction and Anxiety

Dizziness is a common and costly condition that causes significant distress and impairment yet often confounds appropriate diagnosis and treatment. Among patients presenting for evaluation and treatment of dizziness, rates of panic disorder are elevated to 5 to 15 times the general population rates. In addition, the limited studies to date of dizziness in patients with panic disorder suggest that panic patients frequently experience significant dizziness and often demonstrate evidence of vestibular dysfunction. In this paper we review studies investigating the relationship between panic disorder and vestibular dysfunction. Currently, there are three main explanatory models for the association between panic disorder and vestibular dysfunction: the psychosomatic model, the somatopsychic model, and the network alarm theory. Systematic investigations of the treatment of patients with vestibular symptoms and panic disorder are lacking, though prevalence, associated costs, and disability suggest that they are needed. Serotonin selective reuptake inhibitors are good candidates for future treatment studies.

The diagnosis and treatment of Munchausen’s syndrome

Patients with Munchausens syndrome--a syndrome characterized by the intentional production of physical symptoms to gain the sick role-present a variety of challenges to health care providers. Their treaters quickly become frustrated by their demanding interpersonal styles, by deception and manipulation, and by multiple unrevealing diagnostic procedures. These difficulties can lead to poor outcomes for patients and staff alike. We present the case of a young woman whose presentation and subsequent evaluation led to significant distress among the hospital staff responsible for her care, and discuss the epidemiology, diagnosis, and management of patients with Munchausens syndrome. The most important role of the psychiatrist in the treatment of Munchausens syndrome is to help the primary treatment team manage the patient in the safest and most appropriate way. Such management includes avoiding unnecessary procedures, preventing further self-harm, and avoiding angry or threatening interactions with the patient. The prognosis for patients with Munchausens syndrome appears to be poor; flexible and creative approaches that emphasize consistency of care and regular outpatient psychiatric treatment have had the greatest success.

Quantitative serum toxic screening in the management of suspected drug overdose.

Data were collected on 176 consecutive cases of drug overdose evaluated in an emergency department. Quantitative serum toxic screening (TS) was performed for 164 (93%) of these patients; positive results were noted for 133 patients (81%). Six classes of drugs (ethanol, benzodiazepines, salicylates, acetaminophen, barbiturates, and tricyclic antidepressants) were responsible for nearly 70% of all drug detections and were associated with 80% of all admissions in this patient sample. Only two patients (1%) had drug-specific treatment initiated because of TS results. In 12 patients (7%), TS confirmed substances for which specific treatments had been initiated on clinical grounds. Four patients (2%) had drug-specific treatment discontinued because of TS results. Thirty-two patients (19%) were admitted to a medical service; however, only seven patients (4%) were admitted primarily because of TS results. All other patients were admitted because of clinical abnormalities that required inpatient care. It is concluded that only a few drugs are responsible for most drug overdoses. Moreover, TS results rarely change the treatment or disposition of overdose patients; these decisions are typically based on clinical parameters.

Depression and Diabetic Neuropathy: A Complex Relationship

In a group of 64 non-insulin-dependent diabetic females, a significant positive correlation between Zung self-rated depression scores and objective measurements of diabetic peripheral neuropathy was limited to those women with Zung scores greater than 50 (depressed group, n = 12). In the overall group, there was no significant linear or quadratic relationship between peripheral neuropathy and depression scores. The associations between depression, peripheral neuropathy, and diabetes are discussed. ( J Geriatr Psychiatry Neurol 1988;1:11-15).

Neuropsychiatric Effects of Prescription Drug Abuse

Prescription drugs have become a major category of abused substances, and there is evidence that the prevalence of prescription drug abuse may soon overtake that of illicit drugs. Study of prescription drugs has been hampered by vague terminology, since prescription drugs are only separated from other drugs of abuse by social and legal constructs. Reviewed herein is published literature on the abuse of four major categories of abused prescription drugs: sedative-hypnotics, stimulants, anabolic steroids, and anticholinergics. The review emphasizes evidence regarding the effects of these drugs on neural systems. Other abused prescription drugs that fall outside of the major categories are also briefly addressed.