William E. Reichman

Psychiatric Consultation in the Nursing Home: A Survey of Six States

The authors examined availability, characteristics, and perceived adequacy of psychiatric consultation in nursing homes, as reported by directors of nursing, who returned 899 questionnaires. Thirty-eight percent of nursing home residents were judged to need a psychiatric evaluation; current frequency of consultation was rated as adequate by half of nursing directors. Nearly two-thirds reported that psychiatrists adequately provided diagnostic and medication recommendations; however, advice on nonpharmacologic management techniques, staff support, and dealing with staff stress and family conflicts was largely viewed as inadequate. Findings suggest that perceived need for psychiatric services is far greater than the level actually provided. Overall, more attention must be directed to identifying incentives for psychiatrists to practice in nursing homes, determining clinical effectiveness of mental health services, and examining effects of alternative payment mechanisms on level of care.

Galantamine Provides Sustained Benefits in Patients with `Advanced Moderate' Alzheimer's Disease for at Least 12 Months

Galantamine (Reminyl®), a novel agent with a dual mode of action, modulates nicotinic acetylcholine receptors and inhibits acetylcholinesterase. Galantamine has consistently demonstrated a broad range of beneficial effects and has shown sustained benefits in cognitive and functional abilities for at least 12 months in patients with mild-to-moderate Alzheimer’s disease (AD). As pivotal studies demonstrating the efficacy of cholinergic drugs were designed to exclude patients with severer AD, many patients with the advanced stage of this condition are currently not treated due to the lack of demonstrated efficacy in clinical trials. We aimed to investigate whether there was any evidence for the benefits of galantamine in patients with severer disease, by performing a post hoc analysis using data extracted from the population of the two long-term galantamine studies. We evaluated the efficacy of galantamine in patients with ‘advanced moderate’ AD. ‘Advanced moderate’ patients were those with baseline Mini Mental State Examination (MMSE) scores ≤14 or Alzheimer’s Disease Assessment Scale – cognitive subscale (ADAS-cog) scores >30. These patients were compared with matched controls who received placebo in a different historical study. Cognitive abilities (assessed using the ADAS-cog scale) of ‘advanced moderate’ AD patients receiving galantamine for 12 months were maintained at baseline levels after 12 months, and significantly improved over those of placebo patients (p < 0.001). Of the ‘advanced moderate’ patients receiving galantamine, 51% with baseline ADAS-cog of >30 maintained or improved their ADAS-cog scores over baseline values, compared with 13% receiving placebo (p < 0.001). In the subgroup of ‘advanced moderate’ patients with baseline MMSE ≤14, 48% of those receiving galantamine and 4% of those receiving placebo maintained or improved their ADAS-cog scores at 12 months (p = 0.001). In both subgroups, the treatment difference (galantamine vs. historical placebo) amounted to approximately 10 points on the ADAS-cog scale. Functional abilities, as assessed using the Disability Assessment for Dementia scale, remained significantly superior in galantamine-treated patients compared with historical placebo-treated patients at 12 months (p < 0.001). In conclusion, galantamine offered sustained efficacy to patients with ‘advanced moderate’ AD, confirming the benefits seen in published studies of patients with mild-to-moderate AD. This drug has potential for broader use in clinical practice.

Clinical Features of Pulmonary Tuberculosis in Young and Old Veterans

Pulmonary tuberculosis (TB) continues to pose a health threat to the elderly population. In order to delineate age‐related differences in disease presentation a comparison between young and old male veterans hospitalized over a five‐year period with culture proven Mycobacterium tuberculosis is reported. The study sample included 27 patients 60 years of age and older (range, 60 to 85; mean, 70) and 52 patients under 60 years of age (range, 22 to 59; mean, 51). The elderly were significantly less likely to demonstrate cavitary lesions on admission radiographs or present with hemoptysis but were more likely to present with right lower lobe infiltrates and complaints of dyspnea. Symptoms prior to admission occurring with equal frequency in both young and old subjects included fever, anorexia, weight loss, and cough. Although treatment was delayed in the elderly, there were no age‐related differences in mortality. Skin testing was underutilized in all patients regardless of age. The results support the notion that the clinical presentation of pulmonary TB is remarkably similar in young and old males.

Current pharmacologic options for patients with Alzheimer's disease

BackgroundThe aim of the current study was to provide general practitioners with an overview of the available treatment options for Alzheimers disease (AD). Since general practitioners provide the majority of medical care for AD patients, they should be well versed in treatment options that can improve function and slow the progression of symptoms.DesignBiomedical literature related to acetylcholinesterase inhibitors (AChEIs) was surveyed. In the United States, there are four AChEIs approved for the treatment of AD: tacrine, donepezil, rivastigmine, and galantamine. There are other agents under investigation, but at present, AChEIs are the only approved drug category for AD treatment.Measurements and Main ResultsAD is becoming a major public health concern and underdiagnosis is a significant problem (with only about half of AD patients being diagnosed and only half of those diagnosed actually being treated). Clinical trials have demonstrated that patients with AD who do not receive active treatment decline at more rapid rates than those who do.ConclusionsGiven that untreated AD patients show decline in three major areas (cognition, behavior, and functional ability), if drug treatment is able to improve performance, maintain baseline performance over the long term, or allow for a slower rate of decline in performance, each of these outcomes should be viewed a treatment success.

A Large, Community-Based, Open-Label Trial of Donepezil in the Treatment of Alzheimer’s Disease

This phase III trial was conducted to evaluate the safety and efficacy of donepezil in Alzheimer’s disease (AD) patients with a greater range of comorbid conditions and concomitant medication use than those previously evaluated in placebo-controlled studies. Patients (n = 1,035) with mild to moderate probable or possible AD were enrolled from 255 sites in the USA; 894 (86%) completed the trial. Mean age was 74.9 years (± 7.8); baseline standardized Mini-Mental State Examination (sMMSE) score was 19.77 (± 5.4). Nearly all patients had at least 1 prior or comorbid medical condition (97%) or were taking at least 1 concomitant medication (93%). Safety assessments included recording treatment-emergent adverse events (AEs). To confirm comparability with past studies, efficacy was measured using the sMMSE. Over the 12-week study period, the mean sMMSE score increased by 1.54 points over baseline (p < 0.0001) in donepezil-treated patients. Most AEs (64%) were mild, and the occurrence of cholinergic-induced AEs was significantly lower after a dose increase at 4 weeks than that seen with a dose increase after 1 week in previous trials. Risk ratios for gastrointestinal side effects were not significantly increased by the use of aspirin or nonsteroidal anti-inflammatory drugs. Risk ratios for bradycardia were not significantly increased by the use of beta-blockers, nondihydropyridine calcium channel blockers or digoxin. Therefore, donepezil improved cognition, as measured by the sMMSE, and was well tolerated despite high concomitant medication use and extensive comorbidity. These results highlight donepezil as a safe and effective treatment for AD patients typically seen by community-based physicians.

Depressive Symptoms in Alzheimer's Disease and Multi-infarct Dementia

We examined the prevalence of major depression, depressed mood/anhedonia, and subjective and neurovegetative symptoms of depression that were unaccompanied by depressed mood/anhedonia in patients with clinically-diagnosed Alzheimers disease (AD) and multi-infarct dementia (MID). The specificity of subjective and neurovegetative depressive symptoms for depressed mood in dementia was examined, as was the impact on depression of clinical variables such as family history, patient age, and dementia severity. Subjects were 105 outpatients who met DSM-III-R criteria for AD (n = 67) or MID (n = 38). Depressed mood/anhedonia was frequently noted in both the AD (40.3%) and MID (34.2%) groups. One or more depressive symptoms, not accompanied by depressed mood/anhedonia, were also common in AD and MID (49.3% and 36.8%, respectively). Major depression was relatively uncommon in AD (10.5%) but was noted more frequently in MID (29.0%). Among AD patients, neurovegetative symptoms of depression were not any more common in patients with depressed mood/anhedonia than in those without depressed mood/anhedonia. Subjective symptoms of depression were also not significantly associated with depressed mood/anhedonia. The study highlights the importance of viewing major depression, depressed mood-anhedonia, and other depressive symptoms (subjective and neurovegetative) as separate entities in AD and MID.

Psychiatric care in the nursing home

1. The Nursing Home as a Psychiatric Hospital 2. General Approaches to Behavioral Disturbances 3. Psychopharmacology 4. Dementia 5. Delirium 6. Mood Disorders 7. Anxiety Disorders 10. Sexuality 11. Mental Retardation 12. Substance Use Disorders 13. Insight-Oriented and Supportive Psychotherapy 14. Cognitive and Behavioral Therapy 15. Working with Families 16. Psychiatric Consultation and Liaison 17. Ethical Issues 18. Medicological Issues

Risperidone in the Treatment of Patients With Alzheimer's Disease With Negative Symptoms

INTRODUCTION Negative symptoms such as diminished initiative, drive, motivation, and emotional reactivity have been described in patients with Alzheimers disease (AD). The purpose of this study was to retrospectively analyze the efficacy and tolerability of risperidone for the treatment of clinically significant positive and negative symptoms in AD. METHODS We reviewed the charts of 50 community-residing AD patients who had been treated in a specialized university-based dementia management clinic. Clinical data comparing baseline and 12 weeks of treatment were obtained by reviewing a series of rating scales that were recorded as part of a comprehensive behavioral assessment. RESULTS Reviewed subjects had a mean age of 79.7 6 years and a mean of 12 +/- 3.6 years of school. Seventy percent of the subjects were female and the majority was White. The mean dose of risperidone prescribed was 1.3 +/- 0.6 mg per day (range from 0.5 mg to 3.0 mg). After 12 weeks of treatment, the severity of positive and negative symptoms was significantly reduced. Importantly, improvement in negative symptoms with the use of risperidone appeared to be independent of a positive treatment effect on positive symptoms. Risperidone had insignificant effects on both cognitive status and the emergence of extrapyramidal symptoms. CONCLUSION This retrospective study demonstrates that risperidone appears to be efficacious in the treatment of clinically significant positive and negative symptoms in patients with AD.

Diagnosis of Rare Dementia Syndromes: An Algorithmic Approach

The etiology of dementia can be diagnosed in most patients using a standard clinical approach consisting of physical, neurologic, and mental status examinations, and laboratory testing, lumbar puncture, and neuroimaging. In some cases, however, the clinical presentation or historical data are unusual, or the results of the workup are inconclusive or atypical. A rare cause of dementia may then be present and a complicated evaluation may be necessary to identify the specific disease process. A potentially useful approach to the diagnosis of rare dementing disorders consists of a series of diag nostic algorithms. This approach utilizes results of neuroimaging studies to guide the evaluation through additional diag nostic steps such as specific enzymatic or immunologic assays or biopsy of extraneural tissues. The disorders potentially detected by these algorithms typically have unusual clinical features such as early age of onset, abnormal neurologic signs and symptoms early in the clinical course, early personality and mood changes, extrapyramidal or cerebellar signs and symptoms, seizures, peripheral neuropathy or myopathy, and extraneural abnormalities involving the dermatologic, car diovascular, musculoskeletal, or ocular systems. Accurate diagnosis of these rare causes of dementia is important for medical and psychiatric management, prognosis, and genetic counseling.

Visuoconstructional Impairment in Dementia Syndromes

Dementia of the Alzheimer type (DAT) affects most neuropsychological domains including language, memory, and visuo-spatial skills. The latter are usually assessed by poorly quantifiable copying tasks. We assessed constructional abilities using the Developmental Test of Visuomotor Integration (VMI) comprised of a series of model drawings of increasing complexity. Twenty-six patients meeting NINCDS-ADRDA criteria for DAT, 21 normal aged subjects with normal mental status examinations, and 14 patients with vascular dementia were tested. In DAT, we found significant correlations between visuoconstructive ability and memory registration, delayed recall, and language functions such as confrontation naming and word-list generation. Less marked, but significant correlations were found in the vascular dementia group between visuoconstructive ability and memory registration and word-list generation. A few normal elderly subjects were unable to copy the most challenging figures. The study demonstrates that: (1) VMI is a convenient method for quantifying constructional deficits in DAT and other dementing illnesses; (2) constructional deficits are highly correlated with dementia severity and memory and language deficits in DAT; (3) neuropsychological deficits are less highly inter-correlated in vascular dementia than in DAT; and (4) abnormal constructional skills are present in some normal elderly.