Biomedical subjects

H Brodaty

Publications and source records attributed to H Brodaty.

At least 37 records · Page 2Linked to original sources

PubMed2001

Use of psychotropics in Sydney nursing homes: associations with depression, psychosis, and behavioral disturbances.

The purpose of this study was to determine the prevalence of psychotropic use in nursing home residents, the extent to which psychotropic dosage is consistent with published guidelines, and the relationships between psychotropic class and psychiatric and behavioral disturbances. Six hundred forty-seven subjects, mean age 82.3 years, residing in 11 nursing homes in the eastern suburbs of Sydney, Australia, were assessed using the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD), the Abbreviated Mental Test Scale, and the Even Briefer Assessment Scale for Depression (EBAS-DEP). Details of psychotropic prescription and diagnoses of depression, dementia, and psychosis were obtained from nursing home charts. Psychotropics were prescribed for 333 (51.5%) residents, 381 (58.9%) if "as required" (PRN) use is included. Prescription of multiple psychotropics was present in 148 (22.7%) residents. Antidepressants were prescribed for 19.8% of residents, with subtherapeutic doses less likely in residents on selective serotonin reuptake inhibitors. On logistic regression, the use of antidepressants was predicted by the affective disturbances subscale on the BEHAVE-AD. Only 30.4% of residents with significant depressive symptoms on the EBAS-DEP were prescribed antidepressants. Antipsychotics were prescribed for 21.3% residents at a mean dosage of 73 mg chlorpromazine equivalence. Residents on antipsychotics had significantly higher scores on the delusions, hallucinations, activity disturbance, and aggressiveness subscales of the BEHAVE-AD. On logistic regression, only the activity disturbance subscale and chart diagnoses of dementia and psychosis were significant predictors. Psychosis (58.8%) and behavioral disturbances (91.9%) were more prevalent in residents prescribed antipsychotics than in residents not prescribed antipsychotics (42.5% and 76.6%, respectively). High rates of behavioral and psychological symptoms of dementia remained in residents prescribed antipsychotics and high rates of depressive symptoms in residents prescribed antidepressants, suggesting a role for nonpharmacological strategies.

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PubMed2000

Dual voxel proton magnetic resonance spectroscopy in the healthy elderly: subcortical-frontal axonal N-acetylaspartate levels are correlated with fluid cognitive abilities independent of structural brain changes.

The published literature suggests that degeneration of the subcorticofrontal networks may underlie cognitive ageing, but appropriate methods to examine this in vivo have been lacking. Proton Magnetic Resonance Spectroscopy ((1)H-MRS) has now been used in a number of clinical studies to assess cerebral pathophysicochemistry and recently has been utilized to examine the relationship between neurochemical markers and cognitive functioning in normal individuals. Results have been somewhat conflicting and difficult to interpret. To further clarify the role of the cognitive spectroscopy technique, we measured N-acetylaspartate (NAA) levels in the frontal subcortical white matter and the occipitoparietal grey matter and correlated them with performance in different cognitive domains in a group of twenty healthy elderly individuals. Subjects underwent whole brain T(1)- and T(2)-weighted magnetic resonance imaging (MRI), dual voxel short echo-time (1)H-MRS, and a comprehensive neuropsychological assessment. Individual tests of executive and attentional abilities, and a principal components composite score reflecting these skills, but not measures of memory or verbal abilities, were correlated with NAA concentration in the frontal white matter only. These relationships were independent of other neurocognitive predictors of executive impairment such as age, midventricular dilation, frontal white matter disease, and presenescent verbal proficiency. This study suggests the ability of (1)H-MRS to differentiate anatomically distinct neurochemical markers related to specific cognitive abilities. In particular, neurometabolic fitness of the frontal subcortical-cortical axonal fibers may be important in mediating fluid intellectual processing. Longitudinal MRS studies are required to determine if the present results reflect different rates of neurocellular degeneration or preexisting individual differences in neuronal density.

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PubMed2000

A prospective follow-up study of ECT outcome in older depressed patients.

BACKGROUND: This study examined the relationship between age and outcome of electroconvulsive therapy (ECT). METHOD: This was a naturalistic, prospective follow-up of 81 consecutive in-patients with primary major depression. ECT outcome was compared for three age groups - under 65, 65-74 and 75 years and over - on the Hamilton Rating Scale for Depression (HRSD), Global Assessment of Functioning scale (GAF) and clinical outcome rating scale. Assessments were performed pre-ECT, immediately post-ECT, 1-3 years later and, for patients suspected of having dementia, 5 years later. RESULTS: At post-ECT and follow-up, improvement on HRSD and clinical outcome ratings were comparable for patients in the three age groups. Improvements on GAF were also comparable post-ECT, but not between post-ECT and follow-up. At follow-up, 35.7% of the oldest group had dementia. Importantly, patients who did and did not develop dementia were clinically indistinguishable prior to ECT. The number and severity of common adverse events were similar pre- and post-ECT and were not associated with age. CONCLUSIONS: Depressive outcome and adverse effects of ECT are largely independent of age. Older patients receiving ECT appear to have a higher risk of developing dementia, possibly underpinned by cerebrovascular disease.

Adult↗

PubMed2000

Hippocampus and amygdala volumes in elderly schizophrenic patients as assessed by magnetic resonance imaging.

Reduced size of the hippocampus and amygdala has been one of the more consistent morphological findings in schizophrenia, but the question of medial temporal abnormalities in elderly schizophrenia patients has been inadequately addressed. We examined 20 elderly subjects with a DSM-III-R diagnosis of schizophrenia, five of whom had a late-onset schizophrenia (LOS), and compared them with 20 healthy volunteers on magnetic resonance imaging (MRI) and neuropsychological parameters. Hippocampus and amygdala volumes were obtained by manual tracing on T1-weighted 1.5 mm thick contiguous coronal slices perpendicular to the long axis of the hippocampus. Patients had smaller left hippocampal and right amygdala volumes than comparison subjects, the mean differences being 9.7 and 11.1%, respectively, but the right amygdala volumes were not significantly different after Bonferroni correction. The hippocampus-amygdala volumes together were smaller in the schizophrenia group bilaterally. In a pilot analysis, the LOS subjects had non-significantly smaller hippocampus-amygdala volumes than did the early-onset schizophrenia (EOS) subjects. For the schizophrenia group, there were significant correlations between amygdala and hippocampus volumes and some neuropsychological performance indices. The findings are consistent with those reported in younger schizophrenics, and are of the same order of magnitude, suggesting that they are not likely to be progressive. This pilot analysis in LOS subjects argues against the condition being secondary to Alzheimer's disease.

Age Factors↗

PubMed1999

Reliability and validity of ratings of signal hyperintensities on MRI by visual inspection and computerised measurement.

Brain magnetic resonance imaging (MRI) scans on 98 elderly subjects, 62 with a diagnosis of schizophrenia and 36 healthy controls, were independently and blindly rated by two investigators using the visual rating methods of Fazekas et al. (Fazekas, F., Chawluk, J.B., Alavi, A., Hurtig, H.I., Zimmerman, R.A., 1987. MR signal abnormalities at 1.5 T in Alzheimer's dementia and normal aging. American Journal of Neuroradiology 8, 421-426) and Victoroff et al. (Victoroff, J., Mack, W.J., Grafton, S.T., Schreiber, S.S., Chui, H.C., 1994. A method to improve interrater reliability of visual inspection of brain MRI scans in dementia. Neurology 44, 2267-2276) for periventricular, deep white matter and subcortical gray matter signal hyperintensities (SHs) on T2-weighted images. The hyperintense signal volumes were measured by manual delineation of the signals on a workstation using Analyze software (computerised method). The subjects also underwent a detailed neuropsychological assessment. There was a high correlation between two experienced raters for both visual ratings, and the correspondence between the two methods was high. The inter-rater reliability for the computerised method was modest but significant, and the association between the visual and computerised methods was good except for ratings for SHs in subcortical nuclei. The Fazekas and computerised methods, and to a lesser degree the Victoroff method, had modest but significant correlations with some neuropsychological test measures. In conclusion, we did not demonstrate a clear superiority in reliability or validity for one demanding computerised method of rating SHs. Visual ratings should therefore be considered adequate for most clinical and research purposes, but such ratings should be accompanied by adequate training and the provision of standard reference images.

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PubMed1999

Vascular dementia: diagnosis, management and possible prevention.

There has been a recent upsurge of interest in the clinical features of and risk factors for vascular dementia, and consensus is emerging on its diagnostic characteristics. We discuss these features and risk factors and the main intervention strategies, both for treatment and prevention.

Dementia, Vascular↗

PubMed1999

Realistic expectations for the management of Alzheimer's disease.

Alzheimer's disease (AD) is a chronic and progressive neurodegenerative disorder characterized clinically by cognitive and functional deficits and behavioural disturbances. Over the past two decades, the devastating nature of AD has captured the attention of the general and medical communities alike. This is due partly to the increased prevalence of AD and the expansion of the aged population. Furthermore, and perhaps inappropriately, the media have encouraged speculation concerning a 'cure' for AD. Such treatment strategies are in the early stages of pre-clinical investigation and well-designed clinical trials are awaited. Nevertheless, other strategies, aimed at reducing the progression or effects through pharmacological symptomatic therapies and psychosocial interventions have demonstrated some clinical benefit and are now available and practicable. This paper critically evaluates the merits of both currently available and potential future therapeutic strategies according to primary, secondary and tertiary levels of preventative treatment.

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PubMed1999

Cognitive function in depression: a distinct pattern of frontal impairment in melancholia?

BACKGROUND: Although depressed patients demonstrate impaired performance on a range of neuropsychological tests, there is little research that examines either frontal cognitive deficits or possible differences in test performance between melancholic and non-melancholic subtypes. METHODS: Depressed subjects were administered a broad neuropsychological battery. In an overall analysis, 77 depressed subjects were compared with 28 controls. In a second set of analyses, the depressed sample was divided into melancholic and non-melancholic subsets according to DSM-III-R, the CORE system and the Newcastle scale. These depressed subsets were contrasted to controls and with each other using ANCOVA controlling for age, IQ, simple reaction time and Hamilton Depression scores where appropriate. RESULTS: The total depressed sample was impaired on most mnemonic tasks, simple reaction time and Trails B. Similar findings applied to DSM-III-R melancholic and non-melancholic subjects. When defined by the CORE and Newcastle (narrower definitions of melancholia), melancholic patients were additionally impaired on WCST (perseverative response) and (for Newcastle) digit symbol substitution. In contrast, the cognitive performance of the CORE and Newcastle-defined non-melancholic patients was largely unimpaired. CONCLUSIONS: Using narrower definitions of melancholia, i.e. CORE and (in particular) Newcastle, melancholic patients were impaired on mnemonic tasks and tasks of selective attention, and set-shifting while non-melancholic subjects were largely unimpaired in their cognitive performance. These differences may be due to impairment of specific neuroanatomical regions in narrowly defined melancholic patients, in particular the anterior cingulate.

Adult↗

PubMed1999

Recall of depressive episode 25 years previously.

BACKGROUND: Lifetime rates of depression reported in epidemiological surveys are generally only twice the 12 month rates. Either people forget the symptoms of depression or many people who have a depressive episode remain depressed for many years. Both may be true. There is a need to examine the long-term clinical validity of interviews that are used to make lifetime diagnoses. METHODS: Forty-five patients who were part of a long-term follow-up study of depression were interviewed 25 years after the index episode. The diagnoses from the original, fully structured interviews were compared with the responses people made for that period when interviewed using the CIDI 25 years later. RESULTS: Twenty-seven patients met CIDI DSM-III-R criteria for depression at index episode. At the 25 year follow-up, 19 of the 27 reported the essential symptoms of 'depression or loss of interest' being present at the index time, and in 14 of the 27 the depressive symptoms recalled met criteria for DSM-III-R major depressive episode at that time. CONCLUSIONS: Seventy per cent of people who were hospitalized for a major depressive episode can recall being depressed but only half can recall sufficient detail to satisfy the diagnostic criteria when interviewed 25 years later. As depressive episodes, especially those severe enough to warrant admission, are recalled better than many other diagnoses, one must be cautious about the lifetime rates for mental disorders reported in retrospective epidemiological surveys.

Adult↗

PubMed1999

Mid-sagittal anatomy in late-onset schizophrenia.

BACKGROUND: Of the midline brain structures, abnormalities have been demonstrated in the corpus callosum and cerebellum in young schizophrenic patients. Whether similar abnormalities are also present in late-onset schizophrenia (LOS) is not known. METHODS: The mid-sagittal cross-sectional areas of brain regions, in particular the corpus callosum and cerebellum, on magnetic resonance imaging were examined in a group of patients with late-onset schizophrenia (N = 25) and contrasted with two comparison groups - early-onset schizophrenia (EOS) (N = 24) and healthy volunteers (NC) (N = 30) matched for age and gender. RESULTS: While the mean corpus callosum area in the LOS group was smaller than in the EOS (by 10.2%) and NC (by 6.2%) groups, the three groups did not differ statistically in the corpus callosum area or the corpus callosum to cerebrum ratios. The cross-sectional cerebellar areas or the cerebellum: cerebrum ratios also did not differ across the groups. The brainstem was smaller in the schizophrenic groups because of smaller cross-sectional areas of the pons, a statistically significant difference which could not be accounted for by any gross lesions on visual inspection. CONCLUSION: We found no abnormality in the mid-sagittal area of the corpus callosum and cerebellum in our early- or late-onset schizophrenia subjects. The significance of the finding of a smaller pontine cross-sectional area is unclear and speculation on it awaits independent replication using a volumetric measure.

Age Factors↗

PubMed1999

An electroencephalographic investigation of late-onset schizophrenia.

We performed awake and resting electroencephalograms (EEGs) on 22 subjects with DSM-III-R schizophrenic disorder of late onset (at or after age 50 years), and compared them with the EEGs of 33 healthy community controls matched for age and gender. The EEGs were rated qualitatively and a 2-minute, artifact-free tracing from each subject was quantified manually by an experienced neurophysiologist unaware of the identity of the subject group. The only significant difference was the presence of more generalized slowing in the EEGs of schizophrenia patients, which was at least partially accounted for by the effect of neuroleptic drugs. The schizophrenic subjects did not have a greater prevalence of epileptiform disturbances or abnormal asymmetry of the EEG compared to the control group. Our study does not suggest the presence of underlying dementia in schizophrenia of late onset.

Age of Onset↗

PubMed1999

Quantitative study of signal hyperintensities on T2-weighted magnetic resonance imaging in late-onset schizophrenia.

OBJECTIVE: The authors investigated the extent and distribution of signal hyperintensities on T2-weighted magnetic resonance imaging (MRI) of the brains of subjects with late-onset schizophrenia. METHOD: The study group consisted of 25 subjects with DSM-III-R schizophrenia and onset at age 50 or more years (late-onset schizophrenia) matched group-wise with 24 subjects with early-onset schizophrenia and 30 psychiatrically healthy volunteers. The subjects underwent clinical and neuropsychological assessments and MRI scans. Transaxial T2-weighted and proton-density images were analyzed manually for signal hyperintensities in cerebral and cerebellar white matter, the basal ganglia, thalamus, and brainstem, and quantitative measures were obtained. RESULTS: Subjects with late-onset schizophrenia had greater periventricular hyperintensities measured as widths of periventricular rims and frontal and occipital caps than the two comparison groups. Hyperintense signals elsewhere in the white matter and in the basal ganglia and brainstem did not differ between groups, but the late-onset schizophrenia group had more signal hyperintensities in the thalamus than the normal comparison group. Signal hyperintensities in the frontal-subcortical circuit regions, when considered together, did not differ between groups. Periventricular hyperintensities had significant negative correlations with intelligence, memory, and frontal-executive functioning in the total group. CONCLUSIONS: The finding of increased periventricular hyperintensities and thalamic signal hyperintensities in late-onset schizophrenia suggests the possibility that cerebrovascular disease, in an interaction with some incompletely understood vulnerability factors, may play a role in the pathogenesis of schizophrenia with onset in advanced age.

Adult↗

PubMed1999

Schizophrenia with onset after age 50 years. I: Phenomenology and risk factors.

BACKGROUND: Schizophrenia occurring for the first time in late life may be a distinct entity or part of a continuum. AIMS: Can late-onset schizophrenia (LOS) and early-onset schizophrenia (EOS) be differentiated by their phenomenology and risk factors to their development? METHOD: Convenience samples of 27 DSM-III-R defined LOS subjects, 30 EOS subjects and 34 control subjects were systematically assessed. RESULTS: Premorbidly, both groups of subjects with schizophrenia had personality traits that were different from controls but not from each other. The EOS subjects had more family members with a history of psychiatric illness or schizophrenia and less hearing impairment than the other two groups, which did not differ from each other. Clinically, LOS and EOS subjects were similar, except that EOS subjects had more negative symptom scores, tended to have more delusions of guilt/sin and of being controlled and more formal thought disorder, and had significantly poorer instrumental activities of daily living. CONCLUSIONS: Phenomenology and risk factors do not distinguish discrete LOS.

Age of Onset↗

PubMed1999

Schizophrenia with onset after age 50 years. 2: Neurological, neuropsychological and MRI investigation.

BACKGROUND: Late-onset schizophrenia (LOS) may have a basis in age-related coarse brain disease, but empirical support for this is conflicting. AIMS: Is LOS characterised by more neurological disease than early-onset schizophrenia (EOS)? METHODS: DSM-III-R-defined LOS subjects (n = 27) were compared with 30 EOS and 34 volunteer control subjects on neurological status, neuropsychological test performance and brain magnetic resonance imaging (MRI). RESULTS: LOS and EOS groups had more 'soft' neurological signs and drug-induced movement abnormalities, and performed more poorly on tests assessing speed of information processing, memory and frontal executive functioning. On MRI, the LOS and EOS groups had greater lateral ventricular size than the control group. The LOS subjects also had more signal hyperintensities in periventricular white matter and subcortical nuclei than controls. CONCLUSIONS: LOS and EOS subjects were very similar on neuropsychological, neurological and structural neuroimaging parameters, except that there were more MRI periventricular hyperintensities in LOS subjects.

Age of Onset↗

PubMed1998

Younger people with dementia: diagnostic issues, effects on carers and use of services.

OBJECTIVE: To determine difficulties experienced by carers of younger people with dementia. DESIGN: Cross-sectional questionnaire survey. PARTICIPANTS: 102 eligible carers of persons less than 65 years of age with dementia, recruited through support groups and clinicians' referrals. MAIN OUTCOME MEASURES: Problems with diagnostic process; professionals/services consulted; psychological, physical, occupational and financial impact of illness on carers and children; use of and satisfaction with services. MAIN RESULTS: Diagnostic problems were reported by 71% of carers. Mean time until diagnosis was 3.4 years (SD 2.8) after consulting 2.8 (1.4) professionals. Carers reported frustration (81%) and grief (73%). Adverse psychological effects were common, more so in female than male carers (p < 0.01). The younger the carer, the more psychological and physical effects were experienced (p < 0.01). Only 8% of carers considered that their children had encountered no problems because of the dementia. Of 61 working carers, 59% reduced their hours or stopped working after diagnosis, and 89% of all carers had experienced financial problems subsequent to diagnosis. Most carers (89%) had used a support service, but 25% had never used community support, 32% had never used respite. Proportions of carers rating services as good ranged between 43 and 100%. CONCLUSIONS: Younger people with dementia, and their carers, face difficulties in obtaining a diagnosis. Carers also experience psychological problems, financial worries, loss of employment and family conflict, and their children are affected. Most carers had used services, but some dissatisfaction existed.

Adult↗

PubMed1998

Suicidal ideation and the 'wish to die' in dementia patients: the role of depression.

OBJECTIVE: To determine the prevalence of self-reported suicidal ideation and the 'wish to die' in dementia patients, their association with depressive symptoms and the type of dementia. DESIGN: The cohort was formed retrospectively of consecutive referrals between 1985 and 1994 of cognitively impaired patients who met American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, third edition and third edition, revised, criteria for dementia. They were assessed for depression using the 21-item Hamilton Rating Scale for Depression (HRSD) which includes an item on suicide. SETTING: An outpatient multidisciplinary memory disorders clinic in Sydney, Australia. PATIENTS: The sample comprised 221 patients with dementia: 148 with Alzheimer's disease according to NINCDS-ADRDA criteria, 24 with vascular dementia diagnosed by a Hachinski ischaemia scale score of seven or more, plus focal neurological signs, symptoms or computed tomography-visible lesions, and 49 with other dementias. MEASURES: Cognitive impairment was measured by the Mini-Mental State Examination and the Blessed orientation-information-memory-concentration test and dementia scales, depression by the 21-item HRSD, suicidal ideation and the 'wish to die' as defined by the suicide item on the HRSD, functional capacity by the activities of daily living scale and the instrumental activities of daily living scale. Caregiver psychological morbidity was assessed with the General Health Questionnaire. RESULTS: 12 patients (5.4%) felt life was not worth living, seven (3.2%) 'wished to die' or had thoughts of death, two (0.9%) had suicidal ideation or gestures and none had made any suicide attempts. The nine patients who 'wished to die' or had suicidal ideation scored 12 or more on the HRSD. Of these, six were clinically depressed. Suicidal ideation and the 'wish to die' were significantly correlated with the presence of depressive symptoms as measured by the HRSD (suicide item excluded), but only in those with Alzheimer's disease. There were no significant differences in HRSD scores between the dementia groups. Suicidal ideation was unrelated to the presence of insight into loss of memory. CONCLUSIONS: Suicidal ideation and/or the 'wish to die' is self-reported in 4% of dementia patients attending a memory disorders clinic and is associated with comorbid depressive symptoms, particularly in Alzheimer's disease.

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PubMed1998

Screening for cognitive impairment in general practice: toward a consensus.

We considered whether general practitioners should examine all older patients over a certain age for cognitive impairment in screening for early dementia. We invited presentations from key experts, selectively reviewed the literature, and developed a consensus statement. The efficacy of and benefits from unselective use of cognitive testing and informant questionnaires for detecting early dementia in older patients attending general practice are limited. Positive predictive values of cognitive screening for dementia are less than 50%, even for older patient populations. Higher values may be obtained by testing patients who have a relevant history of cognitive or functional decline. Whatever procedures are adopted for screening older general practice attenders for cognitive impairment or early dementia, investigation is still required into the relative merits of different health professionals performing the screening, the positive and negative effects on patients and their families, and the cost-benefit ratio. The majority view of workshop participants was that cognitive testing should occur for older patients when there is a reason to suspect dementia. Testing may occur in an individual considered to be at risk because of an informant history of cognitive or functional decline, clinical observation, or, sometimes, very old age. No single instrument for cognitive screening is suitable for global use. Screening programs must be supported by training and supplemented by education for professionals and families in management of dementia.

Age of Onset↗

PubMed1998

Psychological morbidity in caregivers is associated with depression in patients with dementia.

The relationship between psychological morbidity in caregivers and depression in patients with dementia was examined using data collected on 193 patient-caregiver dyads attending a memory disorders clinic. Caregivers had high rates and levels of psychological morbidity which were associated with the severity of dementia (but neither the type nor duration), with the caregiver being a spouse and female and living with the person with dementia. A logistic regression analysis identified clinician-rated patient depression score and demanding problem behaviors as being independently and significantly associated with caregiver psychological morbidity. This new finding of a link between patient depression and caregiver psychological morbidity has implications for more focused treatment programs for both caregivers and patients.

Activities of Daily Living↗