The public health model for mental health care for the elderly.
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Biomedical subjects
I R Katz
Publications and source records attributed to I R Katz.
Dehydroepiandrosterone sulfate and psychiatric measures in a frail, elderly residential care population.
BACKGROUND: Previous reports have found low levels of dehydroepiandrosterone sulfate (DHEA-S) in association with physical illness, and with frailty in the elderly. In a preliminary study, we also found low DHEA-S associated with increased disability and number of pain sites. However, we found the opposite relationship between DHEA-S and cognitive impairment. Therefore, we conducted a study of a second sample to confirm this unexpected finding and the expected inverse correlations between DHEA-S levels and increased disability and number of pain sites. METHODS: Psychiatric symptoms and disorders were correlated with DHEA-S and related steroid levels in a second convenience sample in the nursing home population. RESULTS: This sample confirmed the previous finding of a positive association of cognitive impairment with higher DHEA-S levels but the inverse association of DHEA-S levels with the numbers of pain sensations did not reach statistical significance. Cognitive impairment was also positively associated with higher dehydroepiandrosterone (DHEA) and estradiol levels (women only). Cortisol levels were inversely associated with depressive symptoms. CONCLUSIONS: The anomalous positive correlation between cognitive dysfunction and DHEA-S levels, and the inverse correlation between cortisol levels and depressive symptoms, suggests that the relationships between psychiatric symptomatology and levels of steroids that are part of the hypothalamic-pituitary adrenal axis are different in the frail elderly population from that of younger and heartier populations.
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Control of aggression and agitation in patients with dementia: efficacy and safety of risperidone.
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Schizophrenia and older adults. An overview: directions for research and policy.
The Group for the Advancement of Psychiatry, Committee on Aging, believes that a crisis has emerged with respect to the understanding of the nature and treatment of schizophrenia in older persons. Moreover, critical gaps exist in clinical services for this population. In this article, we examine the epidemiology of aging and schizophrenia; life-course changes in psychopathology, cognitive function, social functioning, and physical health; and various concerns regarding treatment, services, and financing. Finally, we propose six research and policy recommendations and suggest methods for addressing the research questions that we have posed.
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Monitoring Alzheimer's patients for acute changes in cognitive functioning.
To develop and evaluate the use of cognitive monitoring for detecting episodes of acute, excess cognitive decline in individual Alzheimer's disease (AD) patients, the authors conducted six repeated cognitive assessments over 11 weeks on 41 otherwise healthy people with mild-to-moderate AD. Patients demonstrated stable cognitive performance over 11 weeks on seven standard neuropsychological tests. Prediction intervals quantitatively defined the expected limits of cognitive decline. They indicated with 90% certainty that over the 11-week period, healthy mild-to-moderate AD patients should not decline more than 4 points on the Word List Recall test, 3 points on the Digit Span test, or 8 items on the Digit Symbol or Verbal Fluency tests. The cognitive stability of healthy AD patients indicates that it is possible to monitor them for acute, excess cognitive decline.
Acute Disease↗
Change in disability follows inpatient treatment for late life depression.
OBJECTIVES: The objective of this study was to examine the relationship between functional disability and improvement in late life depression after acute inpatient treatment. DESIGN: The study was a longitudinal assessment of depression and disability. Patients were assessed during an initial inpatient hospitalization and then 3 months postdischarge. SETTING: All patients were evaluated initially after admission to one of 71 inpatient psychiatric treatment facilities. PARTICIPANTS: The study comprised of 2572 patients older than age 60 who were relatively cognitively intact and experiencing significant depressive symptoms. MEASUREMENTS: Depressive symptoms were measured using the Geriatric Depression Scale. Disability was measured using the Instrumental Activities of Daily Living Scale and the Medical Outcomes SF-36. RESULTS: Depressive symptoms improved in the majority of patients. Moreover, improvement in depressive symptomatology was significantly related to improvement in instrumental activities of daily living (IADLs) and to health-related quality of life as measured by the SF-36. This relationship was strongest among those who initially presented with some disability in IADLs. CONCLUSIONS: This work underscores further the disabling nature of depression. Moreover, findings from this study suggest that treatment focused on depression can lead to significant improvements in both depressive symptoms and functional abilities. However, the results also suggest that the relationship between depression and disability is complex and that the effect of treating depression is not the only factor in the reversal of disability.
Activities of Daily Living↗
Heuristic comparison of sertraline with nortriptyline for the treatment of depression in frail elderly patients.
Studies have demonstrated that the selective serotonin reuptake inhibitor antidepressants have similar efficacy to other agents, such as tricyclic antidepressants. However, data are limited for direct comparisons with other antidepressants. The authors conducted a contemporaneous comparison of nursing home residents treated with open-label sertraline in doses up to 100 mg/day with nursing home residents treated in a double-blind randomized study of low vs. regular doses of nortriptyline. There were 97 patients enrolled in the study (28 treated with sertraline), with an average treatment duration of 55 days. There were no differences in the tolerability of sertraline vs. nortriptyline. However, in this group of frail older adults, sertraline was not as effective as nortriptyline for the treatment of depression.
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Drug treatment of depression in frail elderly nursing home residents.
The authors conducted a randomized, double-blind, 10-week clinical trial of two doses of nortriptyline in eight nursing homes. Sixty-nine patients, average age 79.5 years, were randomized to receive regular doses (60 mg-80 mg/day) vs. low doses (10 mg-13 mg/day) of nortriptyline. Among the more cognitively intact patients, there was a significant quadratic relationship defining a "therapeutic window" for nortriptyline plasma levels and clinical improvement. There were also significant differences in plasma level-response relationships between depressed patients who were cognitively impaired and those who were more cognitively intact. Depression remains a syndrome that responds to specific treatment, even in frail nursing home patients, and those depressions that occur in patients with significant dementia may represent a treatment-relevant condition with a different plasma level-response relationship than in depression alone.
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Effects of alcohol consumption on the treatment of depression among elderly patients.
The authors examined the effects of alcohol use on the short-term and 3-4-month treatment outcomes of patients with late-life depression. Patients (N=2,666) were assessed for symptoms of depression, alcohol use, and disability during an initial inpatient hospitalization and then 3-4 months postdischarge. Contrary to our hypothesis that alcohol consumption imparted a significant additive detriment to treatment outcome in patients already suffering from major depression, the results suggest that treatment was effective even in those with concomitant use of alcohol. Moreover, there appeared to be an added benefit when even modest alcohol consumption was decreased among elderly patients suffering from depression.
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Clinical laboratory measures in relation to depression, disability, and cognitive impairment in elderly patients.
To characterize the dimensions of physiological abnormalities that commonly occur in older individuals in a residential care setting and to evaluate their association with clinical measures, the authors conducted an exploratory factor analysis on clinical laboratory measures from a sample of 231 elderly residents (mean age: 86) living in a nursing home and congregate apartment facility. An eight-factor solution accounted for 70.2% of the variance in these measures; factors identified were interpreted as indices of renal function, protein/calorie/nutritional status, serum electrolytes/osmolarity, liver function, acute-phase processes, plasma lipids, acid/base status, and renal-tubular function. The nutritional factor was significantly associated with measures of disability and the presence of depression. The acute-phase processes factor was significantly associated with cognitive impairment.
Activities of Daily Living↗
The disabling nature of comorbid depression among older DUI recipients.
Alcoholism and depression are two of the most common and disabling mental illnesses in late life. This study is a descriptive report of a sample of 49 adults who had recently been convicted of Driving Under the Influence of alcohol (DUI). A lifetime history of alcohol abuse or dependence was present in 48 subjects (98%), while a depressive disorder occurred in 24 (49%) of the subjects. Concurrent alcoholism and depression, present in 12 subjects (24.5%), produced greater self-reported disability compared to those subjects with alcoholism alone. One-year longitudinal follow-up was available on 31 subjects (63.3%). Over the course of one year, there were no changes in drinking behavior, depressive symptoms, or self-reported quality of life. These data support previous studies that suggest greater disability in patients with concurrent mental illnesses.
Adult↗
Comparison of risperidone and placebo for psychosis and behavioral disturbances associated with dementia: a randomized, double-blind trial. Risperidone Study Group.
BACKGROUND: We report the findings from the first large, double-blind, placebo-controlled study conducted to evaluate the efficacy and safety of risperidone in the treatment of psychotic and behavioral symptoms in institutionalized elderly patients with dementia. METHOD: 625 patients (67.8% women; mean age = 82.7 years) with DSM-IV diagnoses of Alzheimer's disease (73%), vascular dementia (15%), or mixed dementia (12%) and significant psychotic and behavioral symptoms were included. Each patient was randomly assigned to receive placebo or 0.5 mg/day, 1 mg/day, or 2 mg/day of risperidone for 12 weeks. The primary outcome measure was the Behavioral Pathology in Alzheimer's Disease rating scale (BEHAVE-AD). RESULTS: The study was completed by 70% of the patients. Baseline Functional Assessment Staging scores were 6 or 7 in more than 95% of the patients, indicating severe dementia. At endpoint, significantly greater reductions in BEHAVE-AD total scores and psychosis and aggressiveness subscale scores were seen in patients receiving 1 and 2 mg/day of risperidone than in placebo patients (p = .005 and p < .001, respectively). At week 12, 0.5 mg/day of risperidone was superior to placebo in reducing BEHAVE-AD aggression scores (p = .02). More adverse events were reported by patients receiving 2 mg/day of risperidone than 1 mg/day. The most common dose-related adverse events were extrapyramidal symptoms, somnolence, and mild peripheral edema. The frequency of extrapyramidal symptoms in patients receiving 1 mg/day of risperidone was not significantly greater than in placebo patients. CONCLUSION: Risperidone significantly improved symptoms of psychosis and aggressive behavior in patients with severe dementia. Results show that 1 mg/day of risperidone is an appropriate dose for most elderly patients with dementia.
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Examination of the cognitive effects of cimetidine in normal elderly volunteers.
The authors evaluated the cognitive effects of acute challenges with the H2 receptor-antagonist cimetidine in normal older volunteers. The study was a double-blind, placebo-controlled, crossover study of 12 volunteers, average age 71.25 years. Baseline assessment was followed by randomized administration of a placebo or ascending doses of cimetidine (400 mg, 800 mg, or 1,600 mg) in test sessions separated by 1 week. Cognitive performance was evaluated with a 1-hour battery of tests beginning 90 minutes after administration of a single dose of drug (or placebo). There were no significant cognitive decrements associated with cimetidine. Despite numerous case reports of cognitive toxicity, this study found no observable decrements in cognitive performance in a group of healthy elderly subjects; therefore, case reports in the literature may be reporting effects for patients with specific impairments or sensitivities.
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A stimulation-retreat special care unit for elders with dementing illness.
Two equivalent special care nursing home units for elders with dementing illness were randomly designated as experimental and control units for an intervention called the "stimulation-retreat" model. This model introduced a set of staffing and program changes whose purpose was to diagnose, prescribe, and apply a package of care according to individual needs for additional stimulation or relief from stimulation ("retreat"). A total of 49 experimental and 48 control unit residents completed 12 months of care and were evaluated at baseline, 6 months, and 12 months. It was hypothesized that the intervention would not affect the basic disability (cognitive and activities of daily living functions), would improve negative behaviors and observed affects, and would have maximum impact in increasing positive behaviors and affects. Over time, most functions worsened, including negative attributes and affects. Lesser decline in positive affect and increases in external engagement, however, led to the conclusion that the intervention showed a marginally significant and selective effect on positive behaviors and affect.
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The structure of depression among elderly institution residents: affective and somatic correlates of physical frailty.
BACKGROUND: Confounding of depression with somatic illness and anxiety, a problem in any age group, may be especially troublesome in frail older persons. This paper examined this problem in a factor analytic study of the structure of depressive symptomatology, identifying affective and somatic symptom clusters and relating those clusters to health and functional variables cross-sectionally and prospectively over a 1-year interval. METHODS: The factor structure of a DSM-IV symptom checklist was examined among 1,245 elderly long-term care residents. Regression analyses examined the association of resulting factors with cognition, functional disability, self- and physician-rated health, and pain at baseline and a year later. One-year mortality was also examined. RESULTS: Factor analysis revealed three unique symptom clusters: depressed mood, somatic symptoms, and psychic anxiety. Depressed mood and somatic symptoms were associated cross-sectionally with all functional health variables, but psychic anxiety was associated only with pain. Longitudinally, depressed mood was the only independent predictor of decline in cognition, functional ability, physician-rated health, and mortality; the last effect, however, did not withstand control for baseline health and functioning. Somatic symptoms at baseline predicted decrement in self-rated health a year later. Effects varied as a function of cognitive status. CONCLUSIONS: These data suggest that concerns about the confounding role of somatic symptoms in the association of depression with physical health are unfounded. Although somatic symptoms of depression and anxiety were associated with health and functional status cross-sectionally, depressed mood was by far the stronger predictor of health declines over time.
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Identification of medications that cause cognitive impairment in older people: the case of oxybutynin chloride.
OBJECTIVES: To evaluate the cognitive effects of acute challenges with the antispasmodic agent oxybutynin hydrochloride in normal older volunteers and to compare these effects with those attributable to diphenhydramine, another commonly used medication with anticholinergic (muscarinic-blocking) activity. DESIGN: A double-blind, placebo-controlled cross-over study. SETTING: Laboratory evaluations of community subjects. PARTICIPANTS: A convenience sample of 12 volunteers, average age 69.17 years. INTERVENTION: Baseline assessment was followed by randomized administration of a placebo, oxybutynin hydrochloride (5 and 10 mg), and diphenhydramine hydrochloride (50 mg) in test sessions separated by 1 week. MEASUREMENTS: Evaluation of cognitive performance with a 1-hour battery of pencil and paper, interviewer-administered, and computer-administered tests beginning 90 minutes after drug (or placebo) administration. RESULTS: Random regression analyses demonstrated that oxybutynin caused significant cognitive decrements on seven of 15 cognitive measures, and diphenhydramine caused decrements on five measures. The most sensitive measures for detecting the effects of oxybutynin hydrochloride were the Buschke Selective Reminding Test and Reaction Time. CONCLUSIONS: These findings demonstrate that oxybutynin can cause cognitive impairment and suggest that physicians prescribing it should monitor their patients to facilitate the early recognition of those who experience drug-related cognitive deficits. More generally, the findings demonstrate that systematic research with normal volunteers can identify cognitive toxicity not recognized during the process of drug development or postmarketing surveillance.
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What should we do about undertreatment of late life psychiatric disorders in primary care?
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Diagnosis and treatment of depression in patients with Alzheimer's disease and other dementias.
Depressive disorders--both major depression and other less severe but nonetheless clinically significant depressions--are common comorbidities, components, or complications of dementia. Depression with reversible cognitive impairment may be a prodrome for dementia rather than a separate and distinct disorder. Recent research has demonstrated that both the diagnosis of major depression and the assessment of typical depressive symptoms can be conducted reliably, even in patients with mild-to-moderate levels of cognitive impairment. Self-ratings of depressive symptoms with the Geriatric Depression Scale remain valid in patients with Mini-Mental State Examination scores of at least 15. Among interviewer-administered instruments, the Hamilton Rating Scale for Depression and the Cornell Scale are the best established. Potential difficulties with assessment include problems with ascertainment (because families, in general, report greater depression in patients than do clinicians) and the ambiguity of symptoms (because apathy and related symptoms can result from both depression and Alzheimer's disease). Brain changes due to Alzheimer's disease may lead to fundamental differences in drug responses. Nevertheless, randomized clinical trials have demonstrated that depression in dementia responds to specific psychopharmacologic or psychosocial treatments.
Alzheimer Disease↗