Psychiatry of old age: from section to faculty

OBJECTIVE

To describe the processes that led to formation of the RANZCP Faculty of Psychiatry of Old Age (FPOA).

METHOD AND RESULTS

Two criteria needed to be fulfilled before Faculty status could be approved. One was to demonstrate a recognised body of knowledge concerning psychiatry of old age, and the other was to be able to offer a comprehensive training program in this subspecialty.

CONCLUSIONS

On 1 January 1999, FPOA came into existence.

The International Psychogeriatric Association--ninth congress. 15-20 August 1999, Vancouver, Canada

In contrast to previous International Psychogeriatric Association (IPA) meetings, there was a preponderance of sessions dedicated to pharmacological management of cognitive decline due to Alzheimer's disease (AD), especially by cholinesterase inhibitors. Donepezil (Eisai Co Ltd) and rivastigmine (Novartis AG) were most frequently featured, while propentofylline (Hoechst AG) has emerged as an agent potentially efficacious in both AD and vascular dementia. A second focus was the treatment of the behavioral and psychological symptoms of dementia (BPSD), particularly by the atypical antipsychotics risperidone (Janssen Pharmaceutica NV), olanzapine (Eli Lilly & Co) and quetiapine (AstraZeneca plc), but also by anticonvulsants. Some attempts were made to redress the balance by examining non-pharmacological treatments. There were surprisingly few presentations on the management of depression. Fortunately, most of the presentations focused on the difficult issue of comorbid depression and medical illness. Overall, there were no major disclosures of new drugs. Most new data was simply a refinement of previously published material.

The Senior Psychiatrist Survey III: attitudes towards personal ageing, life experiences and psychiatric practice

OBJECTIVE

The aim of this study is: to explore whether there is a relationship between the effects of gender, age and perceptions of personal health on psychiatrist's reactions to personal ageing; and to determine the effects of psychiatrist's reactions to personal ageing upon their approach to clinical practice, retirement planning and post-retirement activities.

METHOD

A postal survey was conducted. Respondents were Fellows of the Royal Australian and New Zealand College of Psychiatrists resident in Australia or New Zealand. Of 1086 eligible subjects, 529 participated. The main outcome measures were: Reactions to Ageing Questionnaire (RAQ); self-rated health; location and type of psychiatric practice; the perceived benefits and drawbacks of age on psychiatric practice and case selection; and retirement plans.

RESULTS

Positive attitudes towards personal ageing were significantly associated with old age, males and good or excellent self-rated health. Negative attitudes were associated with working in universities and anticipated retirement due to poor health. Field of practice, anticipated post-retirement activities and approach to clinical practice were not found to have a significant effect on attitudes towards personal ageing.

CONCLUSIONS

The effects of life experiences on psychiatrists' attitudes towards personal ageing are complex. Attitudes towards personal ageing have little impact on psychiatric practice.

The Senior Psychiatrist Survey I: age and psychiatric practice

OBJECTIVE

The aim of this study is to determine the effects of age on the practice, roles, status and attitudes of psychiatrists within the Royal Australian and New Zealand College of Psychiatrists (RANZCP).

METHOD

A postal survey of Fellows of the RANZCP resident in Australia or New Zealand was conducted. The main outcome measures were: age; location and type of psychiatric practice; hours of work; attitudes towards re-accreditation; changes in work practices over the career; and the perceived benefits and drawbacks of age to psychiatric practice and case selection.

RESULTS

Of 1086 eligible subjects, 629 participated. The mean age of the sample was 52.7 years (SD = 13.5). Those psychiatrists favouring re-accreditation were younger. Psychiatrists practising psychotherapy, forensic psychiatry or general psychiatry; working in psychiatric hospitals and private practice were more likely to be older. Older psychiatrists worked shorter hours. There was largely no association between case selection and age. Psychiatrists reporting increased credibility and respect as a benefit of their current age upon their psychiatric practice were older, as were those identifying fatigue and an inability to keep up to date as a drawback of age. Psychiatrists reporting a lack of credibility and respect were younger, as were those who reported increased enthusiasm and optimism.

CONCLUSIONS

Age is associated with benefits and drawbacks to the practice of psychiatry and this may be reflected in the different practice profiles of older and younger psychiatrists.

The Senior Psychiatrist Survey II: experience and psychiatric practice

OBJECTIVE

The aim of this study is to determine the effects of experience on the practice, roles, status and attitudes of psychiatrists within the Royal Australian and New Zealand College of Psychiatrists (RANZCP).

METHOD

A postal survey of Fellows of the RANZCP resident in Australia or New Zealand was conducted. The main outcome measures were: years of psychiatric experience; higher medical qualifications; location and type of psychiatric practice; attitudes about senior psychiatrists and mentorship; changes in work practices over the career; and the perceived benefits and drawbacks of experience on psychiatric practice and case selection.

RESULTS

Of 1086 eligible subjects, 629 participated. Over 96% of respondents, particularly the younger and less experienced, believed that senior psychiatrists have wisdom to offer to junior colleagues. This wisdom principally related to mentorship/supervision. Increased 'respect and tolerance' of patients as a benefit of experience was more likely to be reported by respondents who were more experienced. Respondents more confident about treating younger patients and treating functional psychoses were more likely to be less experienced, as were those reluctant to take on psychotherapy cases. Those respondents reluctant to take on 'dangerous or acting-out patients' were more experienced. The field of psychiatric practice significantly influenced case selection.

CONCLUSIONS

Senior psychiatrists have accumulated wisdom through experience that is sought by junior colleagues via mentorship. It is recommended that the RANZCP should specifically address the needs of early career and senior psychiatrists.

Treatment of vocally disruptive behaviour of multifactorial aetiology

OBJECTIVE

To describe the treatment of vocally disruptive behaviour (VDB) of multifactorial aetiology.

METHOD

Three case reports were used to illustrate the treatment of multifactorial VDB.

RESULTS

A biopsychosocial assessment is required to identify the different aetiologies involved and the way they interact. Acute medical and psychiatric factors may demand that interventions are introduced simultaneously rather than in succession.

CONCLUSION

Successful interventions require the combination of biopsychosocial strategies tailored to the individual case with realistic goals that include the acceptance of a residual level of VDB as a reasonable outcome.

Stress in carers of the elderly. A controlled study of patients attending a Sydney family medical practice

AIM

To examine stress in carers of the elderly who attended a solo family medical practice.

METHOD

Eighty-seven carers were compared with 102 non-caregiving controls. Subjects were asked to complete survey questionnaires either in the surgery or at home. The General Health Questionnaire (CHQ) was used to assess psychological morbidity, the Relative Stress Scale as a measure of subjective burden and information was collected on activities of daily living and instrumental activities of daily living.

RESULTS

No significant difference was found in GHQ scores, reflecting the high level of stress in this family practice sample (mean GHQ = 4.7, standard deviation = 6.2). Psychological morbidity in carers was associated with the provision of assistance with instrumental activities of daily living such as shopping, cooking and finances.

CONCLUSIONS

We suggest that because carers often encounter specific challenges which may be amenable to intervention, general practitioners should familiarise themselves with these issues, determine the caregiving status of their patients and provide information about community services to carers.

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.

Quantification of factors contributing to length of stay in an acute psychogeriatric ward

OBJECTIVE

To identify variables that predict length of stay (LOS) in an acute psychogeriatric ward; quantify psychiatric, medical and social factors that contribute to LOS; and identify factors that prolong LOS.

DESIGN

Prospective audit of admissions over 12 months.

SETTING

Acute psychogeriatric ward in teaching hospital.

PATIENTS

73 consecutive patients with a total of 88 admissions.

MAIN OUTCOME MEASURES

Main psychiatric, medical and social reasons for admission; Physical Health Schema; total LOS; number of days attributable to psychiatric, medical, social and treatment (non-response and adverse reactions) reasons; DSM-IV diagnosis; global clinical outcome; discharge living arrangements; discharge psychotropic medication.

MAIN RESULTS

Presence of depressive symptoms was the most common psychiatric reason for admission and carer stress the main social reason for admission. Principal diagnosis of major depression and carer stress were significant predictors of LOS and accounted for 24.3% of the variance (p < 0.0001). Physical health and psychiatric comorbidity were not able to predict LOS. The proportion of psychiatric, medical and social reasons involved in LOS varied significantly by principal diagnosis (p < 0.001). Almost 42% of bed days were attributable to delays--for medical, social (eg placement problems), treatment (adverse events, non-response) or hospital system reasons.

CONCLUSIONS

The quantification of factors contributing to LOS in an acute psychogeriatric unit allows for more accurate identification of issues that can be addressed to improve the efficiency of bed utilization.

Adapting to needs in old-age psychiatry

The patient described is a 56-year-old man presenting with chronic depression and eventually found to have Alzheimer's disease. Issues in the diagnosis and evolution of early dementia are discussed. The importance of long-term psychological support to the dementing patient, as well as their carers, is emphasized.

Effect of relaxation music on patient tolerance of gastrointestinal endoscopic procedures

The use of relaxation music as an adjunct to sedation has not been well studied. We tried to determine whether the use of relaxation music can improve patient tolerance of gastrointestinal endoscopic procedures. Fifty-nine patients undergoing gastrointestinal endoscopic procedures were randomly assigned to receive either relaxation music (n = 28) or no music (n = 31) using headphones and a portable compact disc player. Patient anxiety before the procedure, tolerance of the procedure, and willingness to undergo a repeated procedure were self-assessed using a visual analog scale. Patient tolerance was also assessed by the assisting nurse. There was no significant difference in the overall tolerance score between the two groups. However, a significantly higher proportion of patients described the experience of a gastrointestinal endoscopic procedure as being at least moderately unpleasant in the no-music group. Patient acceptance of the relaxation music was high: 82% in the group stated they would have music again if they required another procedure. We conclude that, even in patients who have sedation, relaxation music can reduce the number who find the experience of gastrointestinal endoscopic procedures unpleasant. Therefore we believe it has a role as an adjunct to sedation in gastrointestinal endoscopic procedures.

The older psychiatrist and retirement

OBJECTIVE

To determine the clinical practices, retirement plans and post-retirement professional activities of older psychiatrists, comparing retirees with working psychiatrists.

DESIGN

Postal survey.

PARTICIPANTS

All Fellows of the Royal Australian and New Zealand College of Psychiatrists aged 55 years and over, resident in Australia or New Zealand. Of 468 eligible subjects, 281 (60%) participated.

MAIN OUTCOME MEASURES

Location and type of psychiatric practice; hours of work; retirement plans; anticipated and actual retirement criteria; anticipated and actual post-retirement professional activities; self-rated health.

RESULTS

Working psychiatrists comprised 79% of the sample, being significantly younger (mean 63.8 years) than retirees (mean 72.3 years, p < 0.001). Over 62% of respondents worked principally in general psychiatry. Working psychiatrists were mainly in private practice (61%) and retirees had been in public psychiatry (53%, p < 0.001). Working psychiatrists worked about 41 hours/week, 98 (49%) having reduced their hours in the previous 5 years. Retirement plans had been commenced by 124 (61%). Fatigue (27%) and memory impairment (10%) were reported as age-related changes adversely affecting work capacity, raising concerns of competence. Working psychiatrists more often anticipated deteriorating health (p < 0.001) and family/personal reasons (p < 0.01) as retirement criteria and anticipated involvement in a significantly higher number of post-retirement professional activities than retirees reported (p < 0.001). Retirees rated themselves in significantly poorer health than working psychiatrists (p < 0.001), even when age was partialed out (p < 0.001).

CONCLUSIONS

Most older psychiatrists gradually retire by reducing work hours and developing new interests. The majority of retirees retain involvement in professional activities, but substantially less than anticipated by those still working.

Psychosocial stressors, physical illness and the spectrum of depression in elderly inpatients

OBJECTIVES

To describe all elderly patients hospitalised with principal and secondary diagnoses of depression, and to determine whether a relationship can be demonstrated between psychosocial stressors, physical illness and type of depression.

METHOD

A retrospective chart review of elderly patients admitted to a general hospital psychiatry ward over a 7-year period with principal or secondary diagnoses of depression was undertaken. Four broad diagnostic categories of depression were used: major depression, psychotic depression, minor depression, and organic depression. Chief outcome measures were: number of medical diagnostic categories, presence of psychosocial stressors, global clinical improvement, and length of stay.

RESULTS

Of 228 patients admitted with depression (194 principal diagnoses and 34 secondary diagnoses), 100 had major depression, 47 psychotic depression, 48 minor depression and 33 organic depression. Psychiatric comorbidity occurred in 70%, about half of which was due to organic brain syndrome. Patients with psychotic depression had the fewest medical problems and those with organic depression the most, while patients with minor depression had the highest rate of family and marital problems, comorbid personality dysfunction and suicide attempts. Patients with psychotic depression had the longest admissions, while those with minor depression had the shortest. Overall, 89% showed significant clinical improvement.

CONCLUSIONS

Elderly inpatients have a wide spectrum of depressive disorders with different psychosocial, medical and treatment profiles. Future studies of depression in old age should include all patients with clinical depression.

The PIE-1 protein and germline specification in C. elegans embryos

Totipotent germline blastomeres in Caenorhabditis elegans contain, but do not respond to, factors that promote somatic differentiation in other embryonic cells. Mutations in the maternal gene pie-1 result in the germline blastomeres adopting somatic cell fates. Here we show that pie-1 encodes a nuclear protein, PIE-1, that is localized to the germline blastomeres throughout early development. During division of each germline blastomere, PIE-1 initially associates with both centrosomes of the mitotic spindle. However, PIE-1 rapidly disappears from the centrosome destined for the somatic daughter, and persists in the centrosome of the daughter that becomes the next germline blastomere. The PIE-1 protein contains potential zinc-finger motifs also found in the mammalian growth-factor response protein TIS-11/NUP475 (refs 4-7). The localization and genetic properties of pie-1 provide an example of a repressor-based mechanism for preserving pluripotency within a stem cell lineage.

The elderly admitted to a general hospital psychiatry ward

In this retrospective study of 489 consecutive elderly admissions to a general hospital psychiatry ward, the main aim was to describe the stressors precipitating admission, psychiatric and medical diagnoses, physical treatments used, length of hospitalisation, and clinical and social outcome. Depression was the predominant diagnosis, with length of stay being correlated with depression severity. The main stressor associated with admissions was a change in medical status of the patient. At least two medical diagnoses were present in 70% of admissions, with many new physical illnesses being diagnosed. Significant improvement was found in 81% of admissions at discharge. Two thirds of admissions were discharged into independent living arrangements. While these outcomes suggested effective interventions, management difficulties were noted with the mix of elderly and young patients. It is recommended that acute psychogeriatric wards be developed in the general hospital and be located near geriatric medical wards.

Psychogeriatric training in Australia and New Zealand: a survey of psychiatry trainees and training program co-ordinators

Psychiatry trainees and training program co-ordinators in Australia and New Zealand were surveyed about psychogeriatric training. Responses were received from the co-ordinators of all training programs and 68% of trainees. Over 94% of responding trainees believe they require at least 3 months' psychogeriatric training. Currently about 70% of trainees obtain a psychogeriatric term by Year 4 of training, with 17 out of 21 training programs having positions available. Most trainees positively rate their psychogeriatric training experiences, with 89% enjoying it and 78% believing it adequate for their needs. It is recommended that psychogeriatric training be available to all trainees before sitting the RANZCP Section 1 examinations.

Body-wall muscle formation in Caenorhabditis elegans embryos that lack the MyoD homolog hlh-1

The myoD family of DNA binding proteins has been implicated in the control of myogenesis in a variety of organisms. Searches for homologs in the nematode Caenorhabditis elegans yielded only one gene, designated hlh-1, expressed in body-wall muscle cells and their precursors. To assess the role of hlh-1 in C. elegans myogenesis, genetic deficiencies spanning the hlh-1 locus were isolated after gamma irradiation. Embryos homozygous for these deficiencies exhibited extensive body-wall muscle differentiation, including expression of several characteristic myofilament proteins and weak contracile behavior. Thus, zygotic hlh-1 expression was not required for body-wall muscle precursors to adopt muscle cell fates.

Potentially reversible dementia: a review

Potentially reversible dementia is reviewed with reference to diagnosis, causes and outcome. Many disorders which cause cognitive impairment, such as drug toxicity and depression, fail to meet diagnostic criteria for dementia. These tend to have the best prognosis. Studies of the neuropsychiatric syndromes associated with disorders causing potentially reversible dementias suggest that dementia is an infrequent outcome and when it does occur, few cases recover. Factors predictive of improvement are short duration of symptoms and mild degree of cognitive impairment, usually subcortical in type. It is suggested that potentially reversible cognitive impairment would be a more accurate term as many cases are due to delirium and depression. While cases of well established dementia do not require extensive investigation, all cases should have a thorough clinical assessment as in many instances dual pathology exists and all require psychosocial management.