Psychotropic medication in the elderly. A survey of prescribing and clinical outcome

Due to the increasing elderly population, an increased number of elderly patients requires treatment for mental and behavioural disorders. There are relatively few clinical studies of the prescribing of psychotropic drugs in patients over 65 years of age. A prospective study was undertaken at three centres caring for the elderly, encompassing patients from general nursing homes and a psychiatric department. Entry of patients into the survey was determined by the clinical decision to prescribe psychotropic medication and an age of 65 years or older. Included in the study were 160 patients. The main reasons for initiating psychotropic medication were indicated, and anamnestic data were collected. Initial and continuing dosages of psychotropic medication were recorded. The clinical condition was assessed at the start of treatment and after four and eight weeks, utilising the Clinical Global Impressions (CGI) scale. The patient's daily activity using an abbreviated Stockton Geriatric Rating Scale (SGRS) was assessed. Side effects were recorded using the UKU Scale. Clinical improvement was seen in about half of the patients with the best effect in patients with mainly psychotic symptoms. Patients with chronic dementia-related problems responded less well. Side effects were few and generally mild. This situation may relate to cautious introduction of the medication and adoption of low-dose regimens. All centres avoided, if possible, psychotropic polypharmacy.

[Mycosis fungoides. A review of the clinical picture, treatment and course in 107 patients]

During the period 1972 till the end of 1987, 107 patients with the diagnosis of mycosis fungoides or cutaneous T-cell lymphoma were examined and treated in the Department of Dermatology, Marselisborg Hospital. This disease belongs to the group of non-Hodgkin T-cell lymphomata. The diagnosis is based on the occurrence of red, scaly plaques in the skin associated with itching or tumours in the skin and, simultaneously, of a pleomorphic infiltrate consisting of CD4-positive T-lymphocytes which show characteristically exocytoses in the epidermis with subsequent formation of Pautrier's microabscesses. The disease may progress with spread to the regional lymph nodes where lymphomata develop. Treatment is initially local with employment of chlormethin ("nitrogen mustard gas") and this treatment can maintain the patients in remission for prolonged periods. In cases with spread to lymph glands or in particularly aggressive forms with tumour formation in the skin, combined chemotherapy is administered (prednisone, cyclophosphamide, etretinate and bleomycin). Thirty-eight of the patients were in stage I in which a clinical suspicion of mycosis fungoides was present but where the histological changes were insufficient to confirm the diagnosis. IVa and ten in stage IVb. The age at the onset of the symptoms was from 59 to 64 years (median values) for the various stages. Stages I and II had approximately 80% five-year survival, while the stages with more extensive spread had approximately 50% survival. The etiology of the disease is unknown but, during recent years, certain evidence has been found suggesting that activation of a retrovirus in the epidermis may be a contributory factor.

Branched chain enriched amino acid versus glucose treatment of hepatic encephalopathy. A double-blind study of 65 patients with cirrhosis

We studied the effects of infusion of a branched chain enriched amino acid mixture versus glucose on acute hepatic encephalopathy in patients with cirrhosis. Sixty-five patients were randomly treated with 1 g/kg per day of an amino acid mixture with 40% branched chain contents (32 patients), or isocaloric glucose (33 patients) for a maximum of 16 days. The regimens further included glucose infusion to a total of 26.5 kcal/kg per day and lactulose. The patients took part in the study for 5-6 days. In each group 17 patients woke up. In the amino acid group eleven died and four developed renal failure. In the glucose group ten died, three developed renal and two respiratory failure, and one remained encephalopathic. The coma score worsened in three of the patients who died in the amino acid group, but in all patients who died in the glucose group. The negative nitrogen balance on entry reversed in the amino acid group, but not in the glucose group. Thus, the branched chain enriched amino acid supplement did not change the prognosis for wake-up, but had other effects on the cerebral state and on nitrogen homeostasis.

A double blind comparative multicentre study of remoxipride and haloperidol in schizophrenia

Seventy-two patients fulfilling the DSM-III criteria for schizophrenia and schizophreniform psychosis were admitted to a multicentre, double-blind controlled study to evaluate the efficacy and safety of remoxipride in comparison to haloperidol. The mean daily dose of remoxipride at the end of treatment was 353 mg and of haloperidol, 11 mg. Patients were assessed each week on the Brief Psychiatric Rating Scale (BPRS), the Clinical Global Impression (CGI) and the symptoms checklist. No significant differences in efficacy were found between the two treatments. The median total BPRS score in the remoxipride group was 25 at start of active treatment and 17 at the last valid rating (n = 31). For the haloperidol group the corresponding figures were 24 and 15 (n = 29). According to the CGI, 40% of remoxipride patients and 50% of haloperidol patients were much or very much improved. Treatment-emergent extrapyramidal symptoms, such as akathisia and rigidity, occurred significantly more frequently, and were more severe during treatment with haloperidol than with remoxipride (p = 0.012 and 0.024, respectively). Haloperidol-treated patients reported significantly more drowsiness and increased sleep during treatment (p = 0.026 and 0.012, respectively). No statistically significant differences were seen in endocrine or autonomic symptoms. Remoxipride seemed to be as effective as haloperidol, had a lower frequency of side effects, and was used safely in the dose range 150-600 mg/day.

[The leopard syndrome]

A man aged 32 years was referred to a dermatological department for alopecia areata. In addition, the patient had multiple lentigines which, together with other abnormalities, suggested the leopard syndrome. Alopecia areata does not appear to have been described previously in this syndrome.

Linkage between serum cholinesterase 2 (CHE2) and gamma-crystallin gene cluster (CRYG): assignment to chromosome 2

Serum cholinesterase 2 (CHE2) was examined in a Danish material of normal families that has been tested earlier for 70-78 classical marker systems and 25 RFLP systems. DNA for RFLP typing was provided by transforming 16-year-old frozen lymphocytes. The frequency of allele CHE2*C5+ in the Danish population was found to be 0.0430. The highest lod score was between CHE2 and the gamma-crystallin gene cluster (CRYG) (zeta = 4.21 at theta = 0.00 in females). The scores were from a single family with 15 children. CHE2 may, accordingly, be assigned to the location of CRYG: chromosome 2, bands q33-q35.

Biochemical and clinical effects of an antioxidative supplementation of geriatric patients. A double blind study

Ninety seven geriatric patients from two Danish homes for old people accepted to participate in a blinded experiment designed to counteract ageing phenomena. The subjects were split into two groups, i.e., the verum and the placebo group. The verum group received daily for one year an antioxidative cocktail consisting of: 300 micrograms selenium as L-selenomethionine, 45 mg zinc, 270 mg vitamin C, 2.7 mg vitamin A, 6 mg vitamin B-6, and 465 mg vitamin E (d-alfatocopherol). Furthermore, in order to enhance exchange in polyenoic acids, each subject received daily 250 mg gamma-linolenic acid. The placebo groups received similar looking pills and capsules without the active components. During one year in the verum group, the whole blood selenium, the hydrogen-dependent glutathione peroxidase (GSH-Px) of erythrocytes, and the vitamin E level in serum was found increased compared to the pretreatment values and to the placebo group. No change could be traced in the t-butylhydroperoxide dependent GSH-Px, an enzyme that also assays the glutathione-s-transferase. During the same period of time, the fasting levels of serum fatty acids and the content of lipofuscin in erythrocytes were estimated. Compared to the pretreatment values, the lipofuscin level declined significantly and the level of w-3 penta- and hexaenoic acids increased in the verum, but not in the placebo group. During the study period, slight, but significant improvements in psychological scores could be traced. Furthermore, the assays of bloodflow in different areas of the brain surface (i.e., the ISI values) revealed a general trend to improvement in all areas, when the ISI values were compared during treatment with the pretreatment values and the values in the placebo group.

The influence of hepatic insufficiency due to alcoholic cirrhosis on the erythrocyte transketolase activity (ETKA)

The erythrocyte transketolase activity (ETKA), the stimulated erythrocyte transketolase activity (ETKAS), and the thiaminepyrophosphate effect (TPPE) were measured in 21 alcoholic patients with cirrhosis and hepatic insufficiency, 13 alcoholic patients without cirrhosis and 21 non-alcoholic persons before and after oral treatment with 100 mg of thiamine daily for 2 weeks in order to investigate the influence of hepatic insufficiency on these variables. A statistically significant rise in ETKA and fall in TPPE were found in all three groups. ETKA, ETKAS and TPPE did not differ from each other in alcoholic patients with and without cirrhosis, but TPPE was significantly higher in these patients than in the non-alcoholic persons. The conclusions are that severe cirrhosis does not affect the erythrocyte transketolase apoenzyme, the ability of the tissues to convert thiamine to thiaminepyrophosphate for use in the erythrocytes or the absorption of thiamine from the gastrointestinal tract. Besides alcoholism seems to dispose to thiamine deficiency to a higher degree than cirrhosis, and the role of the liver as a thiamine store appears to be of minor importance in the development of thiamine deficiency. Finally, ETKA, ETKAS, and TPPE are considered to be usable as thiamine deficiency indicators in patients with cirrhosis as well as in patients without cirrhosis.

Influence of rifampicin and isoniazid on the kinetics of phenytoin

Clearance of phenytoin after i.v. injection of 100 mg was studied in six patients before and after 2 weeks daily treatment with 450 mg rifampicin, and in 14 patients with tuberculosis receiving standard treatment with 450 mg rifampicin, 300 mg isoniazid, and 1200 mg ethambutol daily. Acetylator status was measured by urinary acetylated sulphadimidine. Clearance of phenytoin in patients receiving only rifampicin increased from 46.7 ml min-1 +/- 20.6 ml min-1 to 97.8 ml min-1 +/- 33.4 ml min-1 (P less than 0.01), while clearance in patients on three drugs increased from 47.1 +/- 23.4 ml min-1 to 81.3 ml min-1 +/- 41.6 ml min-1 (P less than 0.01). No significant differences were observed between the six fast acetylators and the eight slow acetylators. Phenytoin kinetics were unchanged after further 3 months of combined treatment. Rifampicin is a strong inducer of the elimination of phenytoin. Combined treatment with isoniazid has no counter-acting effect in either fast or slow acetylators.

High resolution chromosomes from first trimester trophoblast cultures

A simple method for obtaining prometaphase chromosomes from cultured first trimester cells involves the addition of BrdU and FdU 11 h before harvest and ethidium bromide 1.5 h before harvest. High resolution R-banding is obtained by acridine orange staining.

Mucus secretion in hypertrophic, hypersecretory, protein-losing gastropathy

A 48-year-old man presented with giant folds of the gastric mucosa, hypoalbuminemia, and hypersecretion of acid. In vivo labeling of plasma proteins by 51CrCl3 disclosed an abnormal gastric protein clearance. Mucus secretion, evaluated by the output of dry matter, mucosubstance constituents (hexosamine and fucose), protein (by the method of Lowry), and sodium were five to eight times those in nine healthy volunteers, but were normalized by the histamine-H2-receptor antagonist cimetidine. The proportion of dry matter and protein was the same in the patient and in healthy subjects, indicating that the loss of plasma protein into the stomach probably occurred as part of an abnormally great secretion of mucus.