Psychiatric illnesses in the elderly: a review

Increased risk among older veterans of prescribing psychotropic medication in the absence of psychiatric diagnoses

OBJECTIVE

This study uses Veterans Health Administration (VHA) pharmacy and encounter claims to evaluate the use of psychotropic medications without a psychiatric diagnosis across age groups.

METHODS

National VHA administrative data for fiscal year 2010 (FY2010) were used to identify all veterans who filled a prescription for at least one psychotropic medication from VHA (N = 1.85 million). Bivariate and multivariate analyses were used to compare the proportion of these veterans without any psychiatric diagnosis, across age groups, adjusting for possible medical indications. Analyses were repeated for six different classes of psychotropic medications and comparing mental health utilizers and non-mental health utilizers. Comparisons were made to prescribing of HIV and diabetes medications without an indicated diagnosis.

RESULTS

Of all VHA patients prescribed a psychotropic medication in FY2010, 30% had no psychiatric diagnosis, with highest proportions among veterans ages 65-85. This practice was most frequent among nonmental health utilizers and far more prevalent for psychotropic medications than for HIV or diabetes medications. Logistic regression analysis found that age greater than 65 was the strongest predictor of being prescribed a psychotropic without a psychiatric diagnosis. Adjustment for possible medical use of psychotropics and overall medical comorbidity did not substantially alter these trends.

CONCLUSION

Older veterans, especially those not using specialty mental healthcare, are more likely to be prescribed psychotropic medications in the absence of a psychiatric diagnosis, perhaps representing unnecessary use, under-diagnosis of mental illness, or incomplete documentation.

Balance and gait in older electroconvulsive therapy recipients: a pilot study

BACKGROUND

Electroconvulsive therapy (ECT) is commonly used to treat depression in older adults. Despite its efficacy in this regard, an associated increase in the risk of falls in this population is a downside of treatment. ECT research has focused on the incidence of falls, but its effect on balance and gait - intrinsic factors in instability and falls - has not been studied. Our aim was to examine changes in balance and gait among older adults before and after a single ECT session and explore the effect of patient-related and treatment factors on any changes found.

METHODS

Participants were 21 older adults requiring ECT for depression in public psychiatric services. Patients with clinically overt mobility problems (impairing test participation or increasing the risk of falls) were excluded. Balance and gait testing 1 hour pre-ECT and 1, 2 and 3 hours post-ECT included: (1) steady standing test; (2) perturbation of standing balance by self-initiated movements; (3) perturbation of standing balance by an external perturbation; and (4) timed up and go test.

RESULTS

No deterioration in test performance was found, using one-way repeated measures analysis of variance.

CONCLUSION

Balance and gait did not deteriorate immediately after ECT. Exclusion of participants with clinically overt mobility problems and falls being better attributable to factors unrelated to balance and gait (such as post-ECT confusion) may account for our findings. This research does not repudiate the occurrence of ECT-related falls but calls into question the utility of introducing routine balance and gait assessment among older ECT recipients without pre-existing mobility problems as a means of preventing them.

Effect of patient gender on late-life depression management

PURPOSE

To determine whether patient gender influences physicians' management of late-life major depression in older and younger elderly patients.

METHODS

In 1996-2001, physician subjects viewed a professionally produced videotape vignette portraying an elderly patient meeting diagnostic criteria for major depression, then answered interviewer-administered questions about differential diagnosis and treatment. Patient gender and other characteristics were systematically varied in different versions of the videotape, but clinical content was held constant. This was a stratified random sample of 243 internists and family physicians with Veterans Health Administration (VA) or non-VA ambulatory care practices in the Northeastern United States. Outcomes were whether physicians followed a guideline-recommended management approach: treating with antidepressants or mental health referral or both and seeing the patient for follow-up within 2 weeks.

RESULTS

Only 19% of physicians recommended treating depression (12% recommended antidepressants and 7% mental health referral), and 43% recommended follow-up within 2 weeks. Patient gender did not influence management recommendations in either younger old (67 year old) or older old (79 year old) patients (p > 0.12 for all comparisons).

CONCLUSIONS

Gender disparities previously documented in the management of major conditions are not seen for the management of depression, a potentially stigmatized condition that does not require resource-intense interventions.

Prevalence, correlates, and associated outcomes of potentially inappropriate psychotropic use in the community-dwelling elderly

BACKGROUND

Previous applications of the Beers criteria have shown significant prescribing of potentially inappropriate psychotropic agents for the community-dwelling elderly. However, there is limited information at the national level on potentially inappropriate psychotropic use, the characteristics of elderly persons at risk, and the impact of this inappropriate use on health care outcomes.

OBJECTIVE

This study addressed the prevalence, correlates, and associated outcomes of potentially inappropriate psychotropic use among community-dwelling elderly persons in the United States who were receiving psychotropic medications.

METHODS

Data from the 1996 Medical Expenditure Panel Survey (MEPS) were employed to examine the use of psychotropic medications that generally should be avoided in the elderly and those that should be avoided in elderly patients with certain preexisting conditions, as defined by the Beers criteria. The MEPS sampling weights were used to derive national estimates. Cross-sectional data were analyzed by multivariate analyses to examine the correlates and associated health care outcomes (health care utilization, economic, and humanistic) of potentially inappropriate psychotropic use in the elderly.

RESULTS

An estimated 2.30 million community-dwelling elderly persons received potentially inappropriate psychotropic medications in 1996. This represented 7.14% of all community-dwelling elderly persons and 37.86% of all community-dwelling elderly persons using psychotropic agents; 32.94% of those taking psychotropic drugs received agents that were generally inappropriate, and 10.21% received agents that were inappropriate in the presence of specific conditions. The rates of potentially inappropriate psychotropic use in those receiving antidepressant, antianxiety, and sedative/hypnotic agents were 50.93%, 31.84%, and 23.49%, respectively. Multivariate analyses showed that correlates of potentially inappropriate psychotropic use in the elderly were age <75 years and use of multiple psychotropic agents. After controlling for predisposing, enabling, and need factors, no association was found between the use of potentially inappropriate psychotropic medications and differences in health care utilization, economic, or humanistic outcomes.

CONCLUSIONS

The study findings suggest that although the use of potentially inappropriate psychotropic medications is common among the community-dwelling elderly who are prescribed psychotropic agents, the unfavorable risk-benefit ratio of these inappropriate medications does not appear to influence broad measures of health care utilization, costs, or quality of life in this population.

Treatment of non-schizophrenic disorders: focus on atypical antipsychotics

Antipsychotics are commonly used for conditions other than schizophrenia, yet support for such use in the literature is unclear. This article reviews the literature on the pharmacologic treatment of specific types of non-schizophrenic disorders: those associated with psychotic depression, obsessive-compulsive disorder, body dysmorphic disorder, bipolar disorder, and dementia. It focuses on the evidence for using antipsychotics in these conditions, placing emphasis on atypical antipsychotics. Medline/HealthStar and PsycInfo databases were used to identify published trials and reports of antipsychotics used specifically for non-schizophrenic disorders. Numerous studies were found supporting the use of atypical antipsychotics for non-schizophrenic disorders; however, with the exception of dementia, few randomized, double-blind controlled trials have been published examining the efficacy and safety of these agents in non-schizophrenic disorders. In general, most trials were restricted to short-term use as adjunctive therapy. The literature reviewed was primarily comprised of small open-label trials, thus making it difficult to draw definitive conclusions. Despite the limitations of the trials reviewed, atypical antipsychotics represent a promising treatment modality when considering their improved side effect profile compared to conventional agents. Appropriate dosing and the use of antipsychotics in combination with psychosocial treatments are important treatment considerations. Due to the frequent clinical use of atypical antipsychotics as adjunctive therapy, well-designed trials of these agents in non-schizophrenic disorders are necessary.

Prescribing of psychotropics in the elderly: why is it so often inappropriate?

Psychotropic medications are an important treatment approach to mental health disorders; such disorders are common in the elderly population. Elderly patients are more likely to experience adverse effects from these agents than their younger counterparts due to age-related changes in pharmacodynamic and pharmacokinetic parameters. Because of these factors, inappropriate use of psychotropic medications in elderly patients has become a focus of concern. In general an agent is considered inappropriate if the risk associated with its use exceeds its benefit. Implicit and explicit criteria for inappropriate use of medications in the elderly have been created and include psychotropic agents. These criteria vary in their make-up but the explicit criteria tend to agree that amitriptyline, doxepin, and benzodiazepines that have long half-lives are not appropriate. Although explicit inappropriate medication criteria have been in existence since 1991, elderly patients continue to receive inappropriate psychotropic medications. A wide array of factors may be responsible for this practice. Provider-related causes include deficits in knowledge, confusion due to the lack of a consensus on the inappropriate psychotropic criteria, difficulties in addressing an inappropriate medication started by a previous provider, multiple prescribers and pharmacies involved in the care of a patient, negative perceptions regarding aging, and cost issues. Patients may contribute to the problem by demanding an inappropriate medication. Finally, the healthcare setting may inadvertently contribute to inappropriate prescribing by such policies as restrictive formularies or lack of reimbursement for pharmacists' clinical services. Successful approaches to optimising prescribing have been either educational or administrative. Educational approaches (e.g. one-on-one sessions, academic detailing) seek to influence decision making, while administrative approaches attempt to enforce policies to curtail the undesired practice. The US Omnibus Budget Reconciliation Act of 1987, which improved psychotropic medication use in long-term care, is an excellent example of administrative intervention. More research specifically focused on the causes of inappropriate psychotropic medication use and methods to avoid this practice is needed before targeted recommendations can be made.

Cognitive impairment in depressed outpatients as measured with the Dementia Checklist: a simple method for primary care and in field research

The Dementia Checklist is a 12-item dementia rating scale for physicians who, for whatever reason, cannot be specifically trained. It addresses symptoms of cognitive decline that can easily be identified, and that are typical for different stages of cognitive impairment. This allows an easy classification of the severity of dementia. In a first study, the dementia checklist was used in 937 geriatric outpatients who were treated by neuropsychiatrists for depression. All items contribute to the accuracy of measurement (Cronbach's alpha = 0.84). Differences in cognitive impairment depending on age (chi 2 = 51.7; p < or = 0.001) and depression (chi 2 = 47.6; p < or = 0.001) indicate external validity of the dementia checklist and 5.7% of the outpatients were rated as demented. The Dementia Checklist provides a very economical and easy-to-use assessment of cognitive decline.

Risk factors for falling in a psychogeriatric unit

OBJECTIVE

To identify risk factors associated with falls in a psychogeriatric inpatient population.

DESIGN

Retrospective cohort study.

SETTING

A psychogeriatric inpatient unit in a Brown University affiliated psychiatric hospital.

PARTICIPANTS

A total of 1834 men and women who represented all admissions to the psychogeriatric inpatient unit between January 1992 and December 1995.

RESULTS

Over the study period a total of 175 falls were recorded, giving a fall rate of 9.5%. Using a logistic regression model, six variables were found to be independently associated with an increased risk of falling: female gender, electroconvulsive therapy (ECT), mood stabilizers, cardiac arrhythmias, Parkinson's syndrome and dementias. Falls and ECT were associated with longer hospital stay, when adjusted for confounders including ECT.

CONCLUSIONS

These findings support previous results and identify ECT as a possible risk factor for falling in a hospital setting.

Electroconvulsive therapy and falls in the elderly

Electroconvulsive therapy (ECT) is commonly used in the practice of geriatric psychiatry. Although it has been found to be both safe and effective, one of the most common complications associated with ECT is falls. A logistic regression model was created to identify independent risk factors for falls in the elderly. Two risk factors were identified: the number of ECT treatments and the diagnosis of Parkinson disease. Further studies are needed to develop strategies aimed at reducing the number of falls. In the meantime, clinicians need to be aware that falls represent an important complication associated with ECT.

Brain biochemistry using magnetic resonance spectroscopy: relevance to psychiatric illness in the elderly

Magnetic resonance spectroscopy (MRS) allows for the noninvasive study of cerebral biochemistry. It has been used to investigate cerebral metabolic changes associated with mental illness in vivo and in vitro. In this review, we will discuss the application of MRS to psychiatric illness in the elderly. Following a brief description of the basic principles of MRS, the use of phosphorus (31P) and proton (1H) MRS to enable a better understanding of normal brain aging, dementia (Alzheimer's disease, multiple subcortical infarct dementia, Down syndrome, frontotemporal dementia, vascular dementia, age-associated memory impairment, and other dementias), major depression, and electroconvulsive therapy is detailed.

Depression, social support, and quality of life in older adults with osteoarthritis

PURPOSE

To develop an understanding of the quality of life of older adults with osteoarthritis (OA) with varying levels of depression and social support as a basis for nursing interventions. Osteoarthritis in the United States is the number one chronic disease in late life and the major cause of disability in older adults. In addition to the functional disability and economic effect of OA, older people with this disease experience suffering, depression, and diminished quality of life.

DESIGN

For this cross-sectional survey, a convenience sample of 50 older adults with OA was recruited from two U.S. hospital-based arthritis clinics in northern Ohio for 3-months during 1995.

METHODS

During face-to-face interviews, the Arthritis Impact Scales, Center for Epidemiological Studies Depression Scale, Social Support Questionnaire, and Quality of Life Survey, were used to measure osteoarthritis severity, depression, informal social support, and quality of life.

FINDINGS

Although few formal social support services were used, high levels of satisfaction from the subjects' large informal networks of family and friends were reported. In addition, satisfaction with subjects' quality of life was extremely high despite depression, co-morbid conditions, pain, and functional limitation.

CONCLUSIONS

Social support appeared to play an important role in moderating the effects of pain, functional limitation, and depression on these subjects' quality of life. Nurses who work with older adults are in a unique position to help them adjust to living with osteoarthritis by providing them the support needed to help them manage their disease.

The process and outcome of life review psychotherapy with depressed homebound older adults

The purpose of this study was to examine the process and outcomes of life review therapy provided by an advanced practice geropsychiatric nurse to older adults discharged from psychiatric hospitals to home health care. Eighty older adults over 65 years of age with a primary diagnosis of depression were treated at home for life review psychotherapy sessions (M = 13.24, SD = 8.65). Content analysis methods, both latent and manifest, were used to analyze the data and identify themes. Themes were classified as empowerment (connection, coping, efficacy, hope, and trust) or disempowerment (denial, despair, helpless, isolation, loneliness, and loss). Findings showed that, as a result of the life review therapy, there was a significant decrease (p < .0001) in total disempowerment themes (M1 = 13.07; M2 = 9.14).