A randomized, double-blind, placebo-controlled study of the efficacy and safety of donepezil in patients with Alzheimer's disease in the nursing home setting

OBJECTIVES

To evaluate the safety and efficacy of donepezil in the management of patients with Alzheimer's disease (AD) residing in nursing home facilities.

DESIGN

Twenty-four-week, randomized, multicenter, parallel-group, double-blind, placebo-controlled trial.

SETTING

Twenty-seven nursing homes across the United States.

PARTICIPANTS

Two hundred eight nursing home patients with a diagnosis of probable or possible AD, or AD with cerebrovascular disease; mean Mini-Mental State Examination (MMSE) score 14.4; mean age 85.7.

MEASUREMENTS

The primary outcome measure was the Neuropsychiatric Inventory-Nursing Home Version (NPI-NH). Secondary efficacy measures were the Clinical Dementia Rating (Nursing Home Version)-Sum of the Boxes (CDR-SB), MMSE, and the Physical Self-Maintenance Scale (PSMS). Safety was monitored by physical examinations, vital signs, clinical laboratory tests, electrocardiograms (ECGs), and treatment-emergent adverse events (AEs).

RESULTS

Eighty-two percent of donepezil- and 74% of placebo-treated patients completed the trial. Eleven percent of donepezil- and 18% of placebo-treated patients withdrew because of AEs. Mean NPI-NH 12-item total scores improved relative to baseline for both groups, with no significant differences observed between the groups at any assessment. Mean change from baseline CDR-SB total score improved significantly with donepezil compared with placebo at Week 24 (P < .05). The change in CDR-SB total score was not influenced by age. Differences in mean change from baseline on the MMSE favored donepezil over placebo at Weeks 8, 16, and 20 (P < .05). No significant differences were observed between the groups on the PSMS. Overall rates of occurrence and severity of AEs were similar between the two groups (97% placebo, 96% donepezil). Gastrointestinal AEs occurred more frequently in donepezil-treated patients. In general, AEs were similar in older and younger donepezil-treated patients, with the majority of patients experiencing only AEs that were transient and mild or moderate in severity. Weight loss was reported as an AE more frequently in older patients, although a loss at last visit of >or=7% of screening weight occurred at the same rate in older and younger patients (9% of donepezil- and 6% of placebo-treated patients). No significant differences between groups in vital sign changes, bradycardia, or rates of clinically significant laboratory or ECG abnormalities were observed.

CONCLUSION

Patients treated with donepezil maintained or improved in cognition and overall dementia severity in contrast to placebo-treated patients who declined during the 6-month treatment period. The safety and tolerability profile was comparable with that reported in outpatient studies of donepezil. These findings also suggest that advanced age, comorbid illnesses, and high concomitant medication usage should not be barriers to donepezil treatment. Given the apparent improvement in behavior in the placebo group, and the high use of concomitant medications in both groups, the impact of donepezil on behavior in the nursing home setting is unresolved and merits further investigation. In summary, effects on cognition, overall dementia severity, and safety and tolerability findings are consistent with previous findings in outpatients and support the use of donepezil in patients with AD who reside in nursing homes.

National Institute of Mental Health Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE): Alzheimer disease trial methodology

The authors describe the development of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) protocol for Alzheimer disease (AD), a trial developed in collaboration with the National Institute of Mental Health (NIMH), assessing the effectiveness of atypical antipsychotics for psychosis and agitation occurring in AD outpatients. They provide an overview of the methodology utilized in the trial as well as the clinical-outcomes and effectiveness measures that were implemented.

Chronic depression in the elderly: approaches for prevention

Depression in old age frequently follows a chronic and/or relapsing course, related to medical comorbidity, cognitive impairment and depletion of psychosocial resources. As endorsed by the US National Institutes of Health (NIH) Consensus Development Conference on the Diagnosis and Treatment of Late Life Depression, a major goal of treatment is to prevent relapse, recurrence and chronicity. We believe that most, if not all, elderly patients with major depressive episodes are appropriate candidates for maintenance therapy, because of the vulnerability to relapse and recurrence and because of the favourable benefit to risk ratio of available treatments. Antidepressant pharmacotherapy is the mainstay of this therapeutic goal, but psychosocial approaches (especially interpersonal psychotherapy) have also been shown to contribute significantly to prevention of a chronic depressive illness and to prevention of the disability that attends depression. Studies published to date have established the long term or maintenance efficacy of the tricyclic antidepressant nortriptyline. Current, ongoing studies are addressing the maintenance efficacy of paroxetine and citalopram to prolong recovery in depression associated with old age. These studies are focusing particularly on patients aged 70 years and above, who are at high risk of recurrence, and on patients in primary care settings, where under-recognition and under-treatment of depression in the elderly have been costly from a public health perspective in terms of increased medical utilisation, burden to patients and families, and high rates of suicide. Depression in old age is a major contributor to the global burden of illness-related disability, but it is extremely treatable if appropriate pharmacotherapy is prescribed and accepted by patients and their caregivers.

Pharmacotherapy of depression in older patients: a summary of the expert consensus guidelines

Depression in older adults increases disability, medical morbidity, mortality, suicide risk, and healthcare utilization. Most studies of antidepressants are conducted in younger adults, and clinicians often have to extrapolate from findings in populations that do not present the same problems as older patients. Older patients often have serious coexisting medical conditions that may contribute to or complicate treatment of depression; they tend to take multiple medications, some of which may contribute to depression or interact with antidepressants; and they metabolize medications slowly and are more sensitive to side effects than younger patients. To address clinical questions not definitively answered in the research literature, the authors surveyed 50 experts on the pharmacotherapy of depressive disorders in older patients. The survey contained 64 questions with 857 options: 618 of the options were scored using a modified version of the RAND 9-point scale for rating appropriateness of medical decisions; for the other 239 options, the experts were asked to write in answers or check a box. The experts reached consensus on 89% of the options rated on the 9-point scale. Categorical rankings (first line/preferred, second line/alternate, third line/usually inappropriate) were assigned to each option based on the 95% confidence interval around the mean rating. Guideline tables indicating preferred treatment strategies were then developed for common and important clinical scenarios. The authors summarize the expert consensus methodology and the experts' recommendations and discuss how they relate to research findings. The experts recommend including both antidepressant medication and psychotherapy in treatment plans for nonpsychotic unipolar major depressive disorder of any severity, as well as for dysthymic disorder or persistent minor depressive disorder. They would also consider using either medication or psychotherapy alone for milder depression. For unipolar psychotic major depression, the treatment of choice is an antidepressant plus one of the newer atypical antipsychotics, with electroconvulsive therapy another first-line option. If the patient has a comorbid medical condition that is contributing to the depression, the experts recommend treating both the depression and the medical condition from the outset. The SSRIs were the top-rated antidepressants for all types of depression, with highest ratings for efficacy and tolerability given to citalopram and sertraline. Paroxetine was another first-line option, and fluoxetine was rated high second line. The preferred psychotherapy techniques for treating depression in older patients are cognitive-behavioral therapy, supportive psychotherapy, problem-solving psychotherapy, and interpersonal psychotherapy. The experts also recommended use of psychosocial interventions (e.g., psychoeducation, family counseling, visiting nurse services) in addition to pharmacotherapy and psychotherapy. Within limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide direction concerning common clinical dilemmas in older patients. They cannot address the complexities of each individual patient's care and can be most helpful in the hands of experienced clinicians.

The expert consensus guideline series. Pharmacotherapy of depressive disorders in older patients

OBJECTIVES

Depression in older patients contributes to personal suffering and family disruption and increases disability, medical morbidity, mortality, suicide risk, and healthcare utilization. The majority of clinical trials of antidepressant treatments are conducted in younger patients. For this reason, clinicians often have to extrapolate from studies in populations that do not present the same problems as older patients. For example, older patients often have serious coexisting medical conditions that may contribute to the depression and complicate the choice of treatment. Older patients as a rule need to be on many medications, some of which may contribute to depression and/or interact with antidepressants. Finally, older adults metabolize medications slowly and are more sensitive to side effects than younger patients. Because of these complexities, we conducted a consensus survey of expert opinion on the pharmacotherapy of depressive disorders in older patients to address clinical questions not definitively answered in the research literature.

METHOD

After reviewing the literature and convening a work group of experts, we prepared a written survey with 64 questions that asked about 857 options. 618 of the options were scored using a modified version of the RAND 9-point scale for rating appropriateness of medical decisions. For the other options, the experts were asked to write in answers (e.g., average doses) or to check a box to indicate their preferred answer. We sent the survey to 50 national experts on geriatric depression, all of whom completed it. Consensus on each option was defined as a nonrandom distribution of scores by chi-square "goodness-of-fit" test. We assigned a categorical rank (first line/preferred choice, second line/alternate choice, third line/usually inappropriate) to each option based on the 95% confidence interval around the mean rating. Guideline tables indicating preferred treatment strategies were then developed for key clinical situations.

RESULTS

The expert panel reached consensus on 89% of the options rated on the 9-point scale. The experts stress the importance of identifying coexisting medical conditions that may be contributing to the depression or complicate treatment. For unipolar nonpsychotic major depression, the preferred strategy is an antidepressant (selective serotonin reuptake inhibitor [SSRI] or venlafaxine XR preferred) plus psychotherapy. For unipolar psychotic major depression, the treatment of choice is an antidepressant (SSRI or venlafaxine XR) plus one of the newer atypical antipsychotics. Electroconvulsive therapy is also first line. For dysthymic disorder or persistent milder depression, the experts recommend combining an antidepressant (SSRIs preferred) and psychotherapy. If the patient has a comorbid medical condition (e.g., hypothyroidism) that is contributing to the depression, the experts recommend treating both the depression and the medical condition from the outset. The SSRIs were the top-rated antidepressants for all types of depression. Among them, the experts gave the highest ratings for efficacy and tolerability to citalopram and sertraline. Paroxetine was another first-line option, and fluoxetine was rated high second line. The preferred psychotherapy techniques for treating depression in older patients are cognitive-behavioral therapy, supportive psychotherapy, problem-solving psychotherapy, and interpersonal psychotherapy. The experts also give strong support to including appropriate psychosocial interventions (e.g., psychoeducation, family counseling, visiting nurse services) in the treatment program. The majority of experts would continue treatment with antidepressant medication for at least 1 year if a patient has had a single episode of severe unipolar major depression, for 1-3 years for a patient who has had 2 such episodes, and for longer than 3 years if there is a history of 3 or more episodes.

CONCLUSIONS

The experts reached a high level of consensus on the appropriateness of including both antidepressant medication, specifically SSRIs, and nonpharmacological modalities in treatment plans for severe depression. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide direction for addressing common clinical dilemmas in older individuals. They can be used to inform clinicians and educate patients regarding the relative merits of a variety of interventions. Nonetheless, the guidelines cannot address the complexities involved in the care of each individual patient and can be most helpful in the hands of experienced clinicians.

Impact of maintenance ECT on concentration and memory

INTRODUCTION

With the increased administration of outpatient electroconvulsive therapy (ECT), it is important to develop methods for monitoring patients for adverse effects of treatment. This pilot study was designed to evaluate the utility of using telephone assessments to determine whether patents receiving maintenance ECT (MECT) experience cognitive deficits related to individual treatments.

METHOD

Patients were recruited from an existing population of outpatients receiving MECT. The consenting patients were called on three occasions and given a battery of telephone cognitive assessments including Orientation-Memory-Concentration, Buschke Selective Reminding, Verbal Fluency, "World" Backwards, Serial Sevens, and Wechsler Logical Memory. The occasions for the telephone interviews were the day before ECT, the day after a treatment, and a week later.

RESULTS

Sixteen patients completed the study. The correlation between baseline and time 3 ranged from 1.00 for spelling "world" backward to 0.509 for Verbal Fluency Category, indicating considerable variability in test-retest reliability. One test, Verbal Fluency Category, showed group level effects, with decrements in performance the day after a treatment. One of the 16 patients showed global cognitive deficits the day after a treatment.

DISCUSSION

The pilot results suggest that telephone assessment may be a useful approach for monitoring patients receiving outpatient ECT. Monitoring may serve to guide clinicians in advising individuals and their caregivers about the return to activities after an individual treatment. Overall these findings support the tolerability of MECT.

Survival of hospitalized elderly patients with delirium: a prospective study

The authors tested the relationship between clinically diagnosed delirium during hospitalization and increased mortality after accounting for pre-hospital measures of global cognition, physical functioning, and medical comorbidity. Patients (N=102), 53 of which were hospitalized during the course of a year, received the Mini-Mental State Exam, Physical Self-Maintenance Scale, Cumulative Illness Rating Scale, and 15-item Geriatric Depression Scale. Mortality rates were determined at discharge and after 3 years. Patients who developed delirium did not differ on pre-hospitalization levels of depression, global cognitive performance, physical functioning, or medical comorbidity. Three-year mortality in the hospitalized subjects was 75% for delirium patients vs. 51% for control patients (risk ratio=2.24). Delirium occurring during hospitalization places elderly subjects at long-term risk of mortality. This effect is not accounted for by earlier measures of cognitive, functional, or health status.

Validating the diagnosis of delirium and evaluating its association with deterioration over a one-year period

The authors probed the associations between clinical diagnoses and independent research measures of cognitive, behavioral, and electroencephalographic (EEG) changes in hospitalized older patients and investigated the contribution of medical illness to deterioration. Patients (N=96; 47 of whom were hospitalized during the course of 1 year; 12 diagnosed with delirium) received tests of cognitive and physical functioning and the Cumulative Illness Rating Scale, specific neuropsychological tests, and a two-channel EEG. Delirium was associated with independent measures of cognitive decline and EEG slowing. Hospitalization was associated with deterioration in functional status during the year, whether or not patients showed delirium. Results suggest that medical illness leading to hospitalization can contribute significantly to deterioration in self-care, and, when it is associated with delirium, to deterioration in cognitive performance and cerebral activity over a period of 1 year.

Pharmacological treatment of depression in older primary care patients: the PROSPECT algorithm

PROSPECT (Prevention of Suicide in Primary care Elderly-Collaborative Trial) is testing whether a trained clinician (the 'health specialist') can work in close collaboration with a primary care physician to implement a comprehensive depression management program and improve outcomes in older depressed patients. An algorithm guiding the selection and use of antidepressant medications has been developed to assist PROSPECT health specialists. This algorithm is presented and the rationale underlying the proposed treatment sequence is discussed. The PROSPECT algorithm builds upon existing guidelines after updating them and adapting them to the special circumstances of older primary care patients. Special attention has been paid to the tolerability and the target doses of the recommended antidepressant agents and to the duration of antidepressant trials. Patients who are unable to tolerate or do not respond to an antidepressant can be switched to another agent or be treated with interpersonal psychotherapy. Agents that produce only a partial response can be combined with other antidepressants or with interpersonal psychotherapy. Treatments for which empirical evidence exists are favored. However, treatments that are often poorly tolerated by elderly patients are given lower priority than treatments more likely to be tolerated. Similarly, trials that are simpler to implement in primary care are favored.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Dehydroepiandrosterone sulfate (DHEA-S) and psychiatric and laboratory measures of frailty in a residential care population

Previous reports have found low levels of dehydroepiandrosterone sulfate (DHEA-S) in association with frailty in elderly patients. The mechanisms underlying these associations are not known. Therefore, psychiatric symptoms and disorders that are common in frail elderly patients were correlated with DHEA-S levels in a convenience sample selected from a nursing home population. Low DHEA-S levels were associated with high degrees of self-rated disability and insomnia. In women, low DHEA-S levels were also associated with increased numbers of pain sites. However, cognitive impairment was associated with higher DHEA-S levels in women. Thus, in frail elderly patients, there are contradictory relationships between DHEA-S and neuropsychiatric measures of frailty (cognitive impairment, disability, insomnia, and number of pain sites), and there may also be gender differences in these relationships.

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.

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.

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.

Neuropsychiatric aspects of failure to thrive in late life

Both depression and dementia can lead to failure to thrive (FTT). Depression can lead to FTT by two routes: a direct path related to decreased appetite as a symptom of depression; and an indirect path related to the effect of depression in increasing disability. Depression associated with FTT should usually be treated with antidepressant medication. In Alzheimer's patients with FTT, the thrust of treatment is the identification and treatment of the medical and psychiatric comorbidities and the appropriate titration of environmental supports.

Diagnosis and treatment of depression in late life. Consensus statement update

OBJECTIVE

To reexamine the conclusions of the 1991 National Institutes of Health Consensus Panel on Diagnosis and Treatment of Depression in Late Life in light of current scientific evidence.

PARTICIPANTS

Participants included National Institutes of Health staff and experts drawn from the Planning Committee and presenters of the 1991 Consensus Development Conference.

EVIDENCE

Participants summarized relevant data from the world scientific literature on the original questions posed for the conference.

PROCESS

Participants reviewed the original consensus statement and identified areas for update. The list of issues was circulated to all participants and amended to reflect group agreement. Selected participants prepared first drafts of the consensus update for each issue. All drafts were read by all participants and were amended and edited to reflect group consensus.

CONCLUSIONS

The review concluded that, although the initial consensus statement still holds, there is important new information in a number of areas. These areas include the onset and course of late-life depression; comorbidity and disability; sex and hormonal issues; newer medications, psychotherapies, and approaches to long-term treatment; impact of depression on health services and health care resource use; late-life depression as a risk factor for suicide; and the importance of the heterogeneous forms of depression. Depression in older people remains a significant public health problem. The burden of unrecognized or inadequately treated depression is substantial. Efficacious treatments are available. Aggressive approaches to recognition, diagnosis, and treatment are warranted to minimize suffering, improve overall functioning and quality of life, and limit inappropriate use of health care resources.

Alcohol abuse: a source of reversible functional disability among residents of a VA nursing home

The prevalence of psychiatric disorders was determined in a sample of 196 VA nursing home residents who were interviewed using the modified Schedule for Affective Disorders and Schizophrenia (mSADS). Of the 160 subjects for whom data were available, 86% had a diagnosis of at least one psychiatric disorder. The prevalence of clinically significant cognitive impairment was 60.6% and of major depression 13.8%. Of 110 residents for whom alcohol histories were obtained, 32 (29%) had a lifetime diagnosis of alcohol abuse. The degree of impairment in activities of daily living improved significantly from the time of admission to the time of the evaluation (average 1.4 years) among those who were recently abusing alcohol compared to those who formerly abused alcohol and those who never abused alcohol. The effect is clinically as well as statistically significant and has the potential benefit of reducing caregiver burden and health care costs for the elderly.

The first Summer Research Institute in Geriatric Psychiatry

In July 1995, the American Association for Geriatric Psychiatry (AAGP) sponsored the first annual week-long Summer Research Institute (SRI) in Geriatric Psychiatry, at the University of California, San Diego. The NIMH-funded SRI was intended for promising postresidency and postdoctoral fellows, as well as junior faculty persons interested in research careers in geriatric psychiatry. The SRI focused on the tools needed to begin, maintain, and succeed on that career path and has been followed by continued communication between trainees and faculty. The SRI was highly successful, judging from the participants' evaluations, as well as the trainees' accomplishments in terms of publications and research funding during 1 year of follow-up. The SRI provides a useful model for an approach to bridging and shortening the transition period from fellowship to first research funding and of ensuring a continued flow of new investigators in geriatric psychiatry.

Identification of drug-related cognitive impairment in older individuals. Challenge studies with diphenhydramine

The authors tested the use of repeated cognitive measures to identify those older individuals who experience cognitive decline after administration of a centrally acting medication. Subjects were 30 medically stable, older volunteers, mean age 71.4. Administration was a double-blind, placebo-controlled, crossover "challenge" from baseline to placebo, 50 mg, or 75 mg of diphenhydramine. More patients exhibited significant cognitive decrements after 75 mg of diphenhydramine than after placebo on the Buschke Selective Reminding Test Total Recall and the Trails B test. Data were consistent with models based on prediction intervals. Quantitative algorithms using prediction equations can characterize the normal limits of within-subject variability and define excessive cognitive change in elderly subjects, showing promise for use in monitoring patients to identify those who experience mild cognitive toxicity from prescribed medications.

Salivary cortisol and daily events in nursing home residents

The authors evaluated the feasibility of using salivary cortisol as a noninvasive measure of hypothalamic-pituitary-adrenal (HPA)-axis responses to stressful events of daily living in elderly nursing home residents. Ten medically stable male nursing home residents (age 81.7 +/- 12.42) gave salivary samples before and after an assisted bath, and at corresponding times on the subsequent (control) day. Regression models, with measures of salivary cortisol on the bath and control days for two timepoints before the bath and four timepoints after the bath as the dependent variables, yielded significant effects of time, bath status, and day. Salivary cortisol testing is noninvasive and easy to collect from long-term care patients, including those with moderate degrees of dementia. It may be of use as a tool for studying the stressors associated with care, the determinants of HPA responses, and the consequences of hypercortisolemia in these vulnerable patients.

Lessons from geriatric psychiatry in the long-term care setting

Of all long-term care settings, the nursing home has served as the most productive laboratory for the study of the mental health problems of late life. Lessons from geriatric psychiatry research and practice in the nursing home have relevance to general psychiatry and to other health care settings, informing us about (a) psychiatric disorders in medically ill and disabled populations; (b) subsyndromes and subtypes of depression; (c) behavioral disturbances in patients with brain injury; (d) the effects of government regulation and education on mental health care; and (e) essential roles for psychiatrists in changing health care systems. Selected areas of knowledge based on geriatric psychiatry research and experience in long term care are reviewed in this paper, and their applications for the field of psychiatry in general are explored.

Affective states in normal and depressed older people

Ratings on a 10-item affect checklist yielding composite positive affect and negative affect scores were made daily for 30 days by older people in residential care: 19 were diagnosed as having major depression, 21 had minor depression, and 37 were without psychiatric diagnosis ("normal"). Mean levels of positive affect were highest in normal people and least in those with major depression; negative affect was lowest in normal ones and highest in those with a major depression. Variability was least among those with major depression in positive affect and among normal people in negative affect, while residents with minor depression showed some tendency, although inconsistent, toward greater day-to-day variability in positive affect. Patterns of invariance were such that those with major depression tended to be consistently lacking in positive affect but were variable in negative affect; normal people showed variability in positive affect but a relatively unvarying lack of negative affect. Clinical major depression was thus characterized less by "pervasive" depressive affect than by anhedonia.

Induction of inhibitory activity for B cell differentiation in human CD8 T cells with pokeweed mitogen, dimaprit, and cAMP upregulating agents: countersuppressive effect of platelet factor 4

As shown previously, native or recombinant (r) human platelet factor 4 (PF4) alleviates the suppression induced by Con A or dimaprit, a histamine type 2 receptor (H2-R) agonist, in a murine system. The effect of rPF4 on human peripheral blood cells has now been studied, using as a model pokeweed mitogen (PWM)-induced, T-cell-mediated suppression of Ig-secreting cell (ISC) formation by Staphylococcus aureus and rIL-2 activated B cells. PWM, but not phytohemagglutinin (PHA), induced inhibitory activity in mitomycin-treated CD8+ T cells, but not unfractionated or CD4+ T cells, for both ISC formation and B cell proliferation. rPF4 and its C-terminal tridecapeptide alleviated the suppressive effect of PWM-activated CD8+ T cells on ISC production but not on proliferation. Heparin did not prevent this immunoregulatory activity of PF4. Neutralizing antibody to TGF-beta, but not to IFN-gamma or TNF-alpha, alleviated the suppression of ISC formation in some of the experiments. The H2-R appeared to play a part in inducing suppression, because the H2-R antagonist, cimetidine, prevented the PWM-induced suppression of ISC production. Furthermore, dimaprit induced suppression of ISC formation when added instead of PWM at the start of culture. Incubation of CD8+ T cells with dimaprit for only 3 hr prior to coculture with S. aureus + IL-2 activated B cells decreased the ISC response. This suppression was also alleviated by addition of rPF4 to the coculture. Similar to dimaprit, known cAMP upregulating agents, such as forskolin, dibutyryl cAMP, and cAMP analog, all induced this immunoregulatory activity in T cells. Moreover, the effect of dimaprit was prevented by the specific protein kinase A inhibitor, HA1004, suggesting strongly that upregulation of cAMP played a role in the H2-R-mediated effect. Cell contact appeared to be necessary, since supernatants from dimaprit or PWM activated T cells failed to suppress ISC production. We suggest that the known ability of PF4 to prevent TGF-beta-mediated effects on endothelial and other target cells may be involved in the alleviating effect of PF4 on the cell-contact-dependent CD8+ T-cell-mediated B cell suppression.

Anticonvulsant and other non-neuroleptic treatment of agitation in dementia

Studies have shown that the vast majority of patients with dementia experience some psychopathologic symptoms during the course of their illness. Symptoms of this nature, which can include frightening hallucinations or anxiety of phobic proportions, are subjectively distressing and can lead both to unsafe or violent situations as well as to the preventable use of inappropriate medication, physical restraint, and frequently to institutionalization. These psychopathologic manifestations of dementia often prove to be a burden on family, caregivers, and the health care system as well. This article presents an overview of the assessment and management of agitation as it relates to the severity of dementia symptoms and cognitive deterioration. Specifically, the use of anticonvulsant and other non-neuroleptic therapies is examined.

Validation of the Cumulative Illness Rating Scale in a geriatric residential population

OBJECTIVE

To evaluate the validity of the Cumulative Illness Rating Scale (CIRS) in a geriatric institutional population by examining its associations with mortality, hospitalization, medication usage, laboratory findings and disability.

DESIGN

A validation of the CIRS using self- and physician-report surveys, with archival data drawn from medical charts and facility records.

SETTING

Long-term care facility with skilled nursing and congregate apartments.

PARTICIPANTS

Four hundred thirty-nine facility residents selected on the basis of completeness of self-report data and physician ratings.

PRIMARY MEASURES

Composite measures of illness severity and comorbidity, based on physicians' CIRS ratings; time to death or acute hospitalization after assessment; medication use, drawn from pharmacy records; medical chart data on laboratory tests; self-reported functional disability.

RESULTS

CIRS illness severity and comorbidity indices, as well as individual CIRS items, were significantly associated with mortality, acute hospitalization, medication usage, laboratory test results, and functional disability. The CIRS showed good divergent validity vis a vis functional disability in predicting mortality and hospitalization.

CONCLUSIONS

The CIRS appears to be a valid indicator of health status among frail older institution residents. The illness severity and comorbidity composites performed equally well in predicting longitudinal outcomes. Item-level analyses suggest that the CIRS may be useful in developing differential illness profiles associated with mortality, hospitalization, and disability.