Scientific Proceedings of the Seventh Annual Meeting and Symposium of the American Association for...

'II ' PROCEEDINGS '. .

Scientific Proceedings of theSeventh Annual Meeting andSymposium of the American

Association for GeriatricPsychiatry

The Journal is pleased to publish abstractsfrom the Annual Meeting of the AmericanAssociation for Geriatric Psychiatry. Thisyear's abstracts describe symposia, workshops, and botll paper and poster sessions.The Sixth Annual Meeting was devoted almost entirely to presentations organized bymembers and selected through competitivepeer review. Also, a one-day preconferencesymposium was organized to provide anupdate on such important topics as medicaland psychiatric problems, the epidemiologyofmajor and minor depression, psychopharmacology, the dementias, psychosocial aspects of geriatric care, and the managementof aggression. A Monday morning workshop, organized by ACGME to train potential site visitors of postgraduate geriatricresidency programs, attests to the rapidmovement toward program accreditation.

George Vaillant, as keynote speaker,presented results from his 50-year study ofthe· course and predictors of men's psychological health. His data demonstrate that theeffects of psychological and social predictors for good or poor short-term outcomeare not immutable across the life cycle.Thus, a subsample of his subjects overcameheavy loading for poor outcomes to achievehigh levels of functioning in late life; thecases indicated that reliance on maladaptivedefense mechanisms in young adulthoodcan be replaced by use of more matureadaptation-enhancing defenses in later life.Furthermore, his data suggested that theoccurrence of first-episode depression in

THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY

middle life is a risk factor for poorer longterm outcome, including shorter life expectancy.

The paper session on depression wasmarked by original studies of unipolar illness. Hugh Hendrie presented data comparing the "etiological" and "inclusive"methods of diagnosis in a primary careclinic. His paper introduced a topic thatrecurred in subsequent sessions: the difficulty of diagnosing depression and measuring its severity in the context of comorhidphysical illness.

Ben Mulsant won this year's Junior Investigator Award for his original work, CCAStudy of the Validity of the Hamilton Depression Rating Scale in Geriatric Patientswith Physical Illness." Dr. Mulsant's paperaddressed the measurement issue by demonstrating validity of the Hamilton scale inthis population when caregiver reports areintegrated with clinician observations. Dr.Mulsant's paper is published in this issue ofthe Jaurna!.

Dan Blazer, M.D., Ph.D., was presentedthe AAGP Senior Investigator Award forcareer achievements in research on aging.In his introduction, Dr. Blazer acknowledged the enormous personal and professional contributions made by his ownmentor, Ewald "Bud" Busse. Dr. Busse, apioneer in academic geriatric psychiatry andboth role model and mentor for many of ourleading investigators, attended the session.Dr. Blazer's paper, CCls Depression More Frequent in Late Life? An Honest Look at the

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Evidence," reviewed the EpidemiologicCatchment Area (ECA) study's provocativefindings that the current and lifetime prevalence of major depression decrease afterage 65. Dr. Blazer also discussed subsequent analyses that have attempted unsuccessfully to attribute the ECA results toage-bias in methodological factors. Dr.Blazer's presentation considered the evidence for a high prevalence of pervasivedepressive symptoms in older individualsand emphasized the distinction between a

.sybsyndromal symptom cluster and a fulldepressive disorder. Dr. Blazer presenteddata supporting the explanation that membership in different birth cohorts contributesto changing prevalences of both major depression and suicide in different agegroups. Dr. Blazer prepared his presentation as a paper for publication in this issueof the Jaurna!.

A brief business meeting was chairedby outgoing AAGP President Alan Siegal,whose steadfast and enormously successfulterm of office lasted a heroic 20 months. Dr.Siegal announced the new officers: GaryGottlieb, president; Ira Katz, president-elect;F.M. Baker, treasurer; and Jeff Foster, treasurer-elect. Dr. Siegal also announced theelection of the t11ree new board members,James Greene, Dilip ]este, and GabeMalletta.

Dr. Siegal introduced Gary Gottlieb,who delivered his presidential address,"Geriatric Psychiatry and Health Care Reform: Proactive Strategies for Leadership,Quality, and Excellence into the 21st Century." Dr. Gottlieb's presentation met theexpectations of its title and provided a comprehensive and scholarly review of the historical background, fiscal context, andpublic health necessity for health care reform. Dr. Gottlieb's presentation provided acritical analysis of strengths and weaknessesof current health care plans; he suggestedthat providers can play an active role increating a system that works optimally forboth psychiatrists and their patients. Dr.Gottlieb has summarized his talk for publi-

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cation in a future issue of the Journal.Monday morning's keynote address,

"Living Long and Well," was given by Dennis Jahnigen, Director, University of Colorado Center on Aging. Dr. ]ahnigrendiscussed the dramatic rise in average lifeexpectancy that has occurred in the UnitedStates during the past century and reviewedboth the fixed and modifiable variables associated with human longevity. He suggested that in the absence of a dramaticbreakthrough in our understanding of theaging process, life expectancy, especiallyfor women, may have reached a plateau.More attention should now be paid to quality of life or Usuccessful" aging. Predictorsof successful aging are more susceptible tobehavioral modification than are predictorsof longevity.

Attendees were challenged in selectingsessions by the large number of symposia onthemes and topics that are central to geriatricpsychiatrists. Symposia covered such topics aspractice issues and models of care, psychotherapy, Alzheimer's disease, etiology, comorbidities, and psychosocial aspects ofdementia, quality of life, and studies of community-based outreach programs.

In the depression symposium, originalresearch was presented at paper sessions onclinical management and biological factorsand epidemiological/clinical issues. Preliminaty findings were presented at our annualwine and cheese-enriched poster session.

Members had the opportunity to interact with colleagues and researchers inworkshops on nursing home practice, treatment of agitation in dementia, group therapy, and the use of carbamazepine foragitation. Panel sessions were devoted toimportant practical topics: Medicare, fromits historical context to practical issues, andmodels of long-term care.

This year's meeting introduced the formatof "Meet the Expert" sessions to allow attendees to interact directly with authorities ontopics of interest. Faculty included F.M. Baker,Sao Borson, Maurice Dysken, Donald Hay,Dilip ]este, 1m Katz, Lawrence Lazarus, and

VOLUME 2 • NUMBER 3 • SUMMER 1994

Alan Siegal. These sessions were particularly well appreciated by attendees.

Dr. Bill Reichman will be chairing theEighth Annual AAGP Meeting, to take placenext February in Cancun, Mexico; HughHendrie, who organized this year's program, has agreed to continue participatingin program planning and coordinatingAAGP's initiative to receive approval forgranting of CME credits. The Program Committee has announced plans to continue thescientific and original contribution empha-.sis of this year's meeting while continuingto provide clinician-oriented practical sessions. Next year's meeting will be enrichedby the attendance of members of the International Psychogeriatric Association, whichwill be holding concurrent workshops.

Goldstein MZ: Aspects of thePractice of Geriatric Psychiatry:

Who and Where?

This symposium focused on the practices ofpsychiatrists in various settings in which theolder adult requires mental health services.Data were collected from the last two APAbiographical and professional surveys. Theanticipated need for geriatric psychiatrists intraining and practice was reviewed in lightof the current number of psychiatrists withadded qualifications in geriatric psychiatryand current status of fellowship accreditation, primary care, and l1ealtll care reforminitiatives. Effective mental health selVicedelivery systems to elderly patients werepresented with reflections on access andbarriers. Consultation-liaison in acute-carehospitals was compared with consultationliaison in the nursing home setting. Researchfindings of practice changes secondary toOBRA regulations were presented. Mentalhealth services in the community as rendered by· outreach, community mentalhealth systems, and in primary care settingswere reviewed with attention to outcome.The Department of Veterans Affairs has re-


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cently completed a survey of its 172 hospitals regarding the range of mental healthservices available to the elderly populationthey service. The results of this survey werepresented with emphasis on need for arange of levels of service.

Reisberg B, Kluger A, Flicker C,Prichep L, Ferris S: An

overview ofAlzheimer'sdisease (AD) course and

treatment'

Recent studies have more clearly delineatedthe borders between changes ,of normalaging and AD. Neuropsychologic and structural measures that appear to be capable ofpredicting subsequent decline in ostensiblynormal aged subjects have also been identified. Other clinical neuropsychologic, neurologic, and electrophysiologic measures fortracking the entire course ofAD, many yearsbeyond the point at which the MMSE consistently results in zero scores, have alsobeen developed. An overview of the courseof AD indicates that behavioral symptomspeak about midway through the potentialcourse of the disease. Consequently, drugtrials of the remediation of behavioral symptoms in AD must take into consideration thenatural history of the evolution of thesesymptoms in the course of the disease, inorder to properly assess pharmacotherapeutic effects. These issues concerning thecourse and treatment of AD are of greatrelevance for current research and practicein geriatric psychiatry.

Raj BA: Dementia: emergingperspectives on etiology,

clinical com.orbidity, socialissues, and cultural differences

The dementias are associated with manyunanswered questions. However, current

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research is adding to our knowledge baseand it is the purpose of this symposium toshare some of these findings. 1) Alzheimer'sdisease (AD) is undoubtedly etiologicallyheterogeneous. The early-onset familial disease has been linked to chromosomes 14and 21. These linkages and research regarding' the association between alleles at theAPOE locus and late-onset disease arediscussed. 2) Comorbid depression isfrequently seen in the dementias. A prospective study of panic disorder in the elderlyidentified a subgroup with coexisting dementia. The clinical and behavioral characteristics of this group and our treatmentexperience is presented. 3) Violence isemerging as a significant challenge in at least20% of families living with a relative diagnosed with dementia. Violent behaviors,regardless of the perpetrator, puts thefamily's health and well-being at risk. Thispresentation describes the results of a semistructured interview with families to helpevaluate factors associated with severe violence. 4) AD seems to have a variable prevalence across racially diverse populations.This review of cross-cultural studies is basedin part on reviews conducted for the APATask Force on Minority Elderly (1993) andthe Summer Institute in Research on Minority Aging (1993). The data include a discussion of the EURODERM meta-analysisproject.

Gurland B: Research on thequality of life of elderly

patients with prolonged mentalillness

This sylnposium presented recent studies onthe assessment of quality of life of olderindividuals with prolonged mental illness.Included in the program were presentationsand discussion of the following researchprojects: models and measurement of quality of life of elderly psychiatric patients; astudy to identify the extent and duration of

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changes in quality of life as they relate tosubsyndromal cognitive impairment; a comparison of the quality of life of elders withprolonged mental illness in inpatient andcommunity-based care settings and corresponding changes in quality of life as theyshift between these settings; studies regarding the efforts of dysthymic disorders on thequality of life in elderly patients; and afollow-up of subjects who participated in across-national diagnostic study.

Abraham IL: Community-basedoutreach programs for elderlypatients: creating pathways for

adaptation

Outreach programs have been suggested aseffective approaches in delivering mentalhealth and related selVices to elderly patients. Since older people most at risk do notpresent to mental health and social serviceagencies, outreach programs provide rapidand effective mental health assessment andtreatment, minimize prelnature institutionalization, and facilitate independence in thehome. This symposium compares the similarities and differences among three outreach programs, serving demographically,culturally, and epidemiologically differentpopulations, and geographically and economically dissimilar regions. The two outreach programs serving rural elderly patientsin Virginia and Iowa are similar in theircommunity-based partnerships, multidisciplinary, and case-management approach tomeeting the needs of their rural elder clients.In contrast, the Psychogeriatric Assessmentand Treatment in City Housing (PATCH)program is designed to serve an urban elderly population who live in large high-risebuildings. All three programs provide outreach, case Inanagement, assessment, treatment, and referral selVices to vulnerable,at-risk elders. Each program was discussedin more detail with special enlphasis ontypes of psychiatric disorders encountered,


interventions initiated, and outcomes of theprograms.

ColahJJ, Abaza A, Rao NR,Abramson TA: Psychotherapy

With Older Adult Clients

With more than one out of every nineAmericans now over the age of 65, theresponsibility of the health care system inthe Clinton Era for meeting the needs of ourolder population cannot be overstated. Approximately 180/0-25% ofelderly individuals,with an estimated 76,000 in New York Statealone, have significant psychiatric symptomatology and are at the greatest risk forsuicide among adults. These figures clearlyindicate the need for the provision of ageappropriate tnental health services. In theage of Clinton's health care reform and anincreasing emphasis on cost-effective services, greater attention will need to be paidto the utilization of outpatient mental healthservices in lieu of the overutilized and costlyinpatient psychiatric care that elderly patients have typically received. This symposium included presentations on the variouspsychotherapeutic interventions in the treatment of the older adult client.

Jonas AM, Lehman RB:Comprehensive managementof a nursing home psychiatric

care practice

The authors have established and maintained a highly successful and expandingnursing home and life-care center psychogeriatric medical practice. They discussed aspects of such a practice, includingthe following topics: 1) the demand fornursing home-based psychiatric services, 2)the attractiveness of a nursing home-basedpractice, 3) the challenges and details ofadhering to federal OBRA regulations, 4)integrated computerized management of the


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practice, 5) incentives of the Medicare system, 6) the use of allied professionals inclinic care, 7) examples of practice experiences, 8) handling emergencies and on-callduties without being overwhelmed, 9) developing effective relationships with nursinghome administration, 10) economic outcomes of potential of the practice.

MintzerJE: Treatment ofagitation in patients with

dementia

Approximately 50/0-10% of the 65-or-olderpopulation will present to their physicianswith denlentia. Forty percent of patientswith dementia will present with symptomsof paranoia, 40% with depression, and over60% will present with severe agitated behaviors, such as wandering, hitting, kicking,grabbing, screaming, intentional falling, repetitious mannerisms, or causing injury toself. These additional manifestations are particularly evident in the late stages of dementia, and the presence of psychiatricdisorders, especially agitated behaviors, aremajor risk factors for patient deterioration inquality of life, nursing home placement, andcaregiver burden. Despite the high prevalence of agitated behaviors in elderly patients with dementia, very little informationis available to aid physicians in the treatmentof these complicated patients. This workshop included four sections: 1) review of thecurrent definitions of agitation, commonsyndromes of agitation, and available assessment tools; 2) review and evaluation ofcurrent trends in behavioral treatment ofagitated behaviors in elderly demented patients; 3) review and evaluation of currenttrends in pharmacological treatment of agitated behaviors; and 4) two clinical vignettesused as a framework for application of thepreviously learned concepts in a joint interactive exercise including both faculty andaudience questions and final remarks.

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Copeland MP: Outpatient grouptherapy for geriatric patients

Therapy groups in geriatric psychiatry haveoften focused on either the inpatient elderlypopulation or caregivers. Outpatient groupsfor geriatric patients with disorders includingdepression, anxiety disorders, and Alzheimer's disease (AD) or other cognitive disorders, have been a much-neglected avenueof treatment and research. For example, onerecent survey identified only four outpatientgroups in the United States for patients diagnosed with AD, compared with the multitudeavailable to caregivers. Group therapy addresses both the isolation that frequentlyplagues geriatric patients and tIle mountingeconomic pressure to limit individual therapy.This workshop covered the history of grouptherapy in geriatrics, treatment modalitiesused, obstacles to group therapy in this population and how to address them, and thecurrent status and future of research in grouptherapy in geriatric psychiatry.

I. Histoty of group therapy for elderlypatientsA. Treatment modalities

1. Reminiscence or life-review.groups

2. Psychoeducational groups3. "Homogeneous" or theme

oriented groups directed atspecific issues of aging (Le.,retirement, grief, physical illness/disability)

4. Cognitive-behavioral groups5. Psychodynamic groups6. Groups for cognitively impaired

patients7. Intergenerational groups

B. Identifying appropriate patients andgetting referrals

C. Anticipating and addressing clinicalobstacles

D. Treattllent goalsII. Research in group therapy for elderly

patients

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A. Literature reviewB. Current status of researchc. Difficulties to anticipate in doing

research on group therapy in thispopulation

D. Future directions

Tariot PN, Leibovici A, Erb R,Frederiksen K, Schneider L:Carbamazepine therapy for

agitation in dementia:status report

Agitation is a frequent complication of dementia. Antipsychotic medications are frequently used for treatment, but alternativesare needed. There is inconclusive preliminary evidence that carbamazepine may beeffective. In the face of clinical equipoise,controlled studies are in order. A non-randomized, placebo-controlled, crossover trialof carbamazepine was conducted in 2S agitated nursing home patients with dementia.Drug and placebo were administered duringtwo 5-week periods separated by a 2-weekwashout. Carbamazepine dose (modal dose= 300 mg/day) was determined for eachpatient by a non-blind physician. Mediantotal Brief Psychiatric Rating Scale scoresdecreased 7 points on carbamazepine vs. 3points on placebo (P = 0.03). Sixteen patients were rated as improved globally oncarbamazepine vs. fOUf patients on placebo(P =0.001). Multiple secondary measures ofindividual symptoms, as well as generalratings, showed similar changes at significant or suggestive levels. One subject developed tics and one died of pneumonia andan elevated white blood cell count; therewere minimal other adverse effects. Thesepreliminary findings suggest that carbamazepine in low doses can reduce agitated behaviors with relatively little toxicityin this population. The discussant reviewedmethodological issues pertinent to studies ofthis nature, related these findings to theknown effects of other psychotropic drugs


in this population, and discussed the potential future directions of research Witll thisagent.

Baker FM, Wiley C, Velli SA,FriedmanJ, Johnson JT:

Reliability and validity of theI5-item 60S and the CES-D in

black and white depressedolder patients

In order to establish the reliability and validity of the 15-item Geriatric DepressionScale (GDS) and the Center for Epidemiologic StudieS-Depression Scale (CES-D) asscreening instruments for depression inolder black and white persons, these instruments were administered to 30 psychiatricpatients with affective illness. All patientsreferred with a diagnosis ofdepression completed the Structured Clinical Interview forDSM-III (SCID) as the reference standard.The sample was composed of 33% whitewomen, 31% black women, 11% white men,and 8% black men; 83% of the sample (n =

30) were ages 60-79 years. Sixty-seven percent of the sample had a diagnosis of majordepressive disorder by the seiDl Of the 14black elderly patients with depressive illness, 9 had CES-D scores of 16 or higher,indicating a sensitivity of 64%. Deleting mildcases ofdepression (two cases ofadjustmentdisorder with depressed mood), 9 of 12older, black patients with depressive illnessscreened positive, a sensitivity of 75%. Ofthe 16 white patients with depressive illness,15 had CES-D scores of 16 or higher, asensitivity of 94%. With the GOS, only 6 of14 depressed, older black patients wereidentified as having depressive symptoms, asensitivity of 43%. Of the 12 older, depressed, white patients, 8 were identified bythe GDS, a sensitivity of75%. Based on thesepreliminary data from an ongoing study, theCES-D is an effective screening instrumentfor depression in both black and whiteelderly patients. The GDS was less effective


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as a screening instrument for depression inboth racial groups.

Boksay I, Reisberg B,Torrossian C: Medical

conditions and problems inpatients with probable

Alzheimer's disease (AD)

In a 5-year prospective study, course andoutcome were prospectively studied in 103outpatients with probable AD. Follow-upwas successful in 92.2% of subjects after amean interval of 4.6 ± 1.4 years. Thirty(32.6%) of locatable subjects had died. Usingthe GDS/BCRS/FAST STAGING SYSTEM wecan account for approximately 25% to 33% ofthe variance in course of AD. Accounting forthe remaining variance is important and mayresult in further information on the underlyingpathophysiology ofAD. The authors reviewedand analyzed the medical history and themedical status of 61 patients with probableAD. The 65 patients who survived had anaverage of 4.64 ±2.92 medical problems orconditions at baseline. Women had significantly more medical problems than men(5.11 ± 3.02 vs. 3.67 ± 2.48). The number ofmedical conditions/problems was similar atdifferent stages of dementia: GOS 4 mean =

4.63 ±2.65, GDS 5 mean = 4.96 ±3.25, andGDS 6 mean = 4.0 ± 2.86. Comparing patients between 49 and 70 years and thosebetween 71 and 85 years, the older grouphad significantly more medical problems(3.59 ±2.44 vs. 5.50 ± 3.02). The number ofmedical problems/conditions did not correlatewith the time course of dementia. Patientswhose actual time courses were slower thanestimated had 4.68 medical conditions; patients whose decline was faster than estimatedhad 4.61. The most frequent medical problemswere cardiovascular disease (61.5% of patients), musculoskeletal disorders (40.0%),gastrointestinal disorders (41.5%), CNS disorders (36.5)0;&), and visual and auditory problems (29.2%).

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Borson S, Bothwell M,CarnahanJ: Brain-derivedneurotrophic factor in thehuman hippocampus and

locus cendeus

Nerve growth factor (NGF), the prototypicalmember of the family of peptide neurotrophins, is synthesized in the hippocampus and cortex and retrogradely transportedby axons of mature basal forebrain cholinergic neurons, which require it for survival.This action underpins the proposal that exogenous NGF may be a therapeutic agentfor the cholinergic deficits of Alzheimer'sdisease (AD). However, AD is characterizedby degeneration of multiple neuronal subtypes, including dopaminergic neurons ofthe substantia nigra and noradrenergic (NE)neurons of the pontine locus ceruleus,which are unaffected by NGF, and levels ofNGF mRNA and peptide appear to be normal in this disease. In the rodent brain,brain-derived neurotrophic factor (BDNF)mRNA is widely expressed and BDNF supports some midbrain monoaminergic, aswell as forebrain cholinergic, neurons; themRNA expression in the AD hippocampusis reduced compared to nondemented control subjects. Extrahippocampal expressionhas not been mapped in humans. The authors examined BDNF mRNA and peptideexpression in the hippocampus and pons ofthree brains from nondemented older persons by in-situ hybridization and immunocytochemistry. Robust labeling ofhippocampal neurons was found with bothBDNF antisense riboprobe and antiserum.NE cells of the locus ceruleus displayedlarge amounts of BDNF InRNA but onlyweak labeling with antiserum, suggestingthat these neurons may not depend onBDNF retrogradely transported from theirtargets, but may synthesize it for export toother neuronal populations. Studies are ongoing to test this hypothesis in rats, and tocompare patterns of expression in AD brainwith those in nondemented control subjects.

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Burke MA, Arber S, Bustillo P,Granville L, Kongrad A: A

clinical case series of patientsin a multidisciplinary

prostate cancer clinic: abiopsychosocia,l approach

Prostate cancer most commonly affects menover the age of 60 years, with 130,000 newlydiagnosed cases in the United States eachyear. Despite the prevalence of prostatecancer, there is controversy in the medicalcommunity concerning both treatment andscreening for this disease. Patients are frequently frustrated and confused in thissituation. Furthermore, there are many psychosocial issues that arise from the diagnosisand treatment of prostate cancer. Some ofthese issues are generic to cancer (fear ofdeath and pain, pain from treatlnent, depression, and anxiety), whereas other issuesare specific to prostate cancer (the fear andreality of sexual dysfunction and urinaryincontinence, body-integrity issues, selfimage, and self-esteem changes associatedwith sexual dysfunction and urinary incontinence). These problems are being addressed in the prostate cancer patient withinthe framework of a Multidisciplinary Prostate Cancer Clinic at the Miami VeteransAdministration Medical Center. Thisclinic's faculty includes urology and radiation therapy to address treatment issues,geriatrics to address the medical issuesfrequently present in this older population, and psychiatry to address the psychosocial issues. To our knowledge, thisis a novel approach to the treatment ofprostate cancer. The authors presented acase series of clinic patients with abiopsychosocial focus. The presentationincluded survey results that incorporateinventories on depression, anxiety, pain,functionality, marital satisfaction, andside-effects from treatment. Ap.proximately 20 patients were observed for thispresentation. There is a scarcity of litera-


ture on the psychosocial effects of prostatecancer, despite its frequency. Discussion ofthe observations and clinical data describedin this case series were used to generatehypotheses for future research in this area.

Class CA, Unverzagt F, HendrieH, Hall K, Indianapolis/Ibadan

Teams: A psychogeriatricsurvey of African-American

nursing home residents

As part of an ongoing comparative community prevalence study of dementia involvingthe communities of Ibadan, Nigeria, andIndianapolis, Indiana, USA, the authors evaluated a random sample of black nursinghome resident patients age 65 years or older.Evaluation of these patients included a structured interview of nursing staff that includedthe Psychogeriatric Dependency RatingScale (PGDRS), neuropsychological testingof patients, using a modified CERAD (Consortium to Establish a Registry forAlzheimer's Disease) battery, and a psychiatric evaluation, including a semistructuredbattery using the Modified Present StateExamination, and a full physical, neurological, and neuropsychiatric examination. Preliminary data revealed that 97% (n = 36) ofthese geriatric patients were given at leastone current psychiatric diagnosis accordingto DSM-III-R. Fifty-six percent of these (20patients) were given a diagnosis of dementia, and 33% (12 patients) were given adiagnosis of schizophrenia. Quite surprisingly, only 6% (2 patients) were given adiagnosis of depression. The mean PGDRSscore was 22.2. The study was scheduled tobe completed inJanuary, 1994. Results werediscussed as they compared with severalprevious studies. To our knowledge thereare no previously published research studiesfocusing on an African-American geriatricnursing home population.

THEAMEmCANJOURNALOFGEmATmCPSYCH~TRY

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Colenda CC, Poses RM, Rapp S,Leist}, Rose S: Treatmentstrategies for aggressivedementia patients: does

specialty make a difference?

The management of aggressive dementiapatients (ADPs) in community settings is adifficult task for practicing physicians. Yetlittle systematic research on managementstrategies has been conducted. In long-termcare settings, the literature suggests thatphysicians rely excessively on psychotropicmedications for ADPs. The authors askedgeriatric psychiatrists (GPs; 11- = 96) and primary care physicians (PCPs; n = 79) howlikely they would be to implement varioustreatments for these patients, hypothesizingthat GPs would use a wider array of treatments because of their training. Physicianswere given a brief vignette depiction of anincreasingly agitated dementia patient livingat home. Using a Likert scale from - 2.5(would not do) to +2.5 (most likely woulddo), respondents were asked to rate howlikely they would be to use a particularintervention. Fifteen intetventions were categorized into four broad domains: patientevaluation, social services referrals, behavioral management, and medications. Initialmultivariate analysis ofvariance (MANOVA)found significant differences between GPsand PCPs (Wilk's lambda F(15,88) = 5.46; P< 0.01). GPs were less likely to recommendbehavioral management than PCPs (F(1,102) = 8.43; P< 0.01). GPs were morelikely to use neuroleptics (F(1,102) = 9.45;P< 0.01) and recommend attendance at dementia support groups for spouses (F(1,102) = 13.04; P< 0.01). For other diagnostic and social service interventions,group differences were not found. Althoughboth physician groups expressed low likelihood of recommending carbamazepine,lithium, or hydroxyzine, GPs were morelikely to recommend carbamazepine andlithium, whereas PCPs were more likely torecommend hydroxyzine (F(1,102) = 7.17;

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P< 0.01; F(1,102) = 3.03; P< 0.05; F(1,102)= 18.36; P< 0.01, respectively). The mostmeaningful group differences in management strategies were found for dementiasupport group recommendations, behavioral management, and neuroleptic use. Results of this survey need to be comparedwith actual community-based practice pattern data to see if physicians do what theysay they do. However the data suggest thatphysicians, regardless of specialty, recommend similar treatment strategies for ADPs.

Devanand DP, Singer T, NoblerMS, Turret N, Sackeim HA,Roose SP: Is dysthytnia a

different disorder in elderlyindividuals?

Elderly individuals living in the communitycommonly suffer from "non-major" depressive illness. In the Epidemiological Catchment Area (ECA) study, dysthymic disorderwas most frequent in the 45-64-year-old agegroup (3%), with the prevalence droppingto 10/0-1.5% after age 65. However, thenotion that a residual state of dysthymiaoccurs in elderly persons has never beentested directly. Thirty-eight of 211 consecutive patients who presented to a Late LifeDepression Clinic met the DSM-III-R criteriafor dysthymic disorder. In these 38 patients,the mean age was 67.6 years (SD = 5.6); 50%were female. Precipitating life events werecommon (70.30/0). The mean age at onsetwas 54.3 ± 16.3 years, and only 8.1% had anearly onset « 21 years) by DSM-III-R criteria. A small minority (13.9%) met criteriafor major depressive disorder earlier in theindex episode, and only 10.5% met diagnostic criteria for a personality disorder (Axis IIdiagnosis). These findings stand in strikingcontrast to those obtained in prior studies ofyoung adult dysthymics. In young dysthymies, most cases are· of early onset; "pure"dysthymia in the absence of major depression is rare, and concomitant personality

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disorders are frequent. Concomitant medicalillness, retirement, bereavement, and loss ofsocial supports often accompany chronicdepression in elderly individuals. These factors may partly account for the markeddifferences in clinical features betweenyoung adult and older dysthymics. The findings strongly suggest that elderly dysthymicsare not simply young dysthymics who havegrown older, and that specific aspects of thecurrent DSM-III-R classification for dysthymic disorder, e.g., early vs. late onset, arenot applicable to older patients. In elderlypatients with dysthymic disorder, furtherstudies of phenomenology, pathogenesis,and treatment strategies are clearly needed.

Frederiksen K, Tariot P, De]onghe E: Comparison of

scores from. the New York StateMDS+ Nursing Home ResidentAssessment with scores from

five rating scales

The Omnibus Reconciliation ACT (OBRA)of 1987 requires nursing homes to completean assessment of each resident's medical,cognitive, functional, and behavioral status.In New York State, nursing homes use the"Mini Data Set Plus" Resident Assessmentform (MDS+). The authors compared MDS+scores, which are often used in planningboth patient care and policy, with scoresreceived on comparable portions of theBrief Psychiatric Rating Scale (BPRS), Mini.;.Mental State Exam (MMSE), the DementiaMood Assessment Scale (DMAS), the Physical Self-Maintenance Scale (PSMS), and thePsychogeriatric Dependency Rating Scale(PGDRS). Data were retrospectively collected from MDS+ forms and from the fivescales for 52 nursing home residents. Allforms and scales were completed, per individual, within a mean of 6 weeks of eachother. MDS+ forms and the scales werecompleted by different observers on different dates. Scores received on items related


to behavior disturbance, activities of dailyliving, dementia, orientation, cognitiveskills, and communication were all highlycorrelated between the MDS+ and corresponding scale questions (P< 0.001). Linearregression revealed that MDS+ scores forbehavior significantly predicted total BPRS(R 2 = 0.32; P< 0.001) and total PGDRS (R 2

= 0.55; P< 0.001), and communication (R 2

= 0.54; P< 0.001) also predicted the totalMMSE score. Dementia scores also predictedthe first half of the DMAS (R 2 = 0.25; p<0.05) and BPRS Factor 3 (R 2 = 0.72; P<0.001). Cognitive skills scores predictedBPRS Factor 3 (R 2 = 0.50; P< 0.001), Moodstate scores did not predict the first half ofthe DMAS (R 2 = 0.07; p= 0.14). The resultssuggest that the New York State ResidentAssessment form can predict correspondingbehavioral rating scale scores for key behavioral categories; however, a large unexplained residual variance remains.

Halpain MC, Jeste DV: The costof schizophrenia in late life

The literature on the cost of schizophreniasuggest that $10 billion was spent in directand indirect costs in 1985. However, little orno work has been done to determine thecost of late-life schizophrenia. The authors.conducted a project to determine the cost oflate-life schizophrenia, calculating the costsfor 100 older (age 45+) schizophrenic patients at the San Diego Veterans AffairsMedical Center. Both direct costs (hospitalstays) outpatient and emergency room visits,medications, and other miscellaneous services) and indirect costs (lost productivity,social assistance, caregiving, and other miscellaneous costs) are reviewed. After thecosts for these individuals was determined,a model was developed to apply to thegeneral population. The following issueswere taken into account in the developmentof the model: 1) prevalence of late-lifeschizophrenia ranges from 0.10/0-0.5%; 2)


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90% of older schizophrenic patients areearly-onset and 10% are late-onset; and 3)for the early-onset individuals who havereached late life: in 20% of patients, symptoms will have worsened, and in another60%, symptoms will have remained relatively unchanged. The following factors arealso used in the development of the costmodel: 1) schizophrenic patients typicallyhave a higher mortality rate than the generalpopulation; 2) in many cases, treatment forcomorbid medical conditions is delayed dueto difficulty accessing the health care system; and 3) older schizophrenic patientshave a higher risk ofdeveloping side effects,especially tardive dyskinesia, from antipsychotic medications. Data were present~d

from the cost-analysis model. Preliminarydata suggest that the total annual cost oflate-life schizophrenia is at least $2.5 billion.This information will be of considerableinterest in light of the pending modificationsin the nation's health care system.

Hendrie HC, Hui S, Callahan C,Musick B, Levitt EE, Austrom

MG, Nurnberger JIJr, TierneyW: A comparison of two

methods of diagnosing majordepression in a primary care

population: the etiologicalmethod and the inclusive

method

Reported prevalence rates of major depressive disorders in elderly medically ill populations have ranged widely from 6% to 45%.One possible explanation for this variabilityis the lack of agreement on the rating ofdepressive symptoms in medically ill subjects. Two major approaches have beenused, the "inclusive" approach counting depressive symptoms regardless of medicalcontext, and the "etiological" approach, excluding symptoms that would be accountedfor by medical illness. To our knowledge,

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no previous study has attempted to use boththese approaches in the same population.As part of a larger clinical trial, all patients60 years and older attending a large primarycare clinic were screened for depressionusing the Center for Epidemiological StudiesDepression Scale (CES-D). A random sample of patients scoring ~ 16 on the CES-D (n= 44) and a random sample of patientsscoring < 16 on the CES-D were recruited toundergo a more comprehensive psychiatricevaluation using the CAMDEX, the HamiltonRating Scale for Depression (Ham-D), andthe Sickness Impact Profile Scale (SIP). Twomethods were used to determine diagnosis,a consensus clinical diagnosis by two psychiatrists using the etiological approach anda computer-generated algorithm diagnosisusing the inclusive method. Using the clinician etiological method, the estimated prevalence of major depressive disorders in theprimary care population was 1.79% (dysthymia = 4.06% and minor depression =

4.73%). Using the computer-generated inclusive method, the estimated prevalence ofmajor depressive disorder was 5.84°,4). Diagnoses of depressive disorders using eithermethod were associated with functional disability as measured by the SIP.

Horwitz G]: Discontinuation ofantipsychotics in nursing

home residents with dementia

Prior to 2-week taper-off of antipsychotic,26 nursing home residents with dementiawere assessed for behavior, cognition, psychotic symptoms, function, and neurologicstatus. Patients had been clinically stable forat least 3 months. Repeated assessments ofthese dimensions continued until subjectscompleted 6 months successfully off themedication or required reinstitution of theantipsychotic (scored as a failure). The mainoutcome variable was failure rate. Fifty percent of the subjects failed. Failure was foundto be related to a highly significant increase

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in aggression. Function, psychotic symptoms, cognition, and neurological statusworsened in all subjects irrespective ofwhether they completed the 6 months offantipsychotic or failed. Improvement infunction and neurologic status off antipsychotic medication was not observed. A comparison group (n = 6) not on antipsychoticsalso declined in function and showed. worsening of extrapyramidal signs and severityof abnormal movements. The intelVentionresulted in a marked increase in aggression.Verbal aggression and other behavior disturbances while on an antipsychotic may predict aggression if the medication isdiscontinued.

Lesser I, Mena I, Boone K,Miller B, Mehringer eM, WohlM: Reduction of cerebral blood

flow in older depressed patients

The authors investigated regional cerebralblood flow (r CBF) in older, drug-free depressed patients and examined factors thatmight be related to rCBF. Thirty-nine physically healthy depressed patients over theage of 50 years and 20 psychiatricallyhealthy control subjects were studied. rCBFwas measured with SPECT, using both133Xenon (to quantify rCBF) and 99"'Tc-hexamethylpropylene amine oxime (HMPAO)(to make regional comparisons). From magnetic resonance imaging, the authors derived a semiquantitative measure ofwhite-matter hyperintensities (WMH) and aventricle-to-brain ratio (VBR). Patients exhibited a global reduction in rCaF cODlparedto control subjects, with orbital frontal andinferior temporal areas affected bilaterally.Also, rCBF was reduced in higher brainslices only in the right hemisphere. LoweredreBF correlated with being depressed, beingmale, and having a larger VBR. There appeared to be a subgroup of patients whodemonstrated large WMH and low rCBF;rCBF in older depressed patients was lower


than in age-matched control subjects, involved orbital frontal and anterior temporalregions and was more reduced in the righthemisphere. It is uncertain whether thesereductions are based on structural braindisease (a state phenomena) or are reflectiveof functional brain derangements (a trait ofthe depression).

LoebeljP, Borson S, Domoto S,Hyde T: OBRA. '87/PASAR:

implementation and fIndingsin nursing homes of one urban

county

OBRA '87 mandated preadmission screening and annual review (PASAR) of residentsin long-term care facilities who meet criteriafor probable mental. illness other than dementia. There is a dearth of reports froin thisnationwide project, in spite of its large scaleand scope. The authors described the process of developing a clinical protocol forevaluation of MDS+ patients, and its implementation in all long-term care facilities(n = 55) in King County, WA. Of all (N=7,000) patients in long-term care, 7.2% (n =

504) scored above the screening cutpoint forprobable mental illness. Data were presented on their 1) demographic characteristics; 2) prior psychiatric diagnosis andtreatment; 3) current DSM-III-R Axis I diagnoses; 4) current severity of cognitive impairment (MMSE), depression (Ham-D),global psychopathology (BPRS), behavioraldisturbance (PBRS, Problem Behaviors Rating Scale, a new instrument developed forthis work); and 5) frequency of need foractive treatment. OfMDS+ patients, 30% hadthought-disorder-related diagnoses, and another 30% had mood disorders; 49% had noprior inpatient psychiatric treatment, suggesting that this tool identifies many patientswho have otherwise escaped care in theformal mental health system, and the dataemphasize the severity of cognitive, mood,and general psychopathologic disturbance


Proceedings

in the group as a whole. A strength of thisapproach is the inclusion of all nursinghomes in a large, heterogeneous county, adiverse group of facilities selVing an equallydiverse population. This study was a firstattempt to define the clinical characteristicsof a broad group ofMDS+ patients; it amplifies previous reports on the nature of psychiatric disturbances among residents inlong-term care. The authors discussed implications of the data for the future of thePASAR process and for provision of psychiatric services to this severely impaired groupof patients.

McGuire MH, Rabins PV, BlackB, German P: Elderly residents

of Baltimore City publichigh-rise buildings:a demographic and

psychological description

Elderly residents of urban public housinghave rarely been a focus of epidemiologicalstudy. The authors reported the demographic and psychological characteristics of945 of 1,194 residents (79.1%) in six Baltimore City high-rise buildings screened forpsychiatric disorder: 75.1% of the respondents were female; 97.8% were black; 90.7%lived alone; and 89.6% were between age60 and 89 years; 99% received medical careregularly; 6% reported a need for moresocial support; 18% had discussed an emotional problem with a health provider duringthe previous 6 months. The General HealthQuestionnaire CGHQ), Mini-Mental StateExam (MMSE), and CAGE questions wereused to screen for emotional, cognitive, andalcohol-related psychopathology, respectively. Of the 945 residents, 342 (36.2%)screened positive on one or more instruments (i.e., GHQ > 5, MMSE < 18, or CAGE> 1); 195 (20.6%) screened positive for emotional distress; 108 (11.4°A» for cognitiveimpairment; and 84 (8.9%) for alcohol-related problems. Respondents who screened

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Proceedings

positive on one or more instruments weremore likely (P = 0.006) to be male, havefewer years of education, have lower LifeSatisfaction Inventory (LSI) scores, and report inadequate social supports. Emotionally distressed respondents were more likely(P< 0.001) to have lower LSI scores, feweryears of residence, and inadequate socialsupport. Cognitively impaired respondentswere more likely (P < 0.001) to be older andless educated. Respondents with alcohol-related problems were more likely (P S 0.001)to be younger and have fewer years ofresidence. Respondents screening positiveon one instrument were not more likely toscreen positive on the other instruments.

MintzerJE, Herman KC:Prevalence of caregiving for

patients with dementia

Dementia is characterized by cognitive andfunctional deterioration. Despite the· highprevalence of dementia in elderly individuals, very little information is available toassist in the development of services to aidcaregivers. This paper reported preliminaryfindings obtained in the NIA-sponsored survey on prevalence of caregiving for elderlypatients with dementia to study characteristics of caregiving for these patients in acommunity sample. Subjects (N= 1,198)were selected in South Carolina (520), Georgia (137), and California (541), using random-digit dialing technique. They wereinterviewed on the phone by trained bilingual (English, Spanish) interviewers using astructured interview. Sixty-three percentwere employed. The combined percentageof households reporting the presence of atleast one tnember involved in caregiving fora person suffering from dementia was 2.91per 100 households. Despite the high riskfor mental health symptoms and the negative impact in lifestyle associated with caregiving in representative communitysamples, to the authors' knowle"dge, this is

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the first study investigating the prevalenceand characteristics of caregiving in a representative community sample, both in thesoutheastern and western areas of theUnited States.

Rockwell E, Juels CW, JacksonJE, Jeste DV: Psychiatric

symptoms in a large cohort ofAlzheimer's disease patients

The psychiatric complications ofAlzheimer's disease (AD) can be among themost disabling aspects of this illness. Demographic and neuropsychiatric symptomswere compared among four groups of subjects from a large cohort of 1,552 ADpatients: not depressed and not psychotic(D - P -; n = 679); depressed and not psychotic (D + P -; n = 318); not depressedand psychotic (0 - p +; 11 = 310); and depressed and psychotic (D + P +; n = 245).Of 5,800 patients consecutively assessedfrom 1985-1992 at the Alzheimer's DiseaseDiagnostic and Treatment Centers (ADDTC)in California (nine campuses), a111,552 withprobable AD as the only neuropsychiatricdiagnosis were included in this study. AllADDTC sites used a similar interdisciplinaryteam approach to the diagnosis and management of dementia, using medical, neuropsychiatric, environmental, and socialevaluations, and then consensus diagnosesand management recommendations. Diagnoses were made using NINCDS-ADRDAand DSM-III criteria. Patients were considered psychotic if they had either hallucinations or delusions, and depressed as judgedby mental status examination or if the clinician listed depression on the patient's problem list. Psychotic AD patients hadsignificantly greater cognitive impairmenton MMSE and the Blessed Dementia Scalethan nonpsychotic patients (both P s <0.00001). The prevalence of the followingpsychiatric symptoms: insomnia, agitation,apathy, psychomotor retardation, anxiety,


loss of energy, diminished concentration,confusion, appetite changes, wandering,anger, and personality change was greatestin the D+ P+ group, least in the D- Pgroup, and intermediate in the D- P+ andD+ P- groups (all Ps < 0.00001). Of theneurological symptoms studied, only emotional incontinence and gait disorder (bothR3 < 0.00001), and aphasia (P = 0.02) exhibited this trend. Presence of both psychosisand depression in AD patients was significantly associated with many psychiatricsymptoms as well as greater cognitive impairment.

Sewell DD,Jeste DV, PaulsenJS,Kramer RL, Gillin JC:

Family history andneuropsychological correlates

of late-life psychotic depression

A number ofstudies of patients with depression have found that the presence of psychosis is associated with an older age atonset. Some studies have reported that olderage at onset is associated with decreasedneuropsychologic function. It remains unclear whether the presence of psychosis isalso associated with decreased neuropsychologic performance. Others have reported that family members of patients withpsychotic depression are more likely to havebeen hospitalized for psychiatric treatment.This study compared demographic characteristics, neuropsychological performance,and family history of older patients with andwithout psychotic depression. Nineteen patients with psychotic depression and nineteen patients with nonpsychotic depression,matched 1:1 according to age, gender, andrace obtained from our Affective DisordersClinical Research Center were studied. Patients were diagnosed using the Schedulefor Affective Disorders and Schizophrenia(SADS). Family history was obtained usingthe Family History-Research Diagnostic Criteria. Most completed a neuropsychological


Proceedings

battery that included the Mattis DementiaRating Scale. Preliminaty results suggest thatpatients with psychotic depression hadlower scores on tests of cognitive function.The authors presented evidence for andagainst the concept of psychotic depressionas a distinct clinical entity.

Sweet RA, Mulsant DB, Gupta B,Rifai All, Pasternak RE,

Zubenko GS: Duration ofneuroleptic treatment and

prevalence of tardivedyskinesia in late life

Increasing age is the most consistently citedrisk factor for the development of tardivedyskinesia (TD) between the second andsixth decades of life, though this relationshipmay not hold within geriatric samples. Tofurther examine the relationship betweenincreasing age and the potential TO riskfactors in elderly patients, the authors examined 386 consecutively admitted geriatricinpatients for evidence of dyskinesia usingthe Abnormal Involuntary Movement Scale(AIMS). Patients were examined within 72hours of admission, at which time demographic, diagnostic, and psychometric datawere recorded. Lifetime neuroleptic history,including use of metoclopramide and prochlorperazine, was obtained from all available sources (patient, family, physician, andchart review). Patients had a mean age of75± 8 years (range 60 to 100 years); 69% werewomen; 84% were white, and 160/0 wereblack. Forty-seven percent were diagnosed(DSM-III-R) with an organic disorder, 38%with a mood disorder, 8% with a schizophrenic, schizoaffective, or delusional disorder,7% with other disorders. Using Schooler andKane severity criteria, 74/386 patients(19.2%) with dyskinesia were identified.Eleven variables were initially examined inunivariate analyses for association with TO.Lower age, diagnosis of a psychotic disorder, lower Global Assessment Scale score

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Proceedings

(GAS), and longer cumulative neuroleptictreatment were all associated with higher TDrates. Sex, race, age at onset of psychiatricillness, duration of psychiatric illness, number 9f medical diagnoses, Mini-Mental StateExam score, and interval since last use ofneuroleptics were not associated with thepresence of TO. After accounting for theeffect of cumulative neuroleptic use in astepwise logistic regression, only the association with GAS remained significant. Therate of TD increased with increasing cumulative neuroleptic use such that 10% of 152patients with no neuroleptic use, 16% of 81patients with < 3 months of neuroleptic use,29% of 49 patients with 3-12 months ofneuroleptic use, 31% of 51 patients with1-10 years of neuroleptic use, and 37% ofpatients with> 10 years of neuroleptic usehad TD. In patients with a history of neuroleptic treatment, the relative risks (95% CI)for these durations of neuroleptic use were1.62 (0.81-3.24), 2.89 (1.5-5.5), 3.16 (1.685.93), and 3.75 (1.97-7.15), respectively.The results suggest that within elderly populations, duration of exposure to neuroleptics is a strong risk factor for TD, whereasage is not, and that this risk increases rapidlywithin the first year of cumulative lifetimeneuroleptic use.

Baker FM, Parker 0, Wiley C,Vellil SA,}ohnson}T: Current

reading level and reportededucation among older, black

medical clinic patients

As part of a study of depressive symptomsamong older, black medical clinic patients,current reading level was determined usingthe Wide Range Achievement Test-Reading(WRAT-R). The current reading level wasconlpared with reported education to determine the percentage of older, black patientswho were reading below their reportededucation level. Sixty percent (46/76) ofolder, black, medical clinic patients were

268

reading a median of 4 years below theirreported education level (range = 1-8years). The median reported education levelwas 7 years, with a range of 1-14 years. Theimplications of this discrepancy betweencurrent reading level and reported education are discussed with respect to informedconsent, reading medication and food labels, and completing required Medicare andSocial Security forms.

Beale M, Kellner CD:Parkinson's disease as a major

public health problem andsource of disability in the

geriatric population

Parkinson's disease (PD) is a major publichealth problem and source of disability inthe geriatric population. Many patients remain disabled by both the illness itselfand/or the side effects of medications usedto treat PD. Anecdotal data suggest thatelectroconvulsive therapy (ECT) is a veryeffective treatment for this illness. MechaniSlns of action may involve potentiation ofdopaminergic transmission in the striatum.The authors have used ECT and systematically rated, using the Unified PD RatingScale (UPDRS), six patients with coexistingPD and psychiatric illness. Overall, a 51%improvement was noted in UPDRS scores.These data were presented along with adiscussion of outcome measures and sideeffects. Recommendations concerning treatment technique and future research werediscussed.

Bradley L, Rockwell E, Jeste DV:ECT for severe agitation in

dementia patients

Agitation in the context of dementia occursin some fonn in about 700/0-80% of patients.It is one of the most serious behavioralassociations of dementia. It negatively af-


feets the quality of care that patients receiveand may lead to institutionalization. Therehave been several case reports in the literature regarding the efficacy of electroconvulsive therapy (EeT) in the treatment ofagitation in dementia. To our knowledgethere had, however, been no systematicstudy examining this issue. The purpose ofthe current study is to evaluate the efficacyof ECT in agitated, elderly patients withdementia. The authors studied inpatients ~

50 years old meeting the DSM-III-R criteriafor dementia, with severe agitation refractory to pharmacotherapy and psychosocialintervention. The following rating scaleswere administered before and after ECT: theMattis Dementia Rating Scale, Mini-MentalState Exam, Cohen-Mansfield Agitation Inventory, Reisberg et al.'s Behave-AD, theHam-D, Cornell Scale for Depression inDementia, and Pfeffer Scale for Activities ofDaily Living. Preliminary experience suggested that improvement in agitation beginsearly in the course of ECI'. Data were presented regarding the course of improvementin agitation compared to improvement indepressive symptoms.

Burke WJ, Rangwani S,Roccaforte WH, Wengel SP,

Folks DG, Bayer B: Use of theGeriatric Depression Scale in

Parkinson's disease

Depression is a frequent occurrence inParkinson's disease (PD). Many ofthe symptoms of PD overlap with the somatic symptoms of depression. The accuracy ofdepression rating scales that incorporatethese symptoms has been questioned. TheGeriatric Depression Rating Scale (GDS)avoids these symptoms, and thus may be ofparticular use in PD. The purpose of thestudy was to examine the usefulness of theGDS in patients with PD. The authors performed a retrospective chart review of consecutive new outpatients being evaluated by


Proceedings

a geriatric psychiatrist. Patients with a diagnosis of major depression (MOD), primarydegenerative dementia with depression(DEM-DEP), or Parkinson's disease with depression (PD-DEP). All patients completedthe short form of the GDS, were administered the Mini-Mental State Exam (MMSE),and had a psychiatric diagnostic interviewincluding, whenever possible, interview ofa collateral source. Psychiatric diagnoseswere based on DSM-III-R criteria. Out of 265patients, 82 had one of the three specifieddiagnoses; 58 patients had MDD, 10 hadDEM-DEP, and 14 had PD-DEP. The DEMDEP patients were significantly older andmore cognitively impaired than the othertwo groups. However, the three groups didnot differ on the total score on the GDS. Acomparison of the individual GDS itemsshowed only that the DEM-DEP group reported significantly less "loss ofenergy" thanthe other two groups. The results of thisstudy suggest that the GDS may be a usefultool in the evaluation of patients with PD.

Burrows A, Nobel K, SalzmanC, SatIht A: Depression in a

long-term care facility:nursing assessment and

antidepressant use

Symptoms of depression are common inlong-term care facilities, but depression isunderdiagnosed and undertreated. Nursesin long-term care facilities identify depression more frequently than primary care physicians, but nursing diagnosis may be lessspecific for major depression. To explore therelationship between nursing identificationof depression and physician diagnosis, theauthors compared nursing assessments ofpatient mood with psychoactive prescribingpatterns in a 725-bed, academic, multilevellong-term care facility. Residents on unitsreserved for advanced dementia were excluded from the analysis en = 230). Amongthe remaining 495 residents, nurses identi-

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fied 195 patients (39.4%) as being "sad,withdrawn, and persistently miserable" on abimonthly functional assessment, and 115patients (23.2%) as having these symptomsevery day. Of the 195 residents with somedepressive features, 81 (41.5%) were receiving antidepressants. Neuroleptics and anxiolytics were prescribed in 26 (13.3%) and25 (12.8%), respectively. Of the 115 residents with daily depressive symptoms, 51(44.3%) were receiving antidepressants; 16(13.9%) were prescribed neuroleptics, and19 (16.5%), anxiolytics. In the group identified by nurses as having daily depressivesymptoms, 46 of 115 (40%) were not prescribed any psychoactive medication. In ourreview, nurses identified a larger populationof long-term care residents with depressionthan were thought by their physicians torequire antidepressants. Possible explanations for these findings are 1) nurses do notdistinguish between major depression andother affective syndromes less responsive toantidepressants, 2) nurses identify atypicalpresentations of major depression that desetve further physician evaluation and treatment, and 3) nurses identify majordepression that is missed by physicians.Nursing assessment offers an opportunity toimprove the diagnosis ofdepression in longterm care facilities, but further investigationis needed to characterize the affective syndromes recognized by nurses.

Fallahpour K, Jonas SP: Elderlypatients missing clinic

appointments: causes andsolutions-an algorithm

Elderly patients miss clinical appointmentsfor a variety of reasons. An algorithm is auseful tool for following the possible different causes, and suggests interventions-alldesigned to help elderly patients back totreatment. This introduction provided aguide for building an algorithm; the paperthen went on to show its application. In

270

seven flow charts, the algorithm meticulously guides the clinician/case managerthrough various clinical and administrativeaspects of a missed appointment. Each ofthe seven charts deals with different causesof missed appointments: 1) identifying anemergency, 2) follow-up on a medical orpsychiatric emergency, 3) chronic medicalproblem, 4) chronic psychiatric problem, 5)social and environmental problems, 6) special requirements, and 7) conference. Inconclusion, the authors underlined the usefulness of an algorithm as an instrument toteach and supervise an inexperienced clinical staff.

Falls I, Hanchuk H: Treatmentof depression in caregivers

Many researchers have noted an increasedincidence ofdepressive disorders in caretakers of individuals with dementia. However,no published reports have examined thetreatment of this disorder, hereafter referredto as "caregiver depression." In an outpatient geriatric psychiatry clinic, a retrospective chart review was conducted of all 156active cases with depressive disorder diagnoses. Twenty-two patients (14% of thisdepressed group) were caregivers: 15 (68%)were female and 7 (32%) were male. Twelve(55%) of the caregivers were spouses, withslightly more husbands than wives; the remainder were female children. Eleven (50%)of the patients carried a diagnosis of recurrent major depression (MDD); 6 (27%) werediagnosed with MDD, single episode; 5(23%) carried an adjustment disorder diagnosis. Eighteen (95%) of the nineteenknown sources of referral were nonphysician mental health professionals: only onewas physician-referred. Eleven (50%) of thepatients had achieved and maintained remission of depression to date. Five patients(23%) had at least one recurrence of depression, two (9%) had a partial remission, one(5%) was still depressed, and three (13%)


were lost to follow-up. Treatment modalitiesincluded psychopharmacotherapy, electroconvulsive therapy (ECT), individual psychotherapy, and use of caregiver supportgroups. Seventeen (77%) of the depressedcaregivers received pharmacotherapy, oneof whom received ECf in addition to medication, 22 (100%) received psychotherapy,and 13/21 (62%) attended support groups.Caregiver depression is a highly treatableentity and a common problem, but is underreferred for treatment by physicians. Allcaregivers of patients with dementia shouldbe screened for depression by the physiciantreating them or their loved one.

Kelsey Me, Grossberg GT:Sertraline and weight changein elderly depressed patients:

a retrospective study

There has been concern regarding the anorectic effects of the selective serotoninreuptake inhibitors (55RIs), especially in elderly patients. A recent report found a significantly increased rate of weight loss inmedically ill patients greater than 7S yearsold who were receiving fluoxetine (47%).The authors conducted a chart review studyof 23 depressed geriatric psychiatry outpatients receiving the SSRI sertraline at St.Louis University Health Sciences Center, Division of Geriatric Psychiatry. The resultsfrom the retrospective chart review follow.N =23; age range =53-95 years; mean age= 77.6 years; range in use = 1-16 months;average duration of use = 6.5 months; therewere 5 men in the sample (22%), and 18women (78%). Thirteen patients (56.5%)gained weight on fluoxetine (Zoloft). Tenpatients (43.5%) lost weight on fluoxetine.Average gain in weight for the 13 patientsonly gaining weight = 9.41bs (6.5% averagegain in weight). The average weight loss forthe 10 patients only losing weight = 5.9 Ibs(4.2%). Average weight gain for all patientscombined was not statistically significant.


Proceedings

Based on the 23 outpatients in the study, theauthors concluded that sertraline does notresult in an appreciable weight loss whenused on a long-term basis.

Kelsey Me, Grossberg GT: Thesafety and efficacy of

caffeine-augmented ECT inelderly depressed patients:

a retrospective study

Prior studies have shown that in youngerdepressed patients whose seizure durationsin ECf declined despite maximum settingson three different ECf devices, pretreatmentwith caffeine lengthened seizures and resulted in clinical improvement. Caffeine waswell tolerated even in patients with preexisting cardiovascular disease. The purposeof this retrospective study was to determinethe safety and efficacy of caffeine-augmented ECf in elderly depressed patients.In the charts of 14 elderly depressed patients(average age 75.6 years) who received medications, blood pressure, pulse, and seizuretimes (cuff and EEG) for each ECT performed were noted. The following datawere obtained:

1) average seizure duration followingcaffeine administration (N= 14): cuff =

88.5% increase; EEG = 93.7% increase;2) average change in pulse without

caffeine = 26.9%; average change in pulsewith caffeine =30.2%;

3) average change in mean arterialpressure without caffeine = 37.QOAl; averagechange in mean arterial pressure with caffeine = 42.5% (Note: Mean arterial pressure= diastolic pressure + [systolic - diastolicpressurel!3);

4) average maximum rate-pressureproduct without caffeine = 21,809; averagemaximum rate-pressure product with caffeine = 22,072 (rate-pressure product = systolic blood pressure X pulse).

The authors conclude from this studythat caffeine-augmented ECT is safe and

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Proceedings

effective for increasing seizure duration inelderly patients. However, more researchneeds to be done to determine optimaldosing and tolerability.

Husain MM, Vobach S, WhitePF, Rush JA: ECT in medicallycompromised elderly patients

ECf is a safe and highly effective treatmentfor mood disorders of elderly individuals.Many elderly patients with mood disordershave concomitant serious medical problems. In such circumstances, they are eitherunable to tolerate some of the commonlyused antidepressant medications or are unresponsive to these medications. With abetter understanding of medical physiologyof ECT and availability of improved monitoring techniques, EeT can be the treatmentof choice for some of these severely illpatients and can be safely applied. In thisreport, the authors presented a series ofseverely medically compromised elderly patients (mean age = 73.8 years, range = 63-81years) with multiple medical problems, including cardiac illnesses, eNS disorders,renal dysfunction, pulmonary difficulties,and other medical complications, who weresuccessfully treated with ECT. This studyalso looks into interactions between medicalcomplications, anesthetic agents, and use ofother drugs during treatment. Some of thesepatients were maintained in continuationphase ECT. Cognitive effects as well assafety and efficacy of ECT for long-termtreatment of depression in these medicallycompromised patients was discussed.

Garcia DJ Jr, Husain M, WeinerM, Risser R: Magnetic

resonance imaging fladingsand severity of dementia

Alzheimer's disease (AD) is a degenerativecentral nervous system disorder associated

272

with a decline in cognitive function. Thediagnosis is primarily made by clinical evaluation and the exclusion ofother underlyingpathologies that may be causing dementia.Magnetic resonance imaging (MRI) is one ofthe tools commonly used in the evaluationof possible AD. To investigate correlationsbetween MRI findings and the extent ofdementia, the authors looked at severalvariables, including periventricularhyperintensities (PVH), subcortical hyperintensities (SCH), ventricular enlargement,and atrophy. These findings were then compared with the cognitive status of the patientas measured by the Blessed, Short Blessed,and Folstein Mini-Mental Status scales.These MRI findings have been investigatedby several groups to demonstrate their relationship to severity of dementia in elderlypatients. Often these studies have been limited by small sample sizes. In this study, theMIUs of 49 random patients from an ADResearch Center were examined independently by two experienced raters blind tothe clinical status of the subjects. Periventricular white-matter disease, subcorticalhyperintensities, ventricular enlargement,and atrophy were measured by standardmethods and correlated with the severity ofdementia. All patients had undergone extensive neuropsychological evaluation as wellas an MRI on a standard protocol. Thedegree of periventricular disease was significantly related to severity of dementia asmeasured by the Blessed Dementia RatingScale (P< 0.04). Correlations between SCH )

ventricular size, and degree of atrophy werealso discussed.

Juels CW,]este DV: Thecomputerized psychiatric

intake applied togeropsychiatric

medical education

Although many medical students and residents are computer literate, most have not


used computers for medical records purposes. Major advantages of using a computer for the psychiatric intake are legibilityand standardized methods of data collection. Using a structured format for components of the mental status examination hasbeen shown to encourage more completedata collection by psychiatric residents. Theauthor (C.W. ]uels) has developed a computer program which can generate acomplete psychiatric intake in SubjectiveObjective-Assessment-Plan format, including five-axis DSM-III-R diagnoses frominformation entered in text fields as well asfrom numeric choices on date entry screens(Le., mental status examination, medications). The geropsychiatric intake requiresthe collection and synthesis of a largeamount of patient information, which to beuseful must be legibly presented to thepatient's referral source. The authors studiedways in which this computer programwould assist medical students and their preceptors as they conduct geropsychiatric intakes. A medical student intetviewed a newgeropsychiatric patient for 1 hour and thenpresented the case to a geropsychiatric fellow (preceptor), who entered the patient'shistory into the computer program. After thepreceptor reinterviewed the patient with themedical student, both returned to the computer program to complete the mental statusexamination, assessment, and plan portionsof the intake. Copies of the computer-generated intake were given to the student, sentto the referral source, and placed in thepatient chart. Ten medical students whocompleted this process enjoyed it, said thatit helped them collect complete patient information, and positively influenced them touse computers for medical records purposes. The patients' referral sources werepleased to have a legible document returnedto them. Observing the use of a computerprogram to enter patient information andgenerate a geropsychiatric p~tient evaluation was a beneficial experience for medicalstudents on an outpatient geropsychiatricrotation.


Proceedings

Kambolz B, Stevenson C,Lnborsky M: PTSD and itssequelae in a VA nursing

home population

Posttraumatic stress disorder (PTSD) and itssequelae are often found in combat veteransin the decade follOWing discharge from thearmed forces. PTSD can exist in chronic orlatent fonns, particularly in former POWs, forsociocultural, psychological, and physiological reasons. However, to our knowledge nostudies have addressed the clinical impact ofcombat- and POW-related PTSD disorders inVA nursing home patients. In one 60-bedward of the Nursing Home Care Unit at thePhiladelphia VAMC, the authors identifiedfour combat-exposed veterans and formerPOWs whose late-life psychiatric presentations, although closely resembling typical neuropsychiatric disorders found in communitynursing home populations, were better explained as late-life reactions to earlier traumatic experiences. Data from the case serieswere presented describing how these latentand recurrent symptoms of PTSD helped distinguish these patients from other dementing,depressed, and behaviorally disordered nursing home residents. These preliminary dataare important because the clinical problemsassociated with PTSD respond to differenttreatment modalities from other late-life psychiatric disorders. Further population-basedstudies will determine the prevalence of combat- and POW-related PTSD in VA nursinghome populations.

Miller D, Kumar A, Burke L,Ewbank D, Gottlieb G: A

comparison ofMRI volumetricsin late-life depression,Alzheimer's disease,and control subjects

To examine the structural basis of late-lifedepression, the authors used magnetic res-

273

Proceedings

onance imaging studies (MRIs) to observecerebral hemispheric and cerebrospinalfluid (CSF) volumes (sulcal, ventricular, andtotal) in 18 patients with late-life depression(7 men, 11 women; mean age = 73.6 ± 8.2years); 34 subjects (17 men, 17 women) whomet criteria for probable dementia of theAlzheimer type (OAT; mean age =66 ± 8.6years); and 29 healthy, age-matched controlsubjects (12 men, 17 women; mean age = 67±8.5 years). All depressed subjects metDSM-III-R criteria for major depression, hadHamilton Rating Scale for Depression scores~ IS, and were cognitively intact at the timeof study. All subjects were medically stableand free of significant other neuropsychiatric illnesses. Proton density and T2-weightedMRIs were used to maximize the contrastbetween neural tissue and CSF. A semiautomated boundary program and segmentationalgorithm were then used to differentiatebrain tissue from CSF. On normalized mea..sures of CSF volumes (ventricular, sulcal,and total) in both hemispheres, depressedsubjects had significantly larger volumescompared to controls (P< 0.05), than DATpatients. When depressed and DAT patientswere compared, the right-hemispheric CSFvolume (larger in those with DAT) was theonly area where there was a statisticallysignificant difference. These preliminarydata suggest that subjects with late-life depression have structural brain changes asdetermined by MRI. CSF volumetric measures in the depressed group were comparable in magnitude to changes with DAT andsignificantly different from normal controlsubjects.

Tueth MJ, CheongJA, BiernatMR: Benefit of interviews on

m.edical students' feelings andbeliefs toward elderly

individuals

To determine whether exposing third-yearmedical students to personal, ·conversa-

274

tionaI-style interviews with hospitalizedmedical/surgical geriatric patients would increase sensitivity and decrease prejudiceand negative stereotyping toward this patient population, a double-blind study wasperformed in which 74 third-year medicalstudents during their psychiatry clerkshipwere randomly assigned to participate in atraditional medical interview and experimental interview using a personal, conversational style, or a control group. Eachmedical student subject completed a preclerkship and postclerkship questionnaireassessing the student'S attitudes, prejudices,beliefs, and stereotypes of elderly patients.Across all three groups, there were no significant differences between the results ofthe preclerkship and the postclerkship questionnaire for 14 of the 16 variables examined. In the two variables that were affected,positive and negative views toward elderlypeople, the experimental group subjectsrated elderly patients less positively andmore negatively than the other two groups.The authors demonstrated in a double-blindstudy that exposing third-year medical students to hospitalized geriatric patient interviews of a personal, conversational naturedoes not increase sensitivity or decreaseprejudice toward this group. In fact, forsome variables the interviews lessened sensitivity and enhanced bias. These datashould alert medical school educators to thefact that didactic classroom instructions inthe biopsychosocial aspects of aging andstructured interviews with healthy ratherthan sick elderly people may be the bestlearning approaches.

Truong UP, Solomon K:Psychiatric and cognitiveaspects of Fahr's disease

Fahr's disease (FD), or idiopathic calcification of the basal ganglia, is a rare cause ofdementia in elderly individuals. Publishedcase reports do not make it clear whether


the disease is associated with specific neurologic, cognitive, or psychiatric symptoms.The authors studied the records of 12 patients with FD; 4 were diagnosed during lifeand the others at postmortem examination.As expected, all our subjects suffered fromdementia, and all demonstrated memol)'deficits, disorientation, and a loss of abilitiesto perform activities of daily living andinstnlmental activities of daily living. Mostsubjects had a comorbid neurologic disorder, most commonly Alzheimer's diseaseand multi-infarct dementia. The most common cognitive deficits, in addition to thosenoted above, were disorders of speech anddyscalculia. As expected from the site of thelesions, Parkinsonia~ symptoms or choreoathetoid tTIovements were present· in twothirds of the sample. There was no particularcommon psychiatric symptom noted, exceptfor irritability. Half the sample had beentreated for depression in the past. Most hadreceived multiple psychotropic medicationsin the past. A surprising finding was the highfrequency of cancers in this group of patients. Other neurologic, cognitive, and psychiatric symptoms occurred with minimaland variable frequency. More research isnecessary to determine whether FD is trulya separate clinical entity, with its uniquesemiology, or a variant form ofother dementias. Our data suggest that the former is true.

Vobach SF, Weiner MF, RisserRC: No association of 5-1nAAwith agitation in Alzheimer's

disease

Low cerebrospinal fluid (CSF) 5-HIAA hasbeen associated with agitation and aggression by other investigators. At one center,patients with NINCDS/ADRDA-definedprobable Alzheimer's disease (AD) wererated at initial evaluation on five behavioralmeasures for the presence of agitation.Those measures were compared with 5HIAA concentration determined in CSF that


Proceedings

was also obtained during routine initial evaluation. None of the agitation measurescorrelated significantly with 5-HIAA concentration. Possible explanations for these findings include early stage of AD and lowfrequency of agitation in these patients.

Walker S, Borson S, Katon W,Peskind E, Raskind M:

Differential clinicalcharacteristics of elderly black

and white nursing homeresidents: a pilot study

Data on clinical characteristics of elderlyminority populations are sparse. In community studies the prevalence of hypertension,stroke/multi-infarct dementia, and possiblydementia generally, is higher in elderlyblack than in white populations. Differentialpatterns of morbidity have not been compared in residents of long-term care facilities. The authors studied all black residents(n = 42; 29% of 181 residents) and a randomsample ofwhite residents (n = 42) in a singleinner-city nursing home. In both groups,mean age was 78 years and 71% werewomen; mean years of education was 9 forblacks and 10 for whites. Chart data werecollected for diagnoses of dementia, hypertension, psychiatric disorders, and severityof chronic medical morbidity. A dementiaspectrum diagnosis was recorded for twothirds of subjects in each group. No groupdifferences were found for specific dementia diagnoses, except diagnosis-not-specified for 38% of blacks (P= 0.05) andParkinsonism among whites (P= 0.04).Whites were significantly more likely tohave received a psychiatric diagnosis (P =

0.004), largely accounted for by depression,and to have a chronic psychiatric or developmental disability (P= 0.05). Total chronicillness burden was significantly greater inblacks (P< 0.01). These pilot data suggestthat dementia remains inadequately assessed in both black and white residents of

275

Proceedings

long-term care facilities, and that blacks maybe medically sicker than whites upon entryinto a nursing home. Depression may be lesscommon, or (more likely) .less readily diagnosed and treated in black than in whiteelderly individuals in long-term care. Larger,detailed studies are needed to develop anadequate basis for providing appropriatelong-term care services for elderly blacknursing home residents.

Weiner MF, Edland SD,Luszczynska 8M: Prevalence

and incidence of majordepression in Alzheimer's

disease

Although major depressive disorder (MOD)represents a treatable cause of excess morbidity in Alzheimer·s disease (AD), there islittle information on its incidence in AD. Inthis study t the investigators retrospectively

reviewed two large AD case series to examine the prevalence and incidence of MODin possible and probable AD. TheAlzheimer's Disease Center CADe) databaseat the University of Texas SouthwesternMedical Center contained 264 cases; 153were followed for an average of3years frominitial evaluation. The Consortium to Establish a Registry for Alzheimer's Disease(CERAD) excluded any patients with historyof MDD at first evaluation, and contained1,095 AD cases; 325 were followed for atleast 2 years. Diagnoses of possible/probable AD were made using NINCDS criteria;MOD was diagnosed according to DSM-III-Rand direct examination. The ADC series ofAD cases demonstrated a 1.5% prevalenceand a 0% incidence of MOD. There was a1.3% 2-year incidence ofMDD in the CERADAD series. It is concluded that there is a lowprevalence and incidence of MDD in ADoutpatients when MOD is diagnosed according to DSM-III-R criteria and direct patientevaluation.

IN MEMORIAM

Kenneth Solomon, M.D., Department of Psychiatry,St. Louis University Medical Scllool, died on April 13, 1994.

Dr. Solomon was an active member of theAmerican Association for Geriatric Psychiatry and

contriblltor to the field of gerontology.

A memorial fund is being estabUshed at St. Louis University.Contributions may be sent to the Kenneth Solomon Memorial Fund,

c/o Dr. Peggy Szwabo, Dept. of Geriatric Psychiatry,St. Louis University, 1221 South Grand Blvd., St. Louis, MO 63104.

276 VOLUME 2 • NUMBER 3 • SUMMER 1994

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