The trauma patient: open hospital choice?

Mental-health service utilization among elderly people has been shown to be low relative to younger age groups. This study was done to determine the current proportion of elderly persons served in a university-affiliated psychiatry outpatient clinic, and to better characterize elderly patients who receive specialized mental-health care in this setting. The proportion of visits from elderly patients (aged 60 and over) was found to be 16%. Demographic and clinical characteristics of a sample of 140 consecutive geriatric patients evaluated at the clinic were obtained. The data revealed that the patients had a mean age of 74.7+/-7.5 (SD) years, and were mostly female (72.1%) and white (78.6%). Surprisingly, the age distribution was found to be bell shaped, with a small upper tail. The three most prevalent psychiatric diagnoses were depression (56.4%), dementia (35.7%), and substance use disorder (20%). Overall, 59.3% of geriatric patients had a history of prior psychiatric treatment. Females were significantly more likely than males to have a psychiatric history (69.3% vs. 33.3%, P = .0001). Among patients with a psychiatric history, females were more likely to have a current diagnosis of major depression (P = .0006), while males were more likely to have a current substance use disorder (P = .03). The prevalence of dementia increased with each successive decade above 60, while the occurrence of bipolar and adjustment disorders was confined to younger geriatric patients. Elderly patients receiving psychiatric treatment in the clinic thus formed a heterogeneous group. Gender, age, and presence of a psychiatric history were all associated with differences in prevalence and distribution of various mental disorders in this geriatric psychiatry outpatient clinic.     

A successful treatment of drug-resistant depression with electroconvulsive therapy

A woman aged 56 had been treated at the age of 23 for a psychotic depression with vital characteristics in the context of a bipolar disorder. The treatment included electroconvulsive therapy (ECT). From the age of 47, she suffered relapses; drug treatment proved inadequate. For the last 3 years, ECT was administered, which resulted in a good condition. ECT is an effective treatment in patients with depression resistant to medication. However, in spite of continuation pharmacotherapy, the proportion of patients relapsing within 6 months after successful ECT is large. For these patients, continuation ECT may be an efficacious method.     

Clinical characteristics of unipolar and bipolar depression

INTRODUCTION: In the last decades affective disorders were divided into unipolar and bipolar and this division has been generally accepted. The bipolar type is manifested by mania or by both mania and depression. On the other hand, unipolar affective disorders are manifested only by depression. In numerous investigations authors have noticed that there are very distinctive differences between these two types of depressive disorders such as: course of illness, personality disorders, sex, family history etc. Nevertheless, in practice it is often very difficult to make the right diagnosis. The bipolar type often starts with a few pure depressive episodes and sometimes mania occurs a few years later so only at that point the psychiatrist can make the right diagnosis and treat the patient correctly. MATERIAL AND METHODS: This investigation comprised 50 patients hospitalized at the Psychiatric Clinic in Novi Sad during 1992-1995. The experimental group consisted of 20 patients with a bipolar affective disorder (according to ICD-X), while the control group consisted of 30 patients with clinical diagnosis of unipolar depression (intensive, without psychiatric features). Both groups of patients were weekly evaluated by Hamilton Depression Rating Scale (HDRS), whereas the initial score for all patients had to be higher than 16. RESULTS: Patients suffering from unipolar depression were older than patients with bipolar depression and there were more females in this group. There were no differences in demographic characteristics (level of education, migration, etc.), but the experimental group had a greater genetic loading for affective disorders. Unipolar depressive patients had more agitation and they were more anxious than patients with bipolar depression. DISCUSSION AND CONCLUSION: The fact that unipolar depressive patients were older than bipolar is similar to most of the results gained in this kind of investigation. On the other hand, we did not find statistical differences in the intensity of disorders, and in the literature these results are contraindicating. Numerous investigators report that bipolar depressives had a stronger genetic loading for affective disorders and our study confirms the same. All these results can help us to make the right diagnosis of unipolar and bipolar affective disorders.     

Valproate prophylaxis in a prospective clinical trial of refractory bipolar disorder

OBJECTIVE: The authors studied the efficacy of valproate plus lithium and of triple therapy with lithium, carbamazepine, and valproate in refractory bipolar illness. METHOD: The subjects were 24 bipolar outpatients who had completed an intended 3-year crossover study comparing lithium, carbamazepine, and their combination. Patients entered a 1-year phase of valproate plus lithium because of inadequate response or major side effects, and patients with inadequate responses were offered an additional year of treatment with all three mood-stabilizing drugs. RESULTS: Six (33%) of the 18 evaluable patients had moderate to marked responses to valproate plus lithium; four of these six had not responded to any previous treatment condition. Three of seven patients responded to triple therapy, although only one response was marked. CONCLUSIONS: Some outpatients with bipolar disorder refractory to lithium and carbamazepine received clinically relevant prophylactic benefit from valproate when used with lithium or in triple therapy.     

Unipolar versus bipolar hemiarthroplasty for the treatment of femoral neck fractures in the elderly

This paper presents the short term results of an ongoing prospective randomized trial comparing a cemented unipolar with a cemented bipolar hemiarthroplasty for the treatment of displaced femoral neck fractures in the elderly. Forty-seven patients with an average age of 77 years completed 6-month followup. Outcomes at 6 weeks, 3 months and 6 months were assessed by completion of a patient oriented hip outcome instrument and by functional tests of walking speed and endurance. No differences in the postoperative complication rates or lengths of hospitalization were seen between the two groups. Patients treated with a bipolar hemiarthroplasty had greater range of hip motion in rotation and abduction and had faster walking speeds. However, no differences in hip rating outcomes were found. These early results suggest that use of the less expensive unipolar prosthesis for hemiarthroplasty after femoral neck fracture may be justified in the elderly.     

Depression of young and elderly patients

OBJECTIVE: To compare the presentation and outcome of depression between young and elderly patients. DESIGN: The clinical presentation, treatment and outcome of 47 young patients (21 to 64 years) were compared with 58 elderly (65 years and older) patients admitted to a general hospital psychiatric ward for the treatment of depressive disorders (based on ICD-10). SUBJECTS: There was no significant difference between the sexes in each age group. The majority of the elderly were either widowed (36%) or married (53%) while 45% of the young were single and 51% married. Seventy per cent of the elderly had retired while 64% of the young were in full-time employment. Most patients lived with their families (87% young and 96% elderly). All but one elderly suffered at least one physical disorder with two-thirds having two or more physical disorders; this contrasts greatly to young patients who were physically healthier (p < 0.001). RESULTS: In clinical presentation and symptomatology, the young patients had significantly more suicide ideation (p < 0.003) and psychomotor retardation (p < 0.001) but there was no difference in suicidal attempt, delusion, hallucination or agitation. More young patients (36%) had a past psychiatric illness (often depressive disorders) than elderly patients (8%) (p < 0.001), more elderly patients (88%) were treated with antidepressants than the young patients (62%) (p < 0.002). At one year follow-up, more elderly patients (46%) recovered compared with the young patients (23%) (p < 0.05). CONCLUSION: There were some differences in the symptomatology of depression between young and elderly patients, but the prognosis was better for elderly patients.     

Tooth recontouring/reshaping a must in the preparation for removable partial denture

OBJECTIVE: To assess the extent of functional and vocational rehabilitation achieved by elderly inner-city patients sustained on maintenance hemodialysis. DESIGN: Inception cohort study of elderly patients who have end-stage renal disease using a modified Karnofsky rating system. The need for a wheelchair, participation in household activities, and effect of comorbid conditions were noted. Current status was compared with patient's recollection of functional activity level 2 years before commencing maintenance hemodialysis. SETTING: Seven outpatient, hospital-affiliated and private hemodialysis units in Brooklyn, NY. PATIENTS: One hundred four patients aged 65 years or older who were receiving maintenance hemodialysis for at least 6 months. MAIN OUTCOME MEASURES: A score of 76 or greater on a modified Karnofsky scale indicated independent function at a level that permitted participation in activities beyond those mandated by the hemodialysis regimen. A comorbidity score 6 or greater on a newly constructed index correlated with severe debility. Employment status was also recorded. RESULTS: Present functional activity had deteriorated to a modified Karnofsky score of 66 +/- 12.3 (+/- SD) compared with patients' recollection of a mean score of 84 +/- 14.3 (P < .001) 2 years before initiation of hemodialysis. Diabetic patients had a lower score than nondiabetic patients. The mean comorbidity index of the entire study group was 7.8 +/- 2.9 (mean +/- SD). Within the diabetic subset, severe debility constrained 71 patients (68%) to limit all activity to their residence with the exception of travel to and from their dialysis facility. By contrast, 2 years prior to commencing dialytic therapy, 81 diabetic patients (78%) had interests and activities that took them outside their homes (P < .001). Generalized weakness was the most common explanation given for the lack of outside activity by nine patients (9%) who were wheelchair bound. Erythropoietin, though regularly administered to 87 patients (84%) in the study group, was unsuccessful in raising mean hematocrit reading above 0.28 +/- 0.05 (mean +/- SD). CONCLUSIONS: Maintenance hemodialysis does not return inner-city elderly patients to their predialysis level of functioning. Few elderly, diabetic hemodialysis patients conduct any substantive portion of their lives outside their homes. For nondiabetic patients, the modified Karnofsky score of whites (70.4 +/- 11.9) and blacks (66.5 +/- 15.3), though low, was equivalent (P < .4).     

Effect of continuation treatment on residual symptoms in late-life depression: how well is "well"?

The objectives of this report were (1) to describe residual depressive symptoms in elderly patients during continuation therapy with combined nortriptyline and interpersonal psychotherapy; (2) to determine which symptoms were persistent; (3) to determine the clinical correlates of residual depressive symptoms; and (4) to document distinct response pattern clusters during combined continuation therapy. METHOD: Box plot analyses of Hamilton depression scores and Global Assessment Scale scores, repeated twice monthly over 4 months, were conducted using data from 105 elderly depressives. Temporal trends in the data were examined via random regression analysis. Individual trajectories for each of the 105 patients were examined for patterns of response during continuation therapy. RESULTS: We observed a low mean Hamilton rating of 7 (SD = 2.3) at the start of continuation therapy and 5 (SD = 3.0) at the end. Both Hamilton and GAS scores showed modest but significant improvement over time. Hamilton variability was most apparent in symptoms of mood lowering, apathy, anxiety (psychological and somatic), feelings of guilt, anergia, insomnia, and loss of libido; other symptoms (retardation, agitation, hypochondriasis, loss of appetite, loss of weight, suicidal ideation, and loss of insight) showed clear resolution. A diagnosis of RDC situational depression was associated with higher levels of residual symptoms, while level of chronic medical burden, personality dysfunction, and social support were not. Examination of response patterns showed that a quarter of patients experienced one or more brief symptomatic exacerbations. CONCLUSION: On average, an excellent level of symptom resolution was achieved for most patients with Hamilton scores comparable to those seen in healthy elderly controls. These data support a position of therapeutic optimism in late-life depression and underscore full remission as an achievable therapeutic goal.     

Analysis of mutations in the thymidine kinase gene of varicella zoster virus associated with resistance to 5-iodo-2''-deoxyuridine and 5-bromo-2''-deoxyuridine

The activity of monoamine oxidase (MAO) and dopamine-beta-hydroxylase (DBH), enzymes involved in monoamine metabolism, were studied in 29 bipolar patients (mean age = 33.12 years, SD = 7.27) who were treated with lithium carbonate and in 20 healthy volunteers (mean age = 30.05 years, SD = 6.04). Platelet MAO activity was higher after lithium withdrawal, whereas plasma DBH activity was lower in remitted euthymic bipolar patients compared with normal volunteers. During lithium treatment, platelet MAO activity decreased and plasma DBH activity increased compared with the lithium-withdrawal values. It was also observed that the activities of these enzymes in the bipolar patients during lithium treatment did not differ from those in the volunteers. Thus, platelet MAO and plasma DBH activities differed in unmedicated patients with bipolar affective disorder from those of healthy subjects. Treatment with lithium appeared to have a normalizing effect on MAO and DBH activity levels.     

Implications of comorbidity for genetic studies of bipolar disorder: P300 and eye tracking as biological markers for illness

In large families with affective illness, identification of a biological variable is needed that reflects brain dysfunction at an earlier point than symptom development. Eye movement disorder, a possible vulnerability marker in schizophrenia, is less clearly associated with affective illness, although a subgroup of affective disorders shows smooth-pursuit eye movement disorder. The auditory P300 event-related potential may be a useful marker for risk to schizophrenia, but a role in bipolar illness is less certain. The distribution of these two biological variables and their association with symptoms in two multiply affected bipolar families is described. In a single, five-generation family identified for linkage studies through two bipolar I (BPI) probands, 128 members (including 20 spouses) were interviewed. The 108 related individuals had diagnoses of BPI (7), bipolar II (2), cyclothymia (3), or major depressive disorder (19). Eight others had generalised anxiety (1), minor depression (5), intermittent depression (1), or alcoholism (1). Sixty-nine subjects had no psychiatric diagnosis. P300 latency (81) and eye tracking (71) were recorded from a subgroup of relatives within the pedigree. Eye tracking was abnormal in 11 of 71 relatives (15.5%) and was bimodally distributed. In these 11 relatives, clinical diagnoses included minor depression (1), alcoholism (1) and generalised anxiety disorder (1). P300 latency was normally distributed and did not differ from controls. In a second family in which five of seven siblings have BPI illness, P300 latency and eye movement disorder were found in affected relatives and in some unaffected offspring. In these large families, clinical diagnoses of general anxiety, alcoholism and minor depression, when associated with eye tracking abnormality, may be considered alternative clinical manifestations of the same trait that in other relatives is expressed as bipolar illness.     

Postperceptual effects and P300 latency

BACKGROUND: Structural and functional brain changes have been described in elderly patients with unipolar affective disorder. Changes appear to be more marked in patients with late-onset depression, but the reversibility of such changes after clinical recovery is not known. METHODS: Magnetic resonance imaging, electroencephalography (EEG), and cognitive tests were performed in 23 elderly patients (mean age 66.5 years) clinically recovered from major depression. Twelve had late-onset depression (first episode over 55 years of age); 11 had early onset (first episode before 50 years). EEG and cognitive testing were also performed on 15 control subjects. RESULTS: Patients with late-onset depression had larger third and lateral ventricles, increased ventricular-brain ratio, and greater frequency and severity of subcortical white matter lesions than those with early onset. There was no difference between early- and late-onset patients in EEG and cognitive measures, but compared with controls patients showed significant changes in EEG evoked potentials and increased slow-wave activity, slowed reaction times, and global impairments in cognitive function. CONCLUSIONS: These results suggest that structural changes are greater in patients with late-onset depression, and that EEG and cognitive impairments persist after recovery, regardless of age of onset of depression, and are independent of structural changes.     

Prolonged mivacurium infusion in young and elderly adults

PURPOSE: This study was designed to evaluate pharmacodynamically and pharmacokinetically if the cis-cis isomer of mivacurium contributed to neuromuscular block during prolonged infusions lasting more than four hours in young adult and elderly (> 60 yr) patients. METHODS: The mechanomyogramic neuromuscular response of the adductor pollicis was recorded in 32 adults 18-59 yr. and 19 elderly (> 60 yr.) patients during N2O:O2:opioid anaesthesia. The mivacurium infusion rate was adjusted to maintain single twitch depression at 95 +/- 4% of control. Blood samples were taken every 30 min to determine the plasma concentration of cis-cis isomer of mivacurium. At the end of the surgical procedure, patients were allowed to recover spontaneously to at least 25% of control twitch response. RESULTS: The mean mivacurium infusion requirement to maintain 97 +/- 1 (mean +/- SD)% depression of the twitch response was 6.0 +/- 0.4 micrograms.kg-1.min-1 in young adults, and 4.3 +/- 0.3 micrograms.kg-1.min-1 in elderly patients (P < 0.001). The infusion requirement in patients with low plasma cholinesterase activity was the lowest 2.4 +/- 1.2 micrograms.kg-1.min-1. Plasma cis-cis isomer concentrations reached peak levels within one-two hours and remained relatively constant throughout the duration of infusion even in patients with low cholinesterase activity. There was no relationship between duration of infusion, plasma concentrations of cis-cis isomer and the early recovery indices of mivacurium (up to 25%). Neuromuscular transmission recovered adequately with or without antagonism in all patients. CONCLUSION: When the mivacurium infusion was titrated to maintain 95 +/- 4% twitch depression, the plasma concentration of the cis-cis isomer did not increase during prolonged infusions (four hours) and neuromuscular transmission recovers satisfactorily.     

Autonomic dysfunction in patients with dementia of the Alzheimer type

Abnormalities of the noradrenergic system have been documented in the central nervous system of patients with dementia of the Alzheimer's type (DAT). To evaluate the autonomic sympathetic system in DAT, we measured lying and standing blood pressure (BP), pulse, and plasma epinephrine (E) and norepinephrine (NE) in 60 DAT patients (mean age +/- SD = 65 +/- 8 years), and 20 normal elderly controls. DAT patients had normal baseline findings (BP, pulse, NE, and E). Upon standing, plasma NE and E significantly increased in both DAT patients and controls, without group differences. However, the systolic BP response to standing was reduced in DAT patients compared with the normal controls (repeated measures ANOVA, p < 0.01). This impaired response of the systolic BP on standing was particularly evident in DAT patients with symptoms of depression. Severely impaired DAT patients did not differ in E, NE, BP, pulse, or in orthostatic changes from mild-to-moderately impaired patients. These results suggest that the sympathetic response to the stress of standing is functionally impaired in DAT. This deficit was especially evident when DAT was accompanied by depression, consistent with prior studies in non-demented depressed patients.     

Comparative studies of the biological distinction between unipolar and bipolar depressions

Although unipolar depression and bipolar depression are considered distinct entities both by clinicians and researchers, it is not clear whether a pathophysiological distinction, which is the bridge between etiology and treatment, exists between these two conditions. The objective of this paper was to systematically review the studies that examined the biological differences between unipolar and bipolar depression. Using computerized Medline and manual searches, we located and reviewed studies that directly compared patients with unipolar depression with bipolar depressed patients on at least one biological variable. The results showed that patients with bipolar depression had lower levels of urinary NE and its metabolites and lower platelet MAO activity, and higher platelet free and stimulated intracellular calcium levels compared with unipolar depressed patients, but none of the variables examined appeared to differentiate the two groups consistently. We discuss some of the methodological flaws that might have contributed to this, and suggest that further studies should control for such confounding variables.     

Hypothalamic-pituitary-adrenal axis activity in depressive illness. Its relationship to classification

Serum cortisol response to the 1-mg overnight dexamethasone suppression test was studied in 221 depressed patients and 109 nondepressed psychiatric controls. Nonsuppression distinguished patients with primary unipolar depression (65/146) from patients with secondary unipolar depression (0/42) and nondepressed controls (0/109). Furthermore, nonsuppression distinguished the three familial subtypes of primary unipolar depressive illness: familial pure depressive disease (FPDD; 38/50 patients), sporadic depressive disease (SDD; 24/55 patients), and depression spectrum disease (3/41 patients). Moderate elevations in baseline serum cortisol levels were found in FPDD, SDD, and bipolar depression. Medication did not affect the results. The data suggest that the depressive syndrome is composed of separate illnesses, each of which has a distinctive pattern of hypothalamic-pituitary-adrenal axis activity during the depressed state as well as a specific clinical and familial psychiatric history.     

Effect of acute exposure of the organophosphate insecticide Rogor on some biochemical aspects of Clarias batrachus (Linnaeus)

The prevalence of DSM-IV atypical depression and comparisons between atypical and typical depression were studied in 203 consecutive unipolar and bipolar depressed outpatients presenting for treatment of depression in private practice. The prevalence of atypical depression was 31%. Of the variables investigated (unipolar/bipolar diagnosis, age at baseline/onset of first major depressive episode, gender, psychosis, comorbidity, chronicity, duration of illness, recurrence, and severity), a bipolar II diagnosis was significantly more common, the age at baseline and duration of illness were significantly lower, and the proportion of females and psychiatric comorbidity were significantly higher in atypical versus typical depression. Secondary analysis showed that bipolar II atypical depression had a significantly earlier age at baseline/onset and affected more females, but there were no other significant differences versus typical depression. The findings suggest important clinical differences between atypical and typical depression, and a bipolar II subtype may be separated from the broad category of atypical depression.     

Triacetyluridine (TAU) decreases depressive symptoms and increases brain pH in bipolar patients.

Eleven patients with bipolar depression were given doses of up to 18 g per day of triacetyluridine (TAU) over 6 weeks to test the effect of uridine on symptoms of depression via Montgomery-Asberg Depression Rating Scale (MADRS; Asberg, Montgomery, Perris, Schalling, & Sedvall, 1978) scores and on cellular bioenergetics using phosphorus magnetic resonance spectroscopic imaging (31P-MRSI). All patients and comparison participants (n = 9) completed baseline 31P-MRSI scans, and 9 patients completed posttherapy scans. The percentage changes for MADRS scores (Week 2, -23.8; Week 3, -34.9; Week 4, -42.5) and the time effects of TAU on MADRS scores (Week 2, z = -2.07, p = .039; Week 3, z = -4.28, p     

Prognostic value of ECG changes detected by Holter monitoring in silent ischemic heart disease in the aged

Ischemic Cardiomiopathy (IC) is the main cause of morbidity and mortality in the elderly and its incidence increases progressively with age. Holter monitoring (HM) is used to study IC which reveals asymptomatic ischemic episodes identifiable with the depression of the ST tract. It has been demonstrated that these electric manifestations have the same unfavourable diagnostic value as those accompanied by pain. In order to evaluate the prevalence and prognostic significance of episodes of silent myocardial ischemia in the elderly patient, we examined 99 consecutive patients with stable clinical symptoms of myocardial ischemia and a positive ergometric test (ET). The patients were randomly divided according to age (< or = 65 years, >65 years) into two groups with homogeneous clinical feature, except for a higher prevalence of women in the second group. The HM analysis, carried out for 24 hours during common every day activities and after suspending anti-ischemic therapy, showed that 62 patients (63%) had 289 episodes of electric ischemia; 216 (75%) of these were asymptomatic, and, in the group of elderly there was a higher incidence of ST depression unaccompanied by pain (A vs B = 86 vs 132 episodes, p < 0.001). Comparing the patients with and without anamnestic evidence of myocardial infarction it was found that the first group presented a higher prevalence of ST depression both asymptomatic and symptomatic (147 vs 71 silent episodes, p < 0.001, and 49 vs 24 symptomatic episodes, p = 0.015 respectively), while no statistically significant differences were found between the two age groups. Electric alterations of the asymptomatic ischemic kind were more often found in subjects with stable angina, above all if elderly; this is important from a prognostic point of view as few elderly patients are capable of performing a maximal TE and it is thus significant of reduced coronary reserve. From our data we observed that in patients with stable angina, especially if elderly, Holter revealed asymptomatic ST depression analyzed considering both its length and magnitude, is able to give prognostic evidence of subsequent coronary events.     

Target-controlled inhalation anesthesia or computer-controlled quantitative inhalation anesthesia

Teniposide (VM26) has been claimed to be active with a moderate toxicity in elderly patients affected by small-cell lung cancer (SCLC). Twenty-two patients with SCLC older than 65 years received VM26 as first-line chemotherapy at a dose of 60 mg/m2 on 5 consecutive days every 3 weeks. Age distribution ranged from 67 to 80 years (median 72 years). Fourteen patients were men and eight were women. Twelve patients had limited disease (LD) and ten extensive disease (ED). One patient (LD) had a complete response, and four (3 LD, 1 ED) achieved a partial response for an overall response rate of 22.7% (95% CI 6-40%). The most frequent toxicity was myelosuppression: 20 and 15% of patients had grade 3 leukopenia and thrombocytopenia, respectively. Our results seem to suggest that VM26 by this schedule is moderately effective in elderly patients with SCLC, and it cannot be recommended as a routine treatment.     

MRI signal hyperintensities in geriatric depression

OBJECTIVE: The authors rated periventricular and subcortical signal hyperintensities on magnetic resonance imaging (MRI) scans in elderly patients with depression and in normal subjects with similar demographic features to examine whether such changes discriminate patients with depression from normal subjects and whether they are associated with any clinical variables. METHOD: Two established hyperintensity rating systems were used to compare the MRI brain scans of 48 elderly patients with depression diagnosed according to DSM-III-R with the scans of 39 normal elderly subjects. RESULTS: Elderly depressed patients manifested significantly more severe hyperintensity ratings in the subcortical gray matter than age-matched comparison subjects. Significant differences were not identified between patients with similar current ages and cerebrovascular disease risk who had early-onset or late-onset depression. CONCLUSIONS: These findings support those of neuroimaging studies implicating the basal ganglia in depression and geriatric depression. The data suggest that the relationship observed in some reports between late-onset depression and MRI hyperintensities is most likely a function of cerebrovascular disease risk and age.