International Journal of Geriatric Psychiatry

Schneider, L. S.; Sobin, P. B.

doi: 10.1002/gps.930061003pmid: N/A

Both neuroleptic and non‐neuroleptic medications are widely used to treat symptomatic behaviors in dementia patients. There is a substantial body of literature suggestig that neuroleptics are modestly effective in treating these symptoms, but the magnitude of their effect is limited. Non‐neuroleptic medications such as anticonvulsants and antidepressants have been advocated as useful in treating certain symptoms but have not been as well studied. This article critically reviews the published evidence for the effectiveness of selected non‐neuroleptic medications in treating behavioral symptoms in elderly dementia patiens, especially those with possible Alzheimer' disease. The medications reviewed include lithium, β‐adrenergic blockers, trazodone, carbamazepine, buspirone, I‐deprenyl, and serotonin uptake blockers, reflecting the point of view that pharmacological approaches to the problem of agitation in dementia have included a variety of psychotropic medications. Most of these medications were not tried specifically with Alzheimer' disease patients, however, but in patients with various organic mental syndromes. The literature consists almost entirely of clnical series and case reports, making interpretations of the efficacy of individual medications difficult. With the singular exception of the serotonin uptake blocker citalopram, the few placebo‐controlled studies are of small sample sizes, showing at best very modest efficacy for the study medication. Despite their widespread use, there is very little published empirical evidence for the effectiveness of these novel treatments for treating behavioral symptoms in elderly dementia patients.

Förstl, Hans; Burns, Alistair; Jacoby, Robin; Eagger, Sarah; Levy, Raymond

doi: 10.1002/gps.930061004pmid: N/A

Sixty patients with senile dementia of the Alzheimer type (DAT) and 30 age and sex‐matched healthy controls were examined by cranial computed tomography (CT). We undertook this study to evaluate a simple and unbiased quantitative method for the estimation of ventricular and subarachnoid spaces by measuring areas of defined Hounsfield units (HUs) in four symmetric quadrants: left and right anterior, left and right posterior. The DAT patients showed a significant enlargement of all ventricles and all measured subarachnoid spaces (p< 0.001). These effects were not related to the age but to the diagnosis. They correlated with the duration of disease and partly with the degree of global cognitive impairment. Seventy‐eight per cent of the patients and controls could be classified correctly by means of the planimetric measurements.

Förstl, Hans; Burns, Aliatair; Jacoby, Robin; Eagger, Sarah; Levy, Raymond

doi: 10.1002/gps.930061005pmid: N/A

The radiodensity of the total intracranial area and of the dorsomedial thalamic nuclei were significantly lower in 60 patients with moderate to severe dementia of the Alzheimer type (DAT) compared to 30 healthy age and sex‐matched controls (p<0.02). The radiodensity of the caudate nuclei was similar in the DAT and the coantrol these effects did not exhibit significant correlations with age, duration of illness or global cognitive impairment. The denstitometric parameters discriminated 78.4% of patients and controls; together with the olanimetric measurements 84.4% of the individuals were classified correctly. A potential contribution of white matter shrinkage to ‘cortical atrophy’ and the possible role of thalamic degeneration in DAT are briefly discussed.

Cooper, James K.; Mungas, Dan; Verma, Maxine; Weiler, Philip G.

doi: 10.1002/gps.930061006pmid: N/A

Memory loss is the hallmark of Alzheimer' disease. However, psychotic symptoms have also been reported. We studied the prevalence of hallucinations and delusions in 677 subjects with probable Alzheimer' disease. Data were collected in six centers and analyzed retrospectively. A two‐stage, multivariate approach was used. The overall prevalence of these psychotic symptoms was 31%. The prevalence of hallucinations was 17%, and of delusions 26%. Both were associated with emotional incontinence, insomnia and agitation as well as with advanced disease. While psychotic symptoms were more prevalent in advanced disease, nonetheless they occurred with notable frequency in early disease. Of subjects with early AD (MMSE scores between 21 and 30), 6% had hallucinations and 17% had delusions. Alzheimer' disease must be considered in the differential diagnosis of any subject over 55 presenting with these psychotic symptoms.

Lindesay, James; Briggs, Kate; Lawes, Matthew; MacDonald, Alastair; Herzberg, Joe

doi: 10.1002/gps.930061007pmid: N/A

This study reports a cross‐sectional comparison between three continuing care facilities for severely disturbed elderly demented people: two mental hospital psychogeriatric wards and a unit run according to the domus philosophy of care. The domus was characterized by greater expectations for residents' functioning, policy choice, resident control and availability of social and recreational activities. The level of staffing was higher on the domus than on the two wards. The residents on the three settings were broadly comparable with regard to age, diagnosis, length of stay, objectively assessed cognitive impairment and depression, but the domus residents were rated by the staff as less disabled in self‐care tasks, orientation and communication. Direct non‐participant observation using the Short Observation Method demonstrated significantly higher levels of activities and staff‐resident interaction on the domus compared to the hospital wards. There were no differences between the settings with regard to staff absenteeism, job turnover or psychological impairment, but the domus staff expressed higher levels of job satisfaction. These findings are discussed in the context of the limitations of study design and method.

Calder, Sheila A.; Ebmeier, Klaus P.; Stewart, Lesley; Crawford, John R.; Besson, John A. O.

doi: 10.1002/gps.930061008pmid: N/A

Stress scores were elicited from relatives living with Parkinsonian patients and correlated with various aspects of the patients' impairment. The (usually female) relatives looking after male patients reported higher levels of stress than husbands looking after their wives. In general, the best predictor of relatives' stress was the behavioural rating scale of the CAPE and a reported selfcare scale designed for the study. The relative contribution of Parkinsonian motor impairment and cognitive impairment to relatives' stress scores was examined. While motor impairment was still associated with relatives' stress after controlling for sex and cognitive deterioration, both dementia and cognitive impairment measured by the Mini‐Mental State Examination were not associated with relatives' stress if Parkinsonian disability was controlled for.

Victor, Christina R.

doi: 10.1002/gps.930061009pmid: N/A

Community care has been the main policy for the care of frail elderly people in Britain in the postwar period. Currently most care is provided by the informal sector, with state domiciliary services playing a residual role. In long‐term hospital beds or residential/nursing homes, institutional care is received by only a minority of elderly and has a very poor public image. One hundred and thirty‐nine medical and nursing hospital staff in an inner London health district were surveyed about (a) their knowledge of elderly people and (b) their views on the care of the frail elderly. Respondents overestimated the proportion of elderly in the general population and the proportion receiving community care services. Community care as opposed to institution care was the respondents' favoured general policy option. However, when presented with different types of frail elderly varying responses were elicted. For personal care tasks the family was seen as the most appropriate provider; state domiciliary services were seen as appropriate for house care tasks and incontinence. For severe dementia institutional provision and domiciliary services and not the family were the favoured care option. This illustrates that the frail elderly are not a homogeneous group and policies for their care must recognise the diversity of needs which this group presents.

Shah, A. K.; Cope, H.

doi: 10.1002/gps.930061010pmid: N/A

With the aid of a case report the efficacy of intravenous diazepam in depressive stupor for diagnostic and therapeutic purposes is described. This may enable use of conventional drug treatment and postpone or avoid use of electroconvulsive therapy.