Cultural modification of neuropsychiatric assessment: complexities to consider.

Cognitive screening tests are culture bound and have been shown to perform differently depending on the culture, even with adequate translation. Khan et al examine in detail ways in which the Montreal Cognitive Assessment (MoCA) has been modified for different languages and cultures and produce a systematic guide for future modifications. However, questions arise regarding the availability of the MoCA. Other important issues in the transcultural use and modification of neuropsychiatric tests include providing a culturally safe context for testing, understanding the cultural context in which screening takes place and assessing other neuropsychiatric conditions, which may manifest differently in different cultural contexts and which affect cognition.

Performance of the Cognitive Performance Scale of the Resident Assessment Instrument (interRAI) for Detecting Dementia amongst Older Adults in the Community.

The Cognitive Performance Scale (CPS) in the widely used interRAI suite of instruments is of interest to clinicians and policy makers as a potential screening mechanism for detecting dementia. However, there has been little evaluation of the CPS in home care settings. This retrospective diagnostic study included 134 older adults (age ≥ 65) who were discharged from two acute psychogeriatric inpatient units or assessed in two memory clinics. The reference test was a diagnosis of clinical dementia, and the index test was interRAI CPS measured within 90 days of discharge. The overall accuracy of the CPS was good, with an area under the Receiver Operating Characteristic curve of 0.82 (95% CI = 0.75-0.89). The optimal cut point was 1/2, coinciding with the recommended cut point, with good sensitivity (0.90, 95% CI = 0.81-0.96) but poor specificity (0.60, 95% CI = 0.46-0.72). Positive predictive value improved from 0.72 (95% CI = 0.66-0.78) to 0.89 (95% CI = 0.75-0.96) when using a cut point of 2/3 instead of 1/2. If the results of the present study are replicated with more generalisable interRAI samples, older adults with a CPS of 3 or above, but without a formal diagnosis of dementia, should be referred for further cognitive assessment.

Development of an autobiographical memory test for older electroconvulsive therapy candidates.

OBJECTIVES: To develop a test of autobiographical memory for monitoring of older people during a course of electroconvulsive therapy (ECT). METHOD: A list of events commonly experienced in later life was gathered from older people (n = 26) at a psychogeriatric day clinic and from psychiatrists (n = 23) who work with older depressed patients. The most common events were chosen as question domains for an autobiographical memory interview. This was piloted with 12 severely depressed older patients. RESULTS: A list of 15 common life events was developed. After pilot testing, a final 30-item questionnaire covering six common life events was proposed. CONCLUSION: This study developed an autobiographical memory test with good face validity and potential for clinical use. It was modelled on a well-validated scale (The Columbia University Autobiographical Memory Interview, CUAMI-SF) and represented a useful first step in the development of a test for memory loss in older patients receiving ECT. The proposed test may be particularly sensitive to autobiographical memory loss in older people undergoing ECT because it uses recent personal memories, which are relatively commonly experienced in the older depressed population.

Prescribing trends and safety of clozapine in an older persons mental health population.

OBJECTIVES: To provide additional data concerning the safety, effectiveness and local prescribing trends of clozapine in elderly patients. DESIGN: Retrospective observational case-series analysis. SETTING: Data were collected from the medical files of 167 patients prescribed clozapine. PARTICIPANTS: All patients prescribed clozapine in the last 15 years by the psychogeriatric service in Christchurch, New Zealand. The subjects were mostly aged over 65; however, patients under 65 are also accepted into the service on a case by case basis if they have an age-related health condition. RESULTS: Twenty-five (15.0%) patients had their clozapine stopped due to a significant adverse reaction, including eleven who developed significant neutropenia. Seventy-four (44.3%) of the patients had no recorded side effects at all. Sixty-five (38.9%) of our elderly patients died while taking clozapine, though none of these deaths was felt to be related to clozapine use. Several patients safely initiated clozapine in either their own home or a nursing home without requiring hospital admission. Only two patients ceased clozapine due to ineffectiveness, and one hundred, forty-two (86.1%) of the patients had positive comments in their medical record regarding the benefits of clozapine for their particular case. CONCLUSIONS: We found clozapine could be used safely and effectively in our patient group, for a wider range of indications and at lower doses than younger patients. Data collection regarding cause of death in elderly patients who were ever prescribed clozapine was problematic, and more research into this area is required.

Perceptions of a cognitive rehabilitation group by older people living with cognitive impairment and their caregivers: A qualitative interview study.

Cognitive rehabilitation has been developed to improve quality of life, activities of daily living and mood for people with cognitive impairment, but the voice of people with cognitive impairment has been underrepresented. This study aimed to understand the experience of people living with cognitive impairment, as well as their caregivers who took part in a cognitive rehabilitation intervention programme. Twelve individuals with cognitive impairment and 15 caregivers participated in individual qualitative interviews. The interview data were analysed in three steps: 1) familiarisation of the transcripts; 2) identification of themes; 3) re-interpretation, refinement and integration of themes with methodological auditors. Both participants living with cognitive impairment and caregivers valued the comfortable environment with friendly, caring and supportive group leaders who taught practical tips and strategies. The participants living with cognitive impairment enjoyed socialising with like others. Caregivers benefited from learning about memory problems and sharing their challenges with other caregivers. The participants living with cognitive impairment emphasised the benefits of relational and practical aspects, whereas the caregivers valued the informational and emotional support. In conclusion, both participants living with cognitive impairment and caregivers found the cognitive rehabilitation group useful.

Should a CT Head be a standard part of the diagnostic process for dementia in New Zealand?

Timely diagnosis of dementia is being encouraged in both primary and secondary care settings in New Zealand via the creation and promotion of internet-based dementia clinical pathways. There is no national consensus about the circumstances in which neuroimaging should be recommended and funded within these pathways. This lack of agreement is driven by uncertainty about the rationale for neuroimaging in the diagnosis of dementia as well as the costs involved. This paper summarises all relevant international guidelines to inform a recommendation that a CT Head should be routine in the dementia work up in the New Zealand setting.

Convergent Validity, Concurrent Validity, and Diagnostic Accuracy of the interRAI Depression Rating Scale.

AIMS: Depression Rating Scale (DRS) is one of the clinical outcome measures of the International Resident Assessment Instrument (interRAI) assessment. The primary aim of this study is to investigate the diagnostic accuracy and concurrent validity of the 3-day assessment window version of the DRS. METHODS: The performance of DRS was compared with a gold standard clinical diagnosis of depression in 92 patients (age ≥65) who had interRAI version 9.1 Home Care assessment completed within 30 days of discharge from psychogeriatric inpatient care or memory clinic assessment. RESULTS: The DRS had poor diagnostic accuracy for depression diagnosis with an area under the curve of 0.68 (95% confidence interval [CI] = 0.57-0.77). The DRS score had a poor to moderate correlation with the Health of the Nation Outcome Scale 65+ depression item score ( rs = 0.30, 95% CI = 0.09-0.48, P = .006). CONCLUSION: This study and the existing literature raise concerns that the DRS is not an adequate measure of depression.

Developing a dementia-friendly Christchurch: Perspectives of people with dementia.

AIM: Christchurch, New Zealand has a unique opportunity to potentially rebuild as a dementia-friendly city in the wake of the 2010 and 2011 earthquakes. The present study gathered insights from people with dementia about what would make it possible for them to live better in Christchurch. METHODS: Twenty-six older people living with dementia were interviewed using a semi-structured questionnaire. Interviews were transcribed for thematic analysis. RESULTS: Participants talked about the importance of being connected and engaged; of accommodation from service providers and others in the community and raising awareness of dementia, and attributes of the physical environment requiring consideration in the rebuild. CONCLUSION: The themes that emerged about what people with dementia seek from dementia-friendly communities reinforce previous research, but with an overlay of the difficulties of living in an earthquake-damaged city.

Geographic variation in psychotropic drug utilisation among older people in New Zealand.

AIM: To examine psychotropic drug utilisation in older people in New Zealand by age, sex, health board domicile and deprivation status. METHODS: A repeated cross-sectional analysis of population-based drug utilisation data stratified by age, sex, ethnicity, health board and deprivation status was conducted from 2005 to 2013. RESULTS: Psychotropic utilisation increased between 2005 and 2013 (ranging from 7.0 to 74.0%) across all the health boards. In people aged 85 years and above, the hypnotic and sedative prevalence ratio compared to the 65- to 69-year age group was 1.45 (95% CI 1.44, 1.46). Between 2005 and 2013, the antidepressants prevalence ratio increased (1.27 (95% CI 1.22, 1.33)) relative to anxiolytics. CONCLUSIONS: Overall psychotropic drug utilisation increased over time. Despite safety concerns, hypnotic and sedative utilisation increased in the oldest vulnerable group. Shifts from anxiolytics to antidepressants in some health boards were consistent with guidelines for extended indications of antidepressant drug use.

"Talking in a new way": older individuals' experiences of group work in an acute psychiatric ward.

Group work is frequently used in mental health, however qualitative studies on service-users' views are rare. Semistructured interviews explored 12 participants' experiences of a café-style social group and a mutual-aid group offered on an older persons psychiatric ward in Christchurch, New Zealand. The values of the strengths-based approach underpinning the groups were reflected back in the experience of an affirming environment, an exchange of strengths, and the capacity to change. The appeal of the café-style may be culturally specific to European women however, reinforcing the importance of an awareness of culture and diversity.

Assessment of older drivers in New Zealand: the current system, research and recommendations.

The purpose of this article is to clarify the current New Zealand driving licensing requirements for older adults and to provide practical recommendations for those health professionals who make decisions regarding driving ability in older adults. Health professionals involved in the assessment of older drivers were asked to clarify areas where more efficient use could be made of assessment resources. A review of driving literature was performed to find specific factors associated with increased risk of negative driving outcomes in older adults. Particular attention was paid to the suitability of different types of on-road assessment for certain patient groups, the effect of specific diseases and medications on driving safety, and the effect of cognitive impairment. A list of seven recommendations were compiled which include a focus on appropriate on-road driving assessment referral, driver refresher courses, cognitive screening for those presenting for licence renewal and sensitive broaching of the topic of driving cessation.

Bipolar affective disorder, type II, apparently precipitated by donepezil.

There is considerable evidence that pro-cholinergic agents can cause depressed mood. However, there are also published case reports of a rare association between cholinesterase inhibitors and mood elevation in patients with pre-existing major functional psychiatric disorders, or organic disorders other than dementia. This report adds to the literature by describing a case of mood elevation in a patient without pre-existing psychiatric disorder.