Bipolar disorder in late life: a review.

Although there is a broad base of literature on depression among elderly patients and on mania in younger patients, there is a relative paucity of information on bipolar disorder in the elderly population. While the quantities of data reflect the relative prevalences of these illnesses, there is evidence to suggest that classification of mania in the elderly with respect to age of onset, natural course, family history, and pathophysiology may be useful in understanding the heterogeneous etiologies of this syndrome. This paper presents a review of the literature on the incidence and course of illness in late-life bipolar disorder. Further, dilemmas of diagnostic classification in relation to associated risk factors will be discussed.

Connectivity and control in the year 2000 and beyond.

By now, most executives are familiar with the famous Year 2000 problem--and many believe that their companies have the situation well in hand. After all, it seems to be such a trivial problem--computer software that interprets "oo" to be the year 1900 instead of the year 2000. And yet armies of computer professionals have been working on it--updating code in payroll systems, distribution systems, actuarial systems, sales-tracking systems, and the like. The problem is pervasive. Not only is it in your systems, it's in your suppliers' systems, your bankers' systems, and your customers' systems. It's embedded in chips that control elevators, automated teller machines, process-control equipment, and power grids. Already, a dried-food manufacturer destroyed millions of dollars of perfectly good product when a computer counted inventory marked with an expiration date of "oo" as nearly a hundred years old. And when managers of a sewage-control plant turned the clock to January I, 2000 on a computer system they thought had been fixed, raw sewage pumped directly into the harbor. It has become apparent that there will not be enough time to find and fix all of the problems by January I, 2000. And what good will it do if your computers work but they're connected with systems that don't? That is one of the questions Harvard Business School professor Richard Nolan asks in his introduction to HBR's Perspectives on the Year 2000 issue. How will you prepare your organization to respond when things start to go wrong? Fourteen commentators offer their ideas on how senior managers should think about connectivity and control in the year 2000 and beyond.

Spontaneous CSF communication to the middle ear and external auditory canal. A case report.

A 27-year-old female with no history of trauma, surgery, infection, or neoplastic process was evaluated for the spontaneous onset of vomiting, headache, and loss of balance. Initial studies demonstrated extensive pneumocephalus. CT revealed a lytic, expansile defect of the right petrous bone, while intrathecal contrast images demonstrated flow of CSF that implied coincidental perforation of the tympanic membrane. MR imaging demonstrated a continuity of CSF signal. The patient underwent surgery to repair the CSF leak and a dural patch was applied. No symptoms of pneumocephalus were seen after surgery and the patient's condition improved.

Neonatal hypoglycemia: CT and MR findings.

A case of neonatal hypoglycemia with extensive occipital cortical loss is presented. Imaging studies revealed a predominance of brain parenchymal loss in the occipital lobes bilaterally with nearly complete absence of cortex in the posterior parietal and occipital regions and generalized thinning of the cortex throughout the brain.

A simple and effective postangiographic femoral artery pressure dressing.

We describe a simple, inexpensive pressure dressing which supplements manual pressure and may be applied quickly and easily following femoral arterial puncture for angiography. This technique has been used on several thousand patients without complications.

Calcification of the trochlear apparatus of the orbit: CT appearance and association with diabetes and age.

OBJECTIVE: Calcification can sometimes be observed on CT scans in the region of the trochlear apparatus of the orbit, the cartilaginous structure through which the superior oblique tendon and its sheath pass. We evaluated associations of trochlear calcifications with age and diabetes. MATERIALS AND METHODS: We retrospectively reviewed CT scans of the orbit in 159 patients to identify the presence of trochlear calcifications. The presence or absence of diabetes, duration of diabetes, type of therapy, and presence or absence of neuropathy were determined from medical charts of 139 patients. We calculated the odds ratio of detecting a trochlear calcification and used logistic regression to evaluate the associations of age, sex, and diabetes with trochlear calcification. RESULTS: Trochlear calcifications were present in seven of the 24 diabetic patients and in 10 of the 115 nondiabetic patients. The odds ratio for detecting trochlear calcifications in diabetic vs nondiabetic patients was 4.3 (p < .01). Logistic regression showed univariate associations with trochlear calcification for both increasing age (p < .001) and diabetes mellitus (p < .01). The effect of diabetes on the prevalence of trochlear calcifications was seen predominantly in those less than 40 years old (odds ratio = 24.0, p = .014). Sex, duration of diabetes, insulin dependence, and neuropathy were not significantly associated with an increase in trochlear calcifications. CONCLUSION: The results show that a trochlear calcification seen on CT is a benign condition that may serve as a marker for diabetes in young patients. Trochlear calcifications are observed frequently (25-30%) in persons more than 50 years old. When it is present in patients younger than 40 years, it is strongly associated with diabetes.

Assessing competency to make a will.

The finding by a court that the author of a will (the testator) lacked mental capacity or was subject to undue influence at the time the will was executed can invalidate the will. A psychiatrist may be asked to assess the competency of a testator when he or she is planning to create or modify a will or after the death of a testator when the will is challenged. To provide guidelines for such evaluations, the authors reviewed the relevant psychiatric, forensic, and legal literature and drew on their own professional experience as well. They outline a systematic approach to the contemporaneous and retrospective evaluation of the elements that affect decisions about mental capacity and undue influence and offer suggestions for the organization and presentation of expert testimony. Awareness of the relevant legal principles and a systematic clinical approach to the assessment can maximize the quality of the psychiatric consultation and expert testimony.

Magnetic resonance imaging for stenosis and subluxation in Klippel-Feil syndrome.

Magnetic resonance imaging and radiographs in neutral flexion and extension were used to evaluate 20 pediatric Klippel-Feil patients for subluxation and stenosis. Radiographs showed subluxation of 5 mm or greater in 5 (25%) of the 20 patients for an incidence of 25%. Magnetic resonance imaging documented stenosis of 9 mm or less below C1 in 5 (25%) of the 20 patients. Cord abnormalities were discovered in three (12%) of the patients: one hydromyelia with Arnold-Chiari I malformation and diplomyelia in two. The incidence of stenosis and subluxation was higher than the literature would suggest in this pediatric population. Magnetic resonance imaging is a useful tool and should be used to evaluate Klippel-Feil patients for cord abnormalities and cord compression.

HLA antigens in depressed, demented, and nondemented elderly.

To identify HLA antigen associations with geriatric depression, the authors typed 36 elderly patients with major depression and, for comparison, 36 patients with Alzheimer-type dementia and 29 nondemented elderly controls. The frequency for antigen Aw32 was significantly higher in the group of patients with major depression (14%) than in the demented (0%) and control (3%) groups. The frequencies for antigens Aw32 (22%) and Bw51 (22%) were significantly higher in the subgroup of 23 patients with endogenous depression than in the demented (Aw32 = 0%; Bw51 = 11%) and the control (Aw32 = 3%; Bw51 = 0%) groups. Although these results were derived from a relatively small sample (n = 101) and become nonsignificant when corrected for multiple comparisons, they suggest that HLA antigen associations may be present for only certain depressive subtypes in geriatric depression.

Desipramine increases circulating growth hormone in elderly depressed patients: a pilot study.

Serial blood samples were collected from 15 elderly depressed inpatients, ages 62 to 95 years, following random assignment to a 50 mg oral test dose of desmethylimipramine (DMI) or amitriptyline (AMI). Nine female and six male subjects began the 210-min study at 0800h. Serum growth hormone (hGH), cortisol, and prolactin (hPRL) were determined by radioimmunoassay. Baseline hormone concentrations were related to self and observer ratings of anxiety and depression. There was a trend for the hGH, cortisol, and hPRL concentrations to decline during the period of study. This trend for all three hormones reversed in those subjects receiving DMI, beginning approximately 90 min after drug ingestion. The DMI-induced increase of hGH reached statistical significance at the very end of the sampling period. There was an apparent latency in the DMI-induced effect for all three hormones. There was no stimulatory effect of AMI on hGH, cortisol, or hPRL. The female subjects had higher baseline hGH levels than the men. In addition, a significant negative correlation was found between baseline hPRL levels and self ratings of anxiety.

A curriculum for education in geriatric psychiatry.

The authors present recommendations for educating medical students and psychiatric residents in geropsychiatry. They are primarily concerned with the objectives and methods rather than the content of training. Proposals are structured in terms of training objectives and educational settings in which such training takes place. The proposals are intended to be specific enough to be truly useful and at the same time sufficiently generalizable to adapt to geropsychiatric training in a variety of institutions. Priority is given to integrating knowledge of normal and abnormal aging with the clinical skills and empathy necessary to approach patients with competence and understanding.

Plasma trazodone concentrations in elderly depressed inpatients: cardiac effects and short-term efficacy.

Twenty-three depressed patients with an average age of 78.86 were treated with trazodone in dosages averaging 354.3 mg/day. Despite pretreatment cardiac conduction delay in 30%, no electrocardiographic abnormalities were produced or exaggerated during the study. Plasma steady state levels averaged 1,474.4 ng/ml and significantly correlated with dosage at r = 0.415. In a subgroup of 13 patients, six who sustained good short-term response to trazodone had lower mean steady state plasma levels than seven who did not, suggesting that plasma levels about 1,500 ng/ml may not be therapeutic in the short run.

Electroencephalographic spectra and coherence in the diagnosis of Alzheimer's-type and multi-infarct dementia. A pilot study.

The accurate diagnosis of dementia is difficult because there are no specific physiologic tests. Computer-analyzed electroencephalography (EEG) has shown promise as a tool for the differential diagnosis of dementia, but topographic methods for data collection and analysis have seldom been used. We used these methods to investigate EEG differences among three groups of elderly subjects: those with mild to moderate dementia of the Alzheimer's type (DAT), those with mild to moderate multi-infarct dementia (MID), and age- and sex-matched normal controls. The two groups of demented subjects were distinguished from the control group by a new criterion, the ratio of high-frequency to low-frequency electrical activity in the left temporal region, which was greatly diminished in demented subjects. Using this single variable, all control subjects and 15 of 18 demented subjects were correctly classified (sensitivity 83%, specificity 100%). The three misclassified subjects were among the least impaired subjects with DAT. Examination of coherence, or synchronization of the EEG signal, enabled us to distinguish subjects with DAT from those with MID. Using discriminant analysis of both EEG frequency and coherence, 92% (22/24) of subjects were accurately classified. These results justify further evaluation of topographic, computer-based EEG analysis as a test for the differential diagnosis of dementia.

Cognitive impairment in late-life depression: clinical correlates and treatment implications.

Elderly depressed inpatients with high vs. low scores on a quantitative mental status examination (the Mini-Mental State (MMS)) were compared with regard to demographic and clinical characteristics, treatment and short-term response, and functional status at 2-year follow-up. Low-MMS patients were less well educated and more likely to be delusional, anxious, and globally impaired than high-MMS patients. The two groups responded equally well to treatment, but the low-MMS group required a lengthier hospital stay and greater use of neuroleptic medications. The two groups also had similar long-term outcomes, although greater attrition was observed among cognitively impaired subjects.

Clinical tests of memory in dementia, depression, and healthy aging.

In Study 1, carefully screened elderly adults with primary degenerative dementia or major depression were compared to healthy aged control subjects on three tests of learning and memory: the Benton Visual Retention Test, Inglis Paired-Associate Learning Test, and the Fuld Object-Memory Evaluation (OME). The sharpest distinction in performance among the groups was observed on the OME, and discriminant equations based on this test correctly classified a high percentage (greater than or equal to 90%) of participants. Study 2 applied the classification rules derived in the first investigation to an unselected series of geropsychiatry inpatients referred for neuropsychological evaluation. There was agreement between memory test classification and general categories of clinical discharge diagnosis (organic vs. functional) for 21 of 25 patients, and with status at follow-up approximately 18 months later. Predictive value computations suggested that the OME is more accurate in confirming true dementia than in detecting dementia syndromes associated with functional disorders.

Acute response to methylphenidate as a predictor of outcome of treatment with TCAs in the elderly.

Acute response to a single-dose, nonblind administration of methylphenidate 20 mg predicted outcome of treatment with desipramine in 42 elderly depressed inpatients. Treatment outcome was not predicted by the methylphenidate challenge in 29 patients who received amitriptyline. These findings are consistent with Maas' biogenic amine hypothesis and are encouraging with respect to the clinical utility of the methylphenidate challenge in geriatric depression.