Risk assessment of wandering behavior in mild dementia.

OBJECTIVE: This prospective longitudinal study aims to determine the risk factors of wandering-related adverse consequences in community-dwelling persons with mild dementia. These adverse consequences include negative outcomes of wandering (falls, fractures, and injuries) and eloping behavior. METHODS: We recruited 143 dyads of persons with mild dementia and their caregivers from a veteran's hospital and memory clinic in Florida. Wandering-related adverse consequences were measured using the Revised Algase Wandering Scale - Community Version. Variables such as personality (Big Five Inventory), behavioral response to stress, gait, and balance (Tinetti Gait and Balance), wayfinding ability (Wayfinding Effectiveness Scale), and neurocognitive abilities (attention, cognition, memory, language/verbal skills, and executive functioning) were also measured. Bivariate and logistic regression analyses were performed to assess the predictors of these wandering-related adverse consequences. RESULTS: A total of 49% of the study participants had falls, fractures, and injuries due to wandering behavior, and 43.7% demonstrated eloping behaviors. Persistent walking (OR = 2.6) and poor gait (OR = 0.9) were significant predictors of negative outcomes of wandering, while persistent walking (OR = 13.2) and passivity (OR = 2.55) predicted eloping behavior. However, there were no correlations between wandering-related adverse consequences and participants' characteristics (age, gender, race, ethnicity, and education), health status (Charlson comorbidity index), or neurocognitive abilities. CONCLUSION: Our results highlight the importance of identifying at-risk individuals so that effective interventions can be developed to reduce or prevent the adverse consequences of wandering.

The use and tolerability of fluoxetine in geropsychiatric inpatients.

BACKGROUND: The efficacy and tolerability of fluoxetine were examined in 31 patients admitted to a geropsychiatric inpatient unit who were initiated and maintained on a regimen of fluoxetine. METHOD: The Hamilton Rating Scale for Depression, the Brief Psychiatric Rating Scale, the Mini-Mental State Examination, and the Rating Scale for Side Effects were administered at admission and discharge, and scores were compared using paired t tests. Two patients were withdrawn from fluoxetine prior to discharge because of side effects; their data are not included in the analysis. RESULTS: We found significant improvement both in depressive symptoms and in general psychiatric symptoms and nonsignificant improvement in cognitive function. Fluoxetine was well-tolerated, and a significant decrease in the total scores of the Rating Scale for Side Effects was found. Subgroups of older patients (mean age = 75 years), less depressed patients, and demented patients were also examined. In all three groups, we found a statistically significant improvement in depressive symptoms, general psychiatric symptoms, and total side effects. CONCLUSION: Fluoxetine appears to be an effective and well-tolerated antidepressant in elderly inpatients of varying age, levels of depression, and psychiatric diagnoses.

Super-obesity: a psychiatric profile of patients electing gastric stapling for the treatment of morbid obesity.

This is a preliminary report designed to identify personality characteristics which are unique to those super-obese electing a surgical intervention for weight loss. We have laid the groundwork to determine prognostic signs for the success or failure of the gastric stapling surgical technique for the treatment of morbid obesity, Self-report rating scales, demographic data forms, and MMPI's were administered to super-obese subjects and psychiatric consultations performed preoperatively and at various intervals postoperatively. Patients report satisfaction with their weight loss and few physical or psychological complications in the immediate post-op period. The MMPI and psychiatric consultations identify fairly high levels of psychopathology in this group. An aggregate psychiatric profile of the female and male morbidly obese patient is discussed.

The prevalence of tardive dyskinesia in geropsychiatric outpatients.

The prevalence of tardive dyskinesia was studied in a geropsychiatric outpatient clinic. All currently active patients were examined using the Abnormal Involuntary Movement Scale (AIMS) and a standardized procedure. Data were collected on a number of previously reported risk factors. A higher prevalence was noted in both tardive dyskinesia and spontaneous involuntary movement disorders in this patient population. Only sex and duration of exposure to antipsychotic drugs were noted to be significant risk factors.

The benefits of psychiatric hospitalization for older nursing home residents.

OBJECTIVE: To examine the demographic characteristics and treatment outcomes of nursing home residents admitted to a geropsychiatric inpatient unit. DESIGN: A retrospective cohort design based on an ongoing data base effort. SETTING: The geropsychiatric inpatient unit of the Houston Veterans Affairs Medical Center Hospital. PARTICIPANTS: All admissions to the unit from nursing homes during an 18-month period. MEASUREMENTS: Mini-Mental State Examination, Brief Psychiatric Rating Scale, Hamilton Rating Scale for Depression, Cohen-Mansfield Agitation Inventory, Rating Scale for Side Effects, and Global Assessment of Functioning were administered on admission and discharge. RESULTS: Paired t tests comparing change scores revealed significant decreases in general psychiatric symptoms (P < .001), depression (P < .001), and agitation (P < .001); significant improvement in global functioning (P < .001); with no significant changes in cognitive status (P = .485) or side effects (P = .120). When the patients were subgrouped according to reasons for admission, paired t tests revealed decreases in violence (CMAI Factor 1; P = .000), psychosis (BPRS thought disorder scale; P = .000 and hostility subscale; P < .008), and depression (HAM-D; P = .002). Four patients were discharged to less restrictive environments, all with chronic mental illnesses. CONCLUSION: Inpatient psychiatric hospitalization significantly benefits nursing home residents with and without dementia who are admitted for severe behavior problems.

Contribution of psychosis and depression to behavioral disturbances in geropsychiatric inpatients with dementia.

BACKGROUND: Specific behavioral disturbances in dementia may be associated with underlying disorders such as the presence of psychosis and depression. The objective of this study was to examine the association of depression and psychosis with behavioral disturbances in geropsychiatric inpatients with dementia. METHODS: All admissions between October 1993 and May 1995 were reviewed to identify those patients admitted to the Houston Veterans Affairs Geropsychiatry Unit with a diagnosis of dementia; 208 patients were included in the study. Hierarchical regression models were constructed to explore the contribution of depressive and psychotic symptoms, and depression and psychosis diagnoses to Cohen-Mansfield Agitation Inventory (CMAI) scores. RESULTS: Both depression and psychotic symptoms were significantly and positively correlated with behavioral disturbances. Psychotic symptoms were associated with aggressive behavioral symptoms, and depressive symptoms were associated with constant requests for help, complaining, and negativism. Dementia severity accounted for significant variance in CMAI scores and was positively associated with behavioral disturbance; though disorder symptoms accounted for more behavioral disturbance variance than did depressive symptoms. CONCLUSIONS: Both depressive and psychotic symptoms were associated with overall behavioral disturbances in patients with dementia. Psychotic symptoms and depressive symptoms were associated with different types of behavioral disturbances. Our findings support the contention that underlying depression or psychosis may partially account for different behavioral disturbances and that not all behavioral disturbances should be globally labeled "agitation." Future studies should address symptom-specific treatment of behaviorally disturbed patients.

Depression in male geropsychiatric inpatients with and without dementia: a naturalistic study.

The authors compared the presentation and course of major depression in male geriatric inpatients with and without a diagnosis of dementia. Of 326 consecutive admissions to an inpatient geropsychiatry unit, 22 (7%) had a diagnosis of major depression without dementia, 35 (11%) had major depression with dementia. Both groups presented with similar types and severity of depressive symptoms, which improved substantially with treatment in both groups, as measured by Hamilton Depression Rating Scale scores. In addition, agitation, psychiatric, and side-effects symptoms decreased significantly in both groups. Our naturalistic results suggest the clinical value of intensive treatment of depressive symptoms in elderly demented patients, whether or not they meet the criteria for major depressive episode.

The contribution of cognitive impairment, medical burden, and psychopathology to the functional status of geriatric psychiatric inpatients.

In order to define the contributions of cognitive impairment, medical burden, and psychopathology to the functional status of geriatric psychiatric patients, a forward-looking, retrospective study of 106 consecutive admissions to a geriatric psychiatric unit at the Houston Veterans Affairs Medical Center Hospital was done. It was found that psychopathology and cognitive status, but not medical burden, contributed to the variance in functional status of geriatric psychiatric inpatients for both admission scores and for changes in scores during hospitalization. Improvements in cognitive state and psychopathology were associated with improvements in functional status during hospitalization.

Relationship between affective disorders and Axis II diagnoses in geropsychiatric patients.

Twenty-four geropsychiatric outpatients and 52 inpatients diagnosed with affective disorders (ADs) via psychiatric evaluation were administered the Structured Interview for Disorders of Personality-Revised (SIDP-R). A chart review yielded 1-year relapse rates for the inpatient sample. Data indicate a 63% personality disorder prevalence rate for the total sample, and a 21% relapse rate for inpatients. No significant differences were found in PD rates between elderly depressed and bipolar patients, and there were no differences in relapse rates for those with and without PDs. Results were discussed in relation to the sizable frequency of PDs in this elderly sample of ADs, the possible effects of severe depression on the personality ratings of older adults, and the differential prognostic value of PDs for geropsychiatric inpatients versus outpatients.

Prevalence of personality disorders in community-living elderly.

There has been limited research on the prevalence of personality disorders in the aged. No studies have documented the extent of personality disorders in community-dwelling elderly with the use of a structured scale specifically designed to detect personality disorders and anchored to DSM-III-R criteria. One hundred male and 100 female community-living elderly (mean age, 72.1 years) were administered the Structured Interview for Disorders of Personality-Revised to compare prevalence rates for specific personality disorders with those of young adults (mean age, 41.7 years) and to identify demographic variables associated with personality disorders in the elderly. Results indicate a tendency toward fewer personality disorders in older than young adults, no differences in the frequency of personality disorders between male and female elderly, and significantly more prior mental health consultations in elderly with personality disorders than in elderly without these disorders. Aging processes and methodologic issues that could account for differences in personality disorder distribution between young and older adults are discussed. Recommendations for future research are outlined.

Prevalence of personality disorders in two geropsychiatric inpatient units.

One hundred males from a Veterans Affairs geropsychiatric inpatient ward, and 100 females from a geropsychiatric inpatient ward of a private hospital completed the Structured Interview for Disorders of Personality-Revised (SIDP-R). Chart reviews provided information including age, years of education, marital status, race, as well as Axis I and Axis II psychiatric diagnoses. Data from a young adult sample, drawn from an initial SIDP-R validation study, were used for comparison. Results indicate a 56.5% rate of personality disorders (PD) for older patients. Significantly more elderly men than elderly women were diagnosed with PD by psychiatric evaluation, and elderly men were also more likely to be diagnosed with paranoid, avoidant, and multiple PD using the SIDP-R. Psychiatrists gave far fewer Axis II diagnoses than were yielded by the SIDP-R, particularly with females. There were no significant differences in total PD rates between aged and young subjects, but older adults with PD were diagnosed less frequently with multiple PD. Older adults were also less likely to be diagnosed with the "Dramatic" cluster PD, and more likely to be diagnosed with the "Odd" cluster PD. The level of depression was related to both clinical and SIDP-R diagnoses.

Delirium in geropsychiatric patients: patient characteristics and treatment outcomes.

The authors examined the effect of hospitalization on cognitive and behavioral symptoms in delirious elderly patients with and without dementia. Forty-four (13%) of the patients admitted to a Veterans Affairs Medical Center geropsychiatric unit were diagnosed with delirium and were administered the Mini-Mental State Examination, the Hamilton Depression Rating Scale, the Brief Psychiatric Rating Scale (BPRS), the Rating Scale for Side Effects, and the Cohen-Mansfield Agitation Inventory. The total sample significantly improved on all measures. When patients with delirium were divided into subgroups with and without dementia, both subgroups improved similarly. Patients discharged to more restrictive environments improved significantly on the BPRS only.

Nonalcohol-related use disorders in geropsychiatric patients.

The authors determined the prevalence and demographic features of drug use disorders in a database of 565 veteran geropsychiatric inpatients. Twenty-four patients (4%) were diagnosed with nonalcoholic substance use disorders, including 18 (3%) with prescription drug use disorders and 6 (1%) with illegal drug use disorders. The patients diagnosed with prescription drug use disorders were predominantly Caucasian, whereas those diagnosed with illegal substance use disorders were predominantly African American. No other significant demographic differences were noted. Nonalcohol substance use disorders represent an unappreciated problem in psychiatrically hospitalized older adults, with illegal substance use disorders making up a larger than expected proportion of this group.

Outcome of psychiatric hospitalization for very low-functioning demented patients.

The authors determined the outcome of geropsychiatric hospitalization for 73 very low-functioning demented patients (GAF score < 21). General psychiatric symptoms, depression, and agitation decreased significantly, and mean GAF scores increased significantly, with no significant change in cognitive function. Psychiatric hospitalization can meaningfully improve function and quality of life even in this very impaired population. Despite these improvements many patients are discharged to more restrictive settings.

Behavioral disturbances in geropsychiatric inpatients across dementia types.

The objective of this study was to compare differences in behavioral, psychiatric, and cognitive status among geropsychiatric inpatients with Alzheimer's, vascular, alcohol-induced, and mixed dementia. Participants included 150 patients with dementia consecutively admitted to an acute geropsychiatric inpatient unit. Measures included the Mini-Mental State Examination, Cohen-Mansfield Agitation Inventory, Cumulative Illness Rating Scale, Basic and Independent Activities of Daily Living, Positive and Negative Syndrome Scale for Schizophrenia, and the Initiation/Perseveration subscale of the Dementia Rating Scale. No significant differences existed in the character or severity of agitation among patients with Alzheimer's, vascular, alcohol-related and mixed dementia. Interestingly, patients with vascular dementia compared to patients with other dementias admitted for behavioral disturbances were less cognitively impaired and more medically burdened.

Association of serum cholesterol and triglyceride levels with agitation and cognitive function in a geropsychiatry unit.

Several studies have reported an association between aggression and cholesterol levels. The purpose of this study was to investigate the relationship of serum cholesterol and triglyceride levels with aggression and cognitive function in elderly inpatients. One hundred ten patients consecutively admitted to the Geriatric Psychiatry inpatient unit at Houston's Veterans Affairs Hospital received comprehensive evaluations by a multidisciplinary team. Fasting serum cholesterol and triglyceride levels were obtained within 3 days of admission. In addition, two geriatric psychiatrists administered the Mini-Mental State Examination (MMSE) and the Cohen-Mansfield Agitation Inventory (CMAI). Correlation coefficients were calculated between lipid levels, CMAI total and subscale scores, and MMSE scores. Multiple linear-regression analyses were done to further investigate the relation between lipid concentrations and various confounders. We found no significant correlation between serum triglyceride levels and MMSE, CMAI total, and CMAI factor scores. In addition, we found a significant positive correlation between serum cholesterol levels and physical nonaggressive behavior, and a significant negative correlation between serum cholesterol levels and MMSE scores. We found no relationship between aggressive behavior and serum cholesterol or triglyceride levels. However, an association between high cholesterol levels and agitation exists, which may be mediated by the association between high cholesterol levels and impaired cognition.

A multidisciplinary ethics teaching conference on a geropsychiatric service.

This article describes an ethics case conference on a multidisciplinary geropsychiatric service, and its unique clinical, training, and research benefits. We describe the structure of the conference, the major topics addressed, the perceived advantages, and the research implications. We conclude that the care of older patients, the education of students and trainees interested in aging issues, and cutting-edge geriatric research are all advanced by such a conference.

Rehospitalization of older psychiatric inpatients: an investigation of predictors.

The purpose of this study was to identify a combination of variables that could predict rehospitalization among a sample of 150 geropsychiatric inpatients. Logistic regression analyses testing a modified model identified risk factors for geropsychiatric rehospitalization and correctly classified approximately 80% of inpatients who were rehospitalized for subsequent treatment. Patients' psychiatric diagnosis (mood or schizophrenic disorder), poor general psychiatric functioning, depressive and agitated behavior at discharge, little or no supervision in living arrangements following discharge, limited social support, change in the social support system preceding hospitalization, and maladaptive family functioning could significantly predict geropsychiatric rehospitalization. The strongest independent predictor was maladaptive family functioning.

Standards for psychological services in long-term care facilities.

Psychologists in Long-Term Care (PLTC), a national network established in 1983, has developed, with input from colleagues and consumers, standards for psychological practice in long-term care facilities. These standards address provider characteristics, methods of referral, assessment practices, treatment, and ethical issues. This article describes the document's development and offers suggestions for its use.