A longitudinal study of psychotropic prescriptions in a teaching nursing home.

This study clarifies the methodological pitfalls of using cross-sectional data to characterize episodic and continuous patterns of prescribing psychotropic medications in nursing homes. Although more than half of the residents in a teaching nursing home received a psychotropic drug during their 5 years of residence, less than one-quarter were continuously medicated. The authors conclude that although the rates of psychotropic prescriptions are an important entry point for concerns about quality and appropriateness of psychotropic administration to older nursing home residents, longitudinal studies including the prescribing pattern, indications, and efficacy are needed to determine more clinically meaningful indicators of quality care.

Zymographic techniques for detection and characterization of microbial proteases.

We have presented a variety of zymographic techniques for identification and characterization of microbial proteases, using SDS-PAGE and PAGE in nondissociating gels. Techniques are described using copolymerized protein substrates, diffusable protein substrates, protein substrates incorporated into indicator gels, as well as synthetic esterase substrates. When a newly discovered protease is being characterized, it is advisable to try a variety of techniques, both to determine optimal conditions for enzyme detection and to characterize the protease. Zymography is a versatile two-stage technique involving protein separation by electrophoresis followed by detection of proteolytic activity. Each particular combination of protease separation and detection techniques had advantages and limitations. Protease separation by SDS-PAGE has as a limitation the fact that some proteases do not renature and hence cannot be detected following treatment with SDS. However, it has an advantage the fact that it allows estimation of the relative molecular weight of proteases. Protein separation using nondissociating PAGE is performed using much gentler protease inactivation conditions than those produced by treatment with SDS. Like SDS-PAGE, nondissociating PAGE permits detection of multiple forms of enzymes; however, a disadvantage is that it cannot be used to obtain molecular weight estimates of proteases. The main variable to control during development of zymograms is the length of time of incubations. Increasing incubation (development) time generally increases the sensitivity of protease detection; however, as the length of time of incubation increases so does the extent of diffusion of proteases and substrates. If incubations are prolonged, protease bands will diffuse, decreasing resolution. Additionally, zones of lysis produced by closely migrating proteolytically active species will merge, eliminating the possibility of detecting all proteolytic species in the sample. Zymographic techniques can be extremely useful in identification and characterization of microbial proteases. If a few properties of a protease are known, such as the pH range over which the enzyme is active, and whether it can renature after exposure to SDS, zymographic techniques can be specifically and readily adapted to optimize conditions for detection and assist in characterization of the enzyme.

Pharmacologic treatment of agitation in dementia: a comprehensive review.

Agitated behaviors are a common and nearly universal occurrence among patients suffering from dementing illnesses. The pharmacologic treatments available for this troubling syndrome are varied, but treatment studies are limited. Clinicians are frequently faced with the challenging management of patients with disruptive behavior who fail to respond to trials with multiple agents. This review summarizes available treatment studies of agitation in dementia and offers a guide to therapy and management. Reports of therapies for agitation in dementia are limited by lack of controlled studies, variability of diagnostic criteria and outcome measures, and small sample size. The need for carefully designed, well-controlled studies of outcome in this growing population is formidable. It is imperative to identify effective and well-tolerated treatment strategies to reduce the morbidity of these distressing and burdensome symptoms.

St. John's wort and antidepressant drug interactions in the elderly.

There is increasing interest in and use of the herbal preparation St. John's wort. Hypericin, the major active ingredient, has many psychoactive properties. The agent is sold in the US as a nutritional supplement and is recommended for numerous conditions, including depression, anxiety, insomnia, and inflammation. We report a series of five cases of clinically diagnosed central serotonergic syndrome among elderly patients who combined prescription antidepressants with St. John's wort. Older adults are large consumers of both over-the-counter and prescription medications. They are particularly vulnerable to interactions between medications and products sold as nutritional or herbal supplements. St. John's wort requires further evaluation due to potential for drug interactions with central nervous system agents and for more definitive therapeutic indications.

The Wellness Group: a novel intervention for coping with disruptive behavior among [corrected] elderly nursing home residents.

Elderly nursing home residents face the challenge of coping with the loss of independence, reduced physical abilities, feelings of isolation, anxiety, depression, and helplessness. Maintaining one's integrity within the nursing home is a challenge easily lost. Issues of coping with disability, change in body image, the promotion of self-empowerment, and autonomy are critical to preserving the personhood of a nursing home resident. Current emphasis on the management of behavior has focused entirely on the control of disruption rather than the promotion of resident strengths and abilities. We developed a group therapy program designed to enhance self-awareness, self-esteem, and body awareness among the demented elderly. Techniques of meditation, relaxation, sensory awareness and guided imagery were introduced and reinforced. This group is easily reproducible and offers benefits to both residents and interdisciplinary staff.

Immunization with Porphyromonas gingivalis cysteine protease: effects on experimental gingivitis and ligature-induced periodontitis in Macaca fascicularis.

Targeting bacterial virulence factors such as proteases for immunization may hold the key to limiting or preventing loss of attachment and alveolar bone in periodontal disease. This study examined the clinical, microbiological, and immununological responses following active immunization with a purified Porphyromonas gingivalis cysteine protease (porphypain-2) in the nonhuman primate (Nhp) Macaca fascicularis. One group of Nhp was immunized with porphypain-2 antigen while control Nhp received placebo injections. All Nhp were subjected to experimental gingivitis followed by ligature-induced periodontitis in a split-mouth design. An enzyme-linked immunosorbent assay demonstrated that immunization elicited a significantly elevated and specific IgG antibody response to both whole cell P. gingivalis (36-fold) and to porphypain-2 (194-fold). Checkerboard hybridization DNA analysis of subgingival plaque from ligated sextants demonstrated that 25% more Gram-negative anaerobic species became significantly elevated from baseline and at earlier timepoints in the control group than in the immununized group. Immunization with this protease did not suppress the emergence of P. gingivalis. Clinical indices showed few changes related to immunization. Alveolar bone density changes demonstrated a highly significant loss in ligated sextants compared to non-ligated sextants within the control group (P < 0.001), and a smaller but significant difference within the immunized group (P = 0.043). Comparison of ligated sextants only demonstrated more bone loss in the control group versus the immunized group (-13.07+/-9.51 versus -9.41+/-6.18; computer-assisted densitometric image analysis units +/- SD); the difference approached, but did not reach, significance. The results suggest that porphypain-2 may contribute to the pathogenic potential of the subgingival plaque microbiota in the Nhp model of ligature-induced periodontitis, and that active immunization with porphypain-2 appeared capable of altering this pathogenic response.

A ten-year review of the effect of OBRA-87 on psychotropic prescribing practices in an academic nursing home.

OBJECTIVE: The Omnibus Budget Reconciliation Act of 1987 (OBRA-87) included provisions for regulating the use of psychotropic medication, particularly antipsychotics, in long-term-care facilities. The study examined the effect of OBRA-87 on patterns of prescribing of psychotropic medication in a 514-bed nursing home affiliated with a large medical school. METHODS: Computerized pharmacy records for the ten-year period from March 1984 through July 1994 were retrospectively reviewed to identify orders written for psychotropic medications and to determine the percentage of nursing home residents who received prescriptions for those agents and the average daily dose of the most frequently prescribed agents. RESULTS: During the period before implementation of the regulations, the percentages of residents who received antidepressants, anxiolytic and sedative-hypnotic medications, and antipsychotic medications were stable. After implementation, prescription of antidepressants increased significantly, coinciding with a reduction in prescription of anxiolytics and sedative-hypnotics and a substantial decrease in prescription of antipsychotics. The total number of residents who received any type of psychotropic medication decreased, and over time a trend toward prescription of agents recommended for geriatric use, such as short-acting benzodiazepines and tertiary tricyclic antidepressants, emerged. CONCLUSIONS: The changes that resulted from the OBRA-87 regulations reffect both the restrictions placed on classes of medication and the prevalence of psychiatric disorders in the nursing home. In this facility, OBRA-87 appears to have served as an impetus for clinical review and change in practice style.

Serotonin syndrome. A common but often unrecognized psychiatric condition.

This case illustrates that compliance with the basic principles of geriatric pharmacology (start low, go slow, and avoid polypharmacy) might have prevented a clinical syndrome that could have caused serious complications. Fortunately, serotonin syndrome was recognized early, the offending agents were discontinued, and supportive treatment was provided. The patient was ultimately treated with mirtazapine, an antidepressant not associated with serotonergic effects.

Suicide in late life. Identifying and managing at-risk older patients.

The patient in this case displayed multiple risk factors for suicide, including depression, loneliness following recent widowhood, use of alcohol, and distribution of possessions to other people. In retrospect, it was found that he was stockpiling old medications and refused to comply with his plan of care. The patient's outcome was tragic despite numerous attempts to provide a support system to meet his needs. Although he appeared to improve with therapy, the patient may have had a suicidal agenda that he managed to hide from everyone, including his family and multiple healthcare professionals. The patient's daughter was offered bereavement counseling services, which she appreciated.

Treatment of impulsivity and aggression in a patient with vascular dementia.

This case illustrates how treatment with divalproex sodium, an agent approved for use as an anticonvulsant and mood stabilizer, led to a reduction in overt aggression, diminished impulsivity, and improved functional status in a patient with vascular dementia. Improved receptivity to care and reduced hostility also led to an increased quality of life for the family caregivers. The daughter also benefited greatly from participation in a family support group.

Alternative medicine. Achieving balance between herbal remedies and medical therapy.

The case patient was taking multiple herbal preparations as well as the prescription hypnotic zolpidem. The combination was probably increasing the patient's confusion, agitation, and aggression. The treatment team reached a compromise with the daughter after providing her with education and support. They continued the wheat germ oil and a multivitamin supplement, which appeared safe, even if of limited value. The patient continued taking valproate, 125 mg bid, which reduced her physical aggression and improved resistance to care. All other herbal remedies and zolpidem were discontinued. Balancing traditional therapies with requests for herbal remedies is a common challenge for physicians. The most successful intervention occurs when doctors familiarize themselves with herbal preparations and educate patients and families about the treatments.

Is it Alzheimer's? Neuropsychological testing helps to clarify diagnostic puzzle.

This patient displayed a pattern of neuropsychological test results that indicated early Alzheimer's dementia. Using neuropsychological testing to make the diagnosis provided an answer for the patient, family, and psychiatrist, who all recognized a problem, and allowed for future planning. Recommendations for the patient included: psychoeducation and support for the patient and family assistance with planning for the future, including discussions of advance directives and financial management re-evaluation of the patient's ability to drive a motor vehicle a trial of a cholinesterase inhibitor such as donepezil or rivastigmine ongoing health maintenance, including periodic screening for depression and other psychiatric symptoms repeat neuropsychological assessment in 6 months to 1 year to assess rate of decline and confirm the diagnosis.

Alzheimer's disease: how to give and monitor tacrine therapy.

Up to one-third of patients with mild to moderate Alzheimer's disease may show improvement in cognitive function with tacrine, a centrally-acting, noncompetitive inhibitor of acetylcholinesterase. Candidates for tacrine must have a diagnosis of probable Alzheimer's dementia based on NINCDS-ADRDA or DSM-IV criteria and should have no history of liver disease. For patients receiving the drug, do follow-up cognitive testing with a sensitive measure such as the Alzheimer's Disease Assessment Scale. The most common adverse effects associated with tacrine therapy are elevated liver transaminases and gastrointestinal effects. Weekly blood tests are necessary to monitor liver function. A reliable caregiver is essential to ensure compliance with frequent dosing and weekly blood testing.

What should biomedical sciences education in dental schools achieve?

Education for the first professional degree in dentistry is intended to produce graduates capable of offering a wide range of high quality dental services to the general public. More than that, it is expected that graduates will be firmly grounded in the scientific basis for their professional practices and be equipped to evaluate critically and integrate selectively new scientific findings that emerge during their professional lifetimes. In addition, they are expected to be able to work effectively with diverse patient populations and to conduct their practices with a high level of sensitivity to the ethical and psychosocial dimensions of patient care. Indiana University School of Dentistry has undergone a process of curriculum reform that has yielded a new first professional degree program. Its hallmarks are large, multidisciplinary courses (seven courses in the first two years) that are taught using a variety of strategies including problem-based learning in small groups as well as lectures. The biomedical sciences curriculum is concept-based. Students will demonstrate their understanding of science concepts and methods by applying them to the solution of research and health care problems. Biomedical sciences will be taught at a level that will provide a comprehensive understanding of the functioning of the human body in health and disease, allow students to assimilate the coming revolution in molecular medicine, and selectively use new diagnostics, preventives, and therapeutics that evolve as molecular biological technologies yield solutions to current medical and dental problems. Using the biomedical sciences curriculum as a vehicle, we will also achieve the goal of training dentists as critical thinkers, problem solvers, lifelong learners, and ethical practitioners, skillful in peer and self-evaluation, and cognizant of the psychosocial as well as biomedical perspective of health and disease.

Tutor and student perceptions of the tutor's role in problem-based learning.

The role of the tutor in problem-based learning (PBL) differs dramatically from the traditional teaching role with which dental students and faculty are familiar. In this investigation, the dimensionality and complexity of the tutor role were assessed by first- and second-year dental students and by the tutors themselves using a twenty-four-item Likert-type questionnaire that served as one component of a comprehensive web-based assessment tool, the PBL-Evaluator. Evaluations were completed after each PBL case over a period of one and a half years by one class of students and for half a year by a second class. Exploratory principal components analyses of the responses to the questionnaire revealed a more complex factor structure for tutors than for students. While a five-factor solution was required for the tutors, a simpler two-factor solution sufficed for both groups of first-year students, and a three-factor solution was necessary for the second-year students. Although tutors displayed a more nuanced perspective on their performance than did students, items related to tutor modeling of professional conduct within tutorials consistently emerged as important for both.

Educating the next generation of dentists.

A new vision for dental education is being shaped by (1) future dentists' need to keep pace with rapid developments in medicine and biomedical science, and changing health-care delivery mechanisms that will transform dentistry; (2) dissatisfaction with unintended, undesirable consequences of traditional approaches to dental education that do not integrate biomedical/clinical, behavioral, ethical, and population perspectives in clinical practice, and fail to cultivate the skills and values which support lifelong learning; (3) new developments in cognitive science demonstrating learning environments' need to be more student-centered, to emphasize active learning strategies, and teach students to use the scientific method to resolve clinical problems. These changes will require efforts in faculty development, and have implications for the administration and function of dental schools.