Review of brief cognitive tests for patients with suspected dementia.

BACKGROUND: As the population ages, it is increasingly important to use effective short cognitive tests for suspected dementia. We aimed to review systematically brief cognitive tests for suspected dementia and report on their validation in different settings, to help clinicians choose rapid and appropriate tests. METHODS: Electronic search for face-to-face sensitive and specific cognitive tests for people with suspected dementia, taking ≤ 20 minutes, providing quantitative psychometric data. RESULTS: 22 tests fitted criteria. Mini-Mental State Examination (MMSE) and Hopkins Verbal Learning Test (HVLT) had good psychometric properties in primary care. In the secondary care settings, MMSE has considerable data but lacks sensitivity. 6-Item Cognitive Impairment Test (6CIT), Brief Alzheimer's Screen, HVLT, and 7 Minute Screen have good properties for detecting dementia but need further validation. Addenbrooke's Cognitive Examination (ACE) and Montreal Cognitive Assessment are effective to detect dementia with Parkinson's disease and Addenbrooke's Cognitive Examination-Revised (ACE-R) is useful for all dementias when shorter tests are inconclusive. Rowland Universal Dementia Assessment scale (RUDAS) is useful when literacy is low. Tests such as Test for Early Detection of Dementia, Test Your Memory, Cognitive Assessment Screening Test (CAST) and the recently developed ACE-III show promise but need validation in different settings, populations, and dementia subtypes. Validation of tests such as 6CIT, Abbreviated Mental Test is also needed for dementia screening in acute hospital settings. CONCLUSIONS: Practitioners should use tests as appropriate to the setting and individual patient. More validation of available tests is needed rather than development of new ones.

Cost-effectiveness of transcranial magnetic stimulation vs. electroconvulsive therapy for severe depression: a multi-centre randomised controlled trial.

BACKGROUND: Electroconvulsive therapy (ECT) has a long history of use in treating depression. Repetitive transcranial magnetic stimulation (rTMS) has been introduced more recently to the treatment spectrum. Its cost-effectiveness has not been explored. METHOD: Forty-six right-handed people with severe depressive episodes referred for ECT were randomised to receive either ECT twice weekly or rTMS on consecutive weekdays. Health and other service use were recorded for retrospective periods of 3 months prior to initiation of treatment and during the 6 months following the end of allocated treatment. Costs were calculated for the treatment period and the subsequent 6 months, and comparisons made between groups after adjustment for any baseline differences. Cost-effectiveness analysis was conducted with incremental change on the 17-item Hamilton Rating Scale for Depression (HRSD) as the primary outcome measure, and quality-adjusted life years (based on SF6D-generated utility scores with societal weights) as secondary outcome, cost-effectiveness acceptability curves plotted. RESULTS: Based on the HRSD scores and other outcome measures, rTMS was not as effective as ECT. The cost of a single session of rTMS was lower than the cost of a session of ECT, but overall there were no treatment cost differences. In the treatment and 6-month follow-up periods combined, health and other service costs were not significantly different between the two groups. Informal care costs were higher for the rTMS group. Total treatment, service and informal care costs were also higher for the rTMS group. The cost-effectiveness acceptability curves indicated a very small probability that decision-makers would view rTMS as more cost-effective than ECT. LIMITATIONS: Small sample size, some sample attrition and a relatively short follow-up period of 6 months for a chronic illness. Productivity losses could not be calculated. CONCLUSIONS: ECT is more cost-effective than rTMS in the treatment of severe depression.

Validation of a screening instrument for post-traumatic stress disorder in a clinical sample of older adults.

OBJECTIVES: To determine the diagnostic validity of the Post Traumatic Disorder Checklist (PCL) against the 'gold standard' of the Clinician Administered PTSD Scale (CAPS) in a clinical sample of older adults. METHODS: A cross-sectional validation study: participants were patients (65 years and over) being treated for medical and/or psychiatric conditions in a hospital setting. Participants completed the PCL, measures of mood, cognition, physical health, alcohol use and the CAPS. A receiver operating characteristics curve was constructed to determine the optimal cut-point of the PCL. Analysis of variance was used to examine clinical differences between PTSD cases, sub-threshold cases and the remainder of the sample. RESULTS: Using the recommended cut-point of 50, the PCL had a sensitivity of 0.40, specificity of 0.97 and positive predictive value of 0.57. However, these values changed to 0.90, 0.87 and 0.45, respectively, when the optimal cut-point of 36 was used. CONCLUSION: With an adjusted cut-point the PCL is an acceptable and brief screening instrument for PTSD in older adults.

A randomized, controlled trial with 6-month follow-up of repetitive transcranial magnetic stimulation and electroconvulsive therapy for severe depression.

OBJECTIVE: Repetitive transcranial magnetic stimulation (rTMS) has been reported to be as effective as electroconvulsive therapy (ECT) for major depression. The authors conducted a multicenter randomized, controlled trial to test the equivalence of rTMS with ECT. METHOD: Forty-six patients with major depression referred for ECT were randomly assigned to either a 15-day course of rTMS of the left dorsolateral prefrontal cortex (N=24) or a standard course of ECT (N=22). The primary outcome measures were the score on the 17-item Hamilton Depression Rating Scale (HAM-D) and the proportion of patients with remissions (Hamilton score,

Controlled chaos: managing your access control system for future success.

How a medical center's protective services department is keeping pace with and planning for future changes in the face of unprecedented rapid growth.

Diversity in action; dealing with a transgender issue.

The problem of gays in the military, police, and security has received considerable publicity in recent years, but what happens when a male security officer, with an excellent performance record, decides to announce a gender change? How a hospital's security and resources departments handled the transition, and what transpired afterwards, is described in this detailed and frank article.

An attempt to determine the benefits of a 'home-for-life' principle in residential care for people with dementia and behavioural problems: a comparative cohort study.

It is not clear whether moving individuals with dementia and behavioural problems as part of a rehabilitation and relocation ('intermediate care', IC) nursing home model worsens behaviour, compared with a 'home for life' philosophy. We studied this in contiguous services with the same formal admission criteria but different models of subsequent care. 37 patients admitted to 'homes for life' and 24 to IC homes were followed up for 1 year using the BEHAVE-AD. Scores were lower at baseline in the IC group. Both groups deteriorated over the year, although more in IC patients (trend), and those actually moving home were worse after the move. Use of neuroleptic medication increased significantly in the IC group. Our results confirm previous studies of the disruptive effects of re-location for patients with severe dementia but do not suggest major differences between the two models of care.

Late-onset startle syndrome and obsessive compulsive disorder.

A case of late onset sporadic startle syndrome in a patient with a right posterior fossa brain tumour is reported. The exaggerated startle response did not respond to treatment with clonazepam. In addition to anxiety and depression, the patient developed obsessive- compulsive symptoms which responded to behavioural therapy. The possible mechanisms for this unique pattern of symptoms are discussed.

Obsessive-compulsive disorder in the elderly.

Four cases of obsessive-compulsive disorder arising in late life in association with a presumed organic aetiology are described. Three of the four had brief episodes of OCD earlier in their lives. Neuropsychological assessment demonstrated impairments in verbal fluency and visuo-spatial tasks. No case exhibited global intellectual impairment. The two patients who complied with appropriate treatment became asymptomatic after 4-6 months.

Attributions of physical symptoms in patients of an old age psychiatry service.

BACKGROUND: Somatization is a phenomenon found across all medical specialities and in all types of care. There has been little in the way of systematic investigation of the phenomenon in older people. OBJECTIVES: The objective was to establish whether treatment for psychiatric illness would be accompanied by a fall in somatic attributions. METHOD: Patients' attributions of physical symptoms were studied in a consecutive group of older people with functional disorders (mostly depression) referred to an old age psychiatry service. Depression, anxiety, physical illness and attributional style were measured soon after referral and seven months later. RESULTS: 41 subjects were interviewed in the first leg. Anxiety was the chief association of abnormal attributional style. At follow up (n = 29) mean depression and anxiety scale scores and somatic attributions of symptoms had fallen significantly. CONCLUSION: Abnormal focus on physical symptoms in depressed elderly patients may resolve with treatment.

Genetics, molecular biology, neuropathology and phenotype of frontal lobe dementia: a case history.

BACKGROUND: Mutations in tau have been found in a group of related disorders including the frontal lobe dementias. AIMS: To describe the clinical features and molecular pathology changes in a single case of a patient with frontal lobe dementia. METHOD: A case report was compiled from neuropathological reports and genomic and gene expression analyses. RESULTS: A case with a splice-site mutation resulting in a typical frontotemporal clinical and neuropathological phenotype was found. Gene expression analysis suggests differential expression of isoforms of tau in regions in the brain. CONCLUSIONS; Frontotemporal dementia can result from gene mutations that alter splicing and expression of tau.