Psychiatric disorders in older adults with cancer referred to psycho-oncology service in a tertiary care cancer centre: a 7-year real world experience from India.

BACKGROUND: Cancer affects mental health in older adults with cancer (OAC), affecting almost 50% of the patients. There are only a few studies on psychiatric disorders in OAC, especially in low resource settings. We report on our real-world experience of prevalence of and factors associated with psychiatric disorders in OAC referred to a psycho-oncology service in an Indian tertiary care cancer institute. METHODS: We retrospectively analysed medical and psycho-oncology records of patients aged 60 + on cancer-directed treatment or follow-up for < 2 years after treatment completion, referred to psycho-oncology services in a tertiary care cancer centre in Mumbai, India, from Jan 2011-Dec 2017. We recorded sociodemographic, clinical, and treatment-related variables, as well as past psychiatric disorders. The ICD-10 was used to record current psychiatric disorder type and presence. IBM SPSS version 24 (Armonk, NY, USA) was used for descriptive measures, tests of association, and logistic regression analysis. The study protocol was approved by Institutional Ethics Committee and registered with the Clinical Trials Registry-India (CTRI/2020/06/026095). RESULTS: Of 763 patients included in the study, 475 (62.3%) were males and 436 (57.1%) were inpatients, with a median age of 65 years. 93% of the patients had a solid tumour and 207 (27.1%) had a history of psychiatric disorder. A current psychiatric diagnosis was noted in 556 patients (72.9%) on initial presentation, of which adjustment disorders, delirium and depression and anxiety disorders were most frequently seen in 25.2%, 21% and 11.1%, respectively. On univariate analysis, a past history of psychiatric disorders (χ2 = 34.6, p < 0.001), lower performance status (χ2 = 9.9, p = 0.002) and haematolymphoid malignancy (χ2 = 4.08, p = 0.04) significantly increased the risk of current psychiatric diagnosis. Logistic regression confirmed these variables as significant. CONCLUSION: Older adults with cancer referred to psycho-oncology services have high rates of psychiatric disorders at their initial presentation, mainly adjustment disorders, delirium and depression and anxiety. A past history of psychiatric disorders, lower performance status and haematolymphoid cancers significantly increased the risk of psychiatric disorders. Multidisciplinary psycho-oncology teams including a psychiatrist should be integrated in comprehensive care of this group of patients. Further research outcomes and effect of psycho-oncological interventions is required in older adults with cancer in LMIC settings.

Insulinoma: an uncommon cause of delirium.

We present the case of an 83-year-old woman with recurrent episodes of delirium occurring overnight, associated with hypoglycaemia. Other causes for delirium were excluded. Laboratory findings were in keeping with endogenous insulin production. Computerised tomography imaging revealed a small mass in the pancreas supporting a presumed diagnosis of an insulinoma. Given the patient's frailty and cognitive impairment, a conservative management approach was taken. Diazoxide was commenced with resolution of episodes of delirium. This case highlights hypoglycaemia, and insulinoma, as a rare, but treatable cause of delirium. It demonstrates the importance of blood sugar screening in delirium. It emphasises the holistic modifications to management, which must be taken to ensure patient-centred care when caring for an older adult living with frailty, who may have cognitive impairment.

Efficacy of two integrated geriatric care pathways for the treatment of hip fractures: a cross-cultural comparison.

INTRODUCTION: Many studies have focussed on the implementation and outcomes of geriatric care pathways (GCPs); however, little is known about the possible impact of clinical practices on these pathways. A comparison was made between two traumageriatric care models, one Swiss (CH) and one Dutch (NL), to assess whether these models would perform similarly despite the possible differences in local clinical practices. MATERIALS AND METHODS: This cohort study included all patients aged 70 years or older with a unilateral hip fracture who underwent surgery in 2014 and 2015. The primary outcomes were mortality and complications. Secondary outcomes were time to surgical intervention, hospital length of stay (HLOS), differences in surgical treatment and the number of patients who needed secondary surgical intervention. RESULTS: A total of 752 patients were included. No differences were seen in mortality at 30 days, 90 days and 1 year post-operatively. In CH, fewer patients had a complicated course (43.5% vs. 51.3%; p = 0.048) and fewer patients were diagnosed with delirium (7.9% vs. 18.3%; p < 0.01). More myocardial infarctions (3.8% vs. 0.4%; p < 0.01) and red blood cell transfusions (27.2% vs. 13.3%; p < 0.01) were observed in CH and HLOS in CH was longer (Mdn difference: - 2; 95% CI - 3 to - 2). Furthermore, a difference in anaesthetic technique was found, CH performed more open reductions and augmentations than NL and surgeons in CH operated more often during out-of-office hours. Also, surgery time was significantly longer in CH (Mdn difference: - 62; 95% CI - 67 to - 58). No differences were seen in the number of patients who needed secondary surgical interventions. CONCLUSIONS: This cross-cultural comparison of GCPs for geriatric hip fracture patients showed that quality of care in terms of mortality was equal. The difference in complicated course was mainly caused by a difference in delirium diagnosis. Differences were seen in surgical techniques, operation duration and timing. These clinical practices did not influence the outcome.

Ogilvie's syndrome presented with delirium in an older lady with corticobasal syndrome.

OBJECTIVE: Corticobasal syndrome (CBS) is one of an atypical parkinsonian syndromes characterized by extrapyramidal features as well as cortical involvement signs. A variety of factors may lead to delirium in older adults with chronic progressive life-limiting neurological illnesses like CBS. Ogilvie's syndrome (OS) is an acute colonic pseudo-obstruction in which abdominal distension, nausea, vomiting, and constipation can be seen. We report a case of OS identified as the underlying possible cause of delirium in an 80-year-old woman with CBS. We also discuss the importance of holistic approach which is essential to manage the underlying cause and to preserve the quality of life in particular for the frail geriatric population who potentially needs palliative care or already benefits from palliative care. METHOD: An older patient with CBS presented with symptoms similar to that of acute colonic obstruction and subsequently developed delirium. The patient was found to have colonic pseudo-obstruction (OS). RESULT: Neostigmin infusion was therefore given to treat it and delirium was resolved. SIGNIFICANCE OF RESULTS: To the best of our knowledge, clinical manifestation of delirium as OS in a patient with CBS has not been previously reported. OS may be superimposed to CBS in older patients, and OS in such patients may play a role as a precipitating factor for the development of delirium. Given the fact that CBS is progressive and rare neurodegenerative disease and almost all of these patients need palliative care, eventually, health-care professionals, especially in palliative care, should be aware of distinctive challenges of life-limiting chronic neurological illnesses, such as conditions that may lead to the development of acute colonic pseudo-obstruction because the rapid treatment of them prevents the use of potentially harmful drugs, surgical procedures, or inappropriate interventions.

"SQiD, the Single Question in Delirium; can a single question help clinicians to detect delirium in hospitalised cancer patients?" running heading Single Question in Delirium" (Bcan-D-20-01665).

AIM: A serious syndrome for cancer in-patients, delirium risk increases with age and medical acuity. Screening tools exist but detection is frequently delayed or missed. We test the 'Single Question in Delirium' (SQiD), in comparison to psychiatrist clinical interview. METHODS: Inpatients in two comprehensive cancer centres were prospectively screened. Clinical staff asked informants to respond to the SQiD: "Do you feel that [patient's name] has been more confused lately?". The primary endpoint was negative predictive value (NPV) of the SQiD versus psychiatrist diagnosis (Diagnostic and Statistics Manual criteria). Secondary endpoints included: NPV of the Confusion Assessment Method (CAM), sensitivity, specificity and Cohen's Kappa coefficient. RESULTS: Between May 2012 and July 2015, the SQiD plus CAM was applied to 122 patients; 73 had the SQiD and psychiatrist interview. Median age was 65 yrs. (interquartile range 54-74), 46% were female; median length of hospital stay was 12 days (5-18 days). Major cancer types were lung (19%), gastric or other upper GI (15%) and breast (14%). 70% of participants had stage 4 cancer. Diagnostic values were similar between the SQiD (NPV = 74, 95% CI 67-81; kappa = 0.32) and CAM (NPV = 72, 95% CI 67-77, kappa = 0.32), compared with psychiatrist interview. Overall the CAM identified only a small number of delirious cases but all were true positives. The specificity of the SQiD was 87% (74-95) The SQiD had higher sensitivity than CAM (44% [95% CI 41-80] vs 26% [10-48]). CONCLUSION: The SQiD, administered by bedside clinical staff, was feasible and its psychometric properties are now better understood. The SQiD can contribute to delirium detection and clinical care for hospitalised cancer patients.

Evaluación de las complicaciones clínicas de los pacientes con fractura de cadera y sus factores asociados en una Unidad de Agudos de Ortogeriatría / Assessment of clinical complications and their associated factors in hip-fracture patients in an Acute Geriatric Orthopaedic Unit

Introducción. Las complicaciones clínicas en pacientes con fractura de cadera (FC) son elevadas y variables por su heterogéneo registro. El objetivo del estudio fue evaluar las complicaciones clínicas y sus factores asociados en pacientes con FC ingresados en la Unidad de Ortogeriatría de un hospital universitario de 283 camas que atiende un promedio de 200 FC/año. Material y métodos. Se incluyó a 383 pacientes ingresados consecutivamente en 2013 y en 2014 en un estudio analítico observacional prospectivo. Las complicaciones clínicas se definieron según recomendaciones avaladas por la AOTrauma Network (Red de Trabajo de la Asociación Internacional de Traumatólogos para el estudio de la osteosíntesis). Resultados. Doscientos setenta y tres pacientes (71,28%) presentaron alguna complicación. Las principales fueron el delirium (55,4%), la insuficiencia renal (15,4%) y las complicaciones cardiacas (12,3%). Se asociaron a la presencia de alguna complicación la clasificación ASA III-IV (OR=1,962; IC del 95%, 1,040-3,704; p = 0,038), un índice de Barthel al alta inferior (b = -3,572;IC del 95%, -0,866 a -0,104; p = 0,01), el incremento en la estancia media (b = 2,683; IC del 95%, 3,522-0,325; p < 0,001) y preoperatoria (OR = 1,165; IC del 95%, 1,050-1,294; p = 0,004). Conclusiones. Las complicaciones clínicas más frecuentes son el delirium, la insuficiencia renal y las complicaciones cardiacas. Una puntuación en la escala de ASA III-IV, una peor situación funcional al alta, así como una estancia preoperatoria y media prolongada, son factores asociados a la presencia de alguna complicación clínica. Las complicaciones cardiacas, pulmonares y digestivas son las principales causas de mortalidad en la unidad

Introduction. The incidence of clinical complications in hip fracture (HF) patients is high and variable due to their heterogeneous nature. The aim of the study was to assess the clinical complications and their associated factors in HF patients admitted to the Orthopaedic Geriatric Unit of a 283 bed University Hospital. An average of 200 HF patients is attended yearly. Material and methods. A prospective, observational and analytical study was conducted on 383 consecutive patients admitted to the unit during the years 2013 and 2014. Clinical complications were defined according to recommendations supported by the AOTrauma Network (International Network of Traumatologists for the Study of Osteosynthesis). Results. A total of 273 patients (71.28%) showed some clinical complication. The main ones were, delirium (55.4%), renal failure (15.4%), and cardiac complications (12.3%). An ASA III-IV score of OR = 1.962 (95% CI; 1.040-3.704, P=.038), lower Barthel index at discharge (b = -3.572, 95% CI -0.866 to -0.104, P=.01), the increase in pre-operative stay (OR = 1.165, 95% CI 1.050-1.294, P=.004) and an increased length of stay (b = 2.663, 95% CI 3.522-0.325; P<.001) were factors associated with clinical complications. Conclusions. Delirium, renal failure, and cardiac complications were the most frequent complications according the new recommendations. An ASA III-IV score, worse functional status at discharge, prolonged pre-operative period, and increased length of stay, were risk factors associated with clinical complications. Cardiac, pulmonary, and gastrointestinal complications were the main causes of mortality in the unit

Plasma melatonin levels in hip fracture patients with and without delirium: A confirmation study.

BACKGROUND: Melatonin plays a major role in maintaining circadian rhythm. Changes in melatonin metabolism might lead to circadian rhythm disturbances which are often observed in delirious patients. AIM: To assess if high morning plasma melatonin concentrations were associated with delirium. METHODS: Consecutive hip fracture patients aged ≥65 years were included. Delirium was assessed daily with the Confusion Assessment METHOD: Blood samples were collected at 11.00am on weekdays during first week of hospitalization. Melatonin was analyzed by liquid chromatography-tandem mass spectrometry. RESULTS: We analyzed 389 samples of 144 participants [mean age 84.0, 70 experienced delirium]. A Generalized Estimating Equations (GEE) model with outcome melatonin level in highest tertile ( >3.36 pg/ml) and covariates delirium group (i.e. never, before, during, post delirium), cognitive impairment, age, sex and anesthesia type, was constructed. Highest melatonin levels were associated with postoperative samples (Odds Ratio(OR) 2.11 compared to preoperative samples; 95% Confidence Interval(CI) 1.17-3.82, p=0.01) and higher age (OR 1.05 per year; CI 1.01-1.11, p=0.03), but not with delirium group(p=0.35). CONCLUSION: Undergoing surgery and aging in general may induce changes in melatonin metabolism. Future research should focus on daily multiple melatonin measurements to determine whether melatonin supplementation might be beneficial for delirium treatment or prevention.

Nursing care for people with delirium superimposed on dementia.

Nursing and healthcare is changing in response to an ageing population. There is a renewed need for holistic nursing to provide clinically competent, appropriate and timely care for patients who may present with inextricably linked mental and physical health requirements. This article explores the dichotomy in healthcare provision for 'physical' and 'mental' health, and the unique role nurses have when caring for people with delirium superimposed on dementia (DSD). Delirium is prevalent in older people and recognised as 'acute brain failure'. As an acute change in cognition, it presents a unique challenge when occurring in a person with dementia and poses a significant risk of mortality. In this article, dementia is contrasted with delirium and subtypes of delirium presentation are discussed. Nurses can recognise DSD through history gathering, implementation of appropriate care and effective communication with families and the multidisciplinary team. A simple mnemonic called PINCH ME (Pain, INfection, Constipation, deHydration, Medication, Environment) can help identify potential underlying causes of DSD and considerations for care planning. The mnemonic can easily be adapted to different clinical settings and a fictitious scenario is presented to show its application in practice.

Worsening cognitive impairment and neurodegenerative pathology progressively increase risk for delirium.

BACKGROUND: Delirium is a profound neuropsychiatric disturbance precipitated by acute illness. Although dementia is the major risk factor this has typically been considered a binary quantity (i.e., cognitively impaired versus cognitively normal) with respect to delirium risk. We used humans and mice to address the hypothesis that the severity of underlying neurodegenerative changes and/or cognitive impairment progressively alters delirium risk. METHODS: Humans in a population-based longitudinal study, Vantaa 85+, were followed for incident delirium. Odds for reporting delirium at follow-up (outcome) were modeled using random-effects logistic regression, where prior cognitive impairment measured by Mini-Mental State Exam (MMSE) (exposure) was considered. To address whether underlying neurodegenerative pathology increased susceptibility to acute cognitive change, mice at three stages of neurodegenerative disease progression (ME7 model of neurodegeneration: controls, 12 weeks, and 16 weeks) were assessed for acute cognitive dysfunction upon systemic inflammation induced by bacterial lipopolysaccharide (LPS; 100 µg/kg). Synaptic and axonal correlates of susceptibility to acute dysfunction were assessed using immunohistochemistry. RESULTS: In the Vantaa cohort, 465 persons (88.4 ± 2.8 years) completed MMSE at baseline. For every MMSE point lost, risk of incident delirium increased by 5% (p = 0.02). LPS precipitated severe and fluctuating cognitive deficits in 16-week ME7 mice but lower incidence or no deficits in 12-week ME7 and controls, respectively. This was associated with progressive thalamic synaptic loss and axonal pathology. CONCLUSION: A human population-based cohort with graded severity of existing cognitive impairment and a mouse model with progressing neurodegeneration both indicate that the risk of delirium increases with greater severity of pre-existing cognitive impairment and neuropathology.

Valoración geriátrica y factores pronósticos de mortalidad en pacientes muy ancianos con neumonía extrahospitalaria / Geriatric Assessment and Prognostic Factors of Mortality in Very Elderly Patients With Community-Acquired Pneumonia

Introducción: Analizar la relación de parámetros Obtenidos en la valoración geriátrica con la mortalidad en ancianos con neumonía extrahospitalaria (NEH) en una unidad de geriatría de agudos (UGA). Método: Un total de 456 pacientes (≥ 75 años). Variables: edad, sexo, procedencia, antecedentes, nivel de conciencia, frecuencia cardíaca y respiratoria, presión arterial, datos de laboratorio, derrame pleural, afectación multilobar, capacidad funcional (independencia para actividades de la vida diaria) previa al ingreso (índice de Lawton [IL], índice de Barthel previo [IBp]) y en el momento del ingreso (IBi), función cognitiva (test de Pfeiffer [TP]), comorbilidad (índice de Charlson [ICh]) y nutrición (proteínas totales, albúmina). Resultados: Los 110 pacientes que fallecieron durante el ingreso (24,2%) tuvieron mayor edad (86,6 ± 6,4 vs 85,1 ± 6,4; p < 0,04), mayor comorbilidad (ICh 2,35 ± 1,61 vs 2,08 ± 1,38; p < 0,083), menor capacidad funcional (IL: 0,49 ± 1,15 vs 1,45 ± 2,32; p < 0,001; IBp: 34,6 ± 32,9 vs 54,0 ± 34,1; p < 0,001; IBi: 5,79 ± 12,5 vs 20,5 ± 22,9; p < 0,001), mayor porcentaje de pérdida funcional al ingreso (85,9 ± 23,2 vs 66,4 ± 28,6; p < 0,0001), mayor deterioro cognitivo (TP: 7,20 ± 3,73 vs 5,10 ± 3,69; p < 0,001) y mayor desnutrición (albúmina 2,67 ± 0,54 vs 2,99 ± 0,49; p < 0,001). Hubo también mayor mortalidad con alteración de conciencia (49,2%; p < 0,01), taquipnea (33,3%; p < 0,01), taquicardia (44,4%; p < 0,002), urea elevada (31,8; p < 0,001), anemia (44,7%; p < 0,02), derrame pleural (42,9%; p < 0,002) y afectación multilobar (43,2%; p < 0,001). En el análisis multivariado resultaron significativos: edad ≥ 90 años (OR: 3,11 [IC 95%: 1,31-7,36]), alteración de conciencia (3,19 [1,66-6,15]), hematocrito < 30% (2,87 [1,19-6,94]), derrame pleural (3,77 [1,69-8,39]) y afectación multilobar (2,76 [1,48-5,16]). El sexo femenino y la capacidad funcional más conservada previa (IL ≥ 5) y en el momento del ingreso (IBi ≥ 40) fueron protectores de mortalidad (0,40 [0,22-0,70]; 0,09 [0,01-0,81] y 0,11 [0,02-0,51]). Conclusiones: Los parámetros de valoración geriátrica y las variables clínicas habituales estuvieron relacionados con la mortalidad

Introduction: To assess the relationship between the parameters obtained in the geriatric assessment and mortality in elderly people with community-acquired pneumonia in an acute care geriatric unit.MethodsFour hundred fifty-six patients (≥ 75 years). Variables: age, sex, referral source, background, consciousness level, heart rate, breathing rate, blood pressure, laboratory data, pleural effusion, multilobar infiltrates, functional status (activities of daily living) prior to admission [Lawton index (LI), Barthel index (BIp)] prior to and at admission (BIa), cognitive status [Pfeiffer test (PT)], comorbidity [Charlson index (ChI)] and nutrition (total protein, albumin). Results: A hundred ten patients died (24.2%) during hospitalization. These patients were older (86.6 ± 6.4 vs 85.1 ± 6.4, P < 0.04), had more comorbidity (ChI 2.35 ± 1.61 vs 2.08 ± 1.38; P < 0.083), worse functional impairment [(LI: 0.49 ± 1.15 vs 1.45 ± 2.32, P < 0.001) (BIp: 34.6 ± 32.9 vs 54.0 ± 34.1, P < 0.001) (BIa: 5.79 ± 12.5 vs 20.5 ± 22.9, P V< 0.001)], a higher percentage of functional loss at admission (85.9±23.2 vs 66.4 ± 28.6; P < 0.0001), worse cognitive impairment (PT: 7.20 ± 3.73 vs 5.10 ± 3.69, P < 0.001) and malnutrition (albumin 2.67 ± 0.54 vs 2.99 ± 0.49, P < 0.001). Mortality was higher with impaired consciousness [49.2% (P < 0.01)], tachypnea [33.3% (P < 0.01)], tachycardia [44.4% (P < 0.002), high urea levels [31.8 (P < 0.001)], anemia [44.7% (P < 0.02)], pleural effusion [42.9% (P < 0.002)], and multilobar infiltrates [43.2% (P < 0.001)]. In the multivariate analysis, variables associated with mortality were: age ≥ 90 years [OR: 3.11 (95% CI: 1.31-7.36)], impaired consciousness [3.19 (1.66-6.15)], hematocrit < 30% [2.87 (1.19-6.94)], pleural effusion [3.77 (1.69-8.39)] and multilobar infiltrates [2.76 (1.48-5.16)]. Female sex and a preserved functional status prior (LI ≥ 5) and during admission (BIa ≥ M40) were protective of mortality [0.40 (0.22-0.70), 0.09 (0.01-0.81) and 0.11 (0.02-0.51)]. Conclusions: Geriatric assessment parameters and routine clinical variables were associated with mortality

Delirium postoperatorio en cirugía general, el fantasma de nuestros abuelos / Postoperative delirium in general surgery, the ghost of our grandparents

En esta revisión descriptiva se realiza una búsqueda bibliográfica en las principales bases de datos biomédicas para detallar los factores de riesgo modificables vinculados al delirium postoperatorio en pacientes ancianos, intervenidos de cirugía general, con la finalidad de optimizar la calidad asistencial. Se obtuvieron siete estudios observacionales que describen los factores de riesgo y predictores independientes de riesgo asociados al delirium postoperatorio. Los factores de riesgo modificables que precipitan este síndrome, en este subgrupo de pacientes quirúrgicos, y que los hacen característico en relación a los pacientes médicos, son el tiempo de ingreso en relación con el procedimiento quirúrgico, la duración de la cirugía, la estancia prolongada en unidad de cuidados intensivos, la hipotensión intraoperatoria, el volumen de infusión de líquidos elevados, la puntuación ASA (Sociedad Americana de Anestesiólogos) alta, saturación de oxigeno cerebral disminuida, dolor postoperatorio mal controlado, retraso en la recuperación de la anestesia y mayor numero de complicaciones postoperatorias. Los ancianos intervenidos de cirugía general son un grupo de pacientes con alto riesgo de delirium postoperatorio debido al gran número de factores de riesgo adicionales anexados a su proceso quirúrgico. La identificación de pacientes en riesgo es fundamental para la prevención, la detección temprana y el tratamiento adecuado del delirium, primordialmente porque el delirium indica la presencia de una alteración orgánica subyacente que debe resolverse (AU)

Introduction: Currently there has been an increased interest from mothers and their environment, by the application of other non-invasive analgesic methods. Therefore, it is a major issue for health professionals related to delivery care, which should develop the skills necessary to help those women who choose childbirth alternative promoted by the application of analgesic action. Objectives: We sought to evaluate the effectiveness and efficiency of the main alternatives analgesic delivery that literature offers us. Methods: We performed a literature search in the following databases: Medline, Pubmed, The Cochrane Database of Systematic Reviews and Ebsco. Results: The studies surveyed reflect that different alternatives as applying analgesic electrotherapy, acupuncture, massage therapy or thermotherapy in childbirth are moderate effective in reducing pain. Conclusions: The application of alternative analgesic action is proven effective, however, it is necessary the development of larger clinical studies with a methodology agreed to endorse the effectiveness of such interventions (AU)

Probable trimethoprim/sulfamethoxazole-induced higher-level gait disorder and nocturnal delirium in an elderly man.

OBJECTIVE: To report a case of probable trimethoprim/sulfamethoxazole (TMP/SMX)-induced higher-level gait disorder (HLGD) and nocturnal delirium in an elderly patient on high-dose oral therapy. CASE SUMMARY: An 82-year-old man with a recent history of depression became comatose following an overdose of escitalopram and oxazepam. He was admitted, ventilated for 7 days in the intensive care unit, and treated with piperacillin/tazobactam and cefepime for aspiration pneumonia. Following discharge to a medical ward, respiratory symptoms persisted and imaging confirmed pulmonary abscesses. Stenotrophomonas maltophilia was isolated from sputum and, on day 15, TMP/SMX 800 mg/160 mg 1 tablet every 12 hours was initiated. On day 35, the dose was increased to 800 mg/160 mg 2 tablets every 12 hours. By day 37, the patient was unsteady when attempting to stand. From day 40, he was noted to have features of HLGD with gait ignition failure, poor balance, and frequent falls. His other medications at this time were thiamine 100 mg daily, multivitamin 1 tablet daily, omeprazole 20 mg every 12 hours, and modified-release venlafaxine 150 mg daily. Investigation did not reveal any cause for his acute gait disturbance. TMP/SMX was stopped on day 48 and, by day 51, the patient's gait had returned to normal. DISCUSSION: Neuropsychiatric adverse reactions with TMP/SMX have been infrequently reported. The Naranjo probability scale indicated that TMP/SMX was the probable cause of HLGD in this patient. CONCLUSIONS: At time of writing, this was the first reported case of HLGD associated with TMP/SMX. Clinicians should consider this adverse reaction as a potential cause of HLGD, especially in the elderly and those with malnutrition and hepatic or renal dysfunction.

Vitamin B(12) supplementation did not improve cognition but reduced delirium in demented patients with vitamin B(12) deficiency.

To examine the effects of vitamin B(12) supplementation on the cognitive function, delirium, and neuropsychiatric symptoms of mild to moderate dementia patients with vitamin B(12) deficiency. Thirty consecutive mild to moderate dementia cases aged over 60 years with low serum B(12) (< 200 pmol/l) were given vitamin B(12) supplementation for 40 weeks. The Mattis Dementia Rating Scale (MDRS), Category Verbal Fluency Test (CVFT), Delirium Rating Scale (DRS), Mini-Mental State Examination (MMSE), and the Neuropsychiatric Inventory (NPI) were performed at baseline, and after 6, 16, and 40 weeks. No significant changes in cognitive function and behavioral symptoms were detected between baseline and 40 weeks. DRS scores decreased significantly at 6 and 40 weeks (median change of -1 at both follow-ups, p=0.006 and 0.04, respectively). Cognitive function of mild to moderately demented older people with vitamin B(12) deficiency did not significantly change with vitamin B(12) supplementation over a 10-month period. The supplementation reduced delirium associated with dementia.

[Clinical aspects of witchcraft delusions].

To distinguish clinical variants and to specify nosologic entity of witchcraft delusions, 69 patients (10 males, aged 15-72 years) have been examined. It was found that witchcraft delusions exist in passive and active forms. In a passive form, the patient is sure that unknown (mystic) power damaged him/her; in an active form the patient, possessing a gift for unusual abilities, can influence the others (bewitches, heals, etc). Five clinical syndromes, in the structure of which the above delusions were found, namely, paranoiac-hypochondriac, hallucination-paranoid, depressive-paranoid, paraphrenic and delirious, were identified. Psychoses of schizophrenia spectrum were diagnosed in 52 patients, organic--in 8, alcoholic--in 7 and recurrent depressive disorder--in 2. Clinical significance of witchcraft delusions is closely related to its social aspect. Being combined with ideas of persecution, poisoning and damage, it results in the brutal forms of delusions defense and may be considered as an unfavorable prognostic trait.

A multidisciplinary approach to the toxicologic problems associated with the use of herbal medicines.

In Hong Kong, a multidisciplinary team consisting of a pharmacist, a chemical pathologist, a scientific officer, and a physician has jointly provided an advisory service on herbal safety to healthcare professionals of all public hospitals since August 2000. This paper reports the first 2 years of experience of this team to emphasize the importance of a multidisciplinary approach to herbal poisoning. Twenty referrals received from the public hospitals from August 2000 to June 2002 were reviewed. The diagnosis of herbal toxicity was made after consideration of the temporal relationship between exposure to the herb and the occurrence of the adverse event and the exclusion of other causes. The causal relationship was seen as much stronger if the herb's pharmacological effects could fully explain the adverse event, if there were similar previous reports, and if the toxicological analysis findings were supportive. In 10 patients, the adverse events were deemed unlikely to be related to the use of herbal medicines. In 3 patients, it was concluded that the adverse events were possibly related to the use of herbal medicines. In 7 patients, the causal relationship was seen to be much stronger because the adverse events in these patients simply reflected the pharmacological effects of the herbs consumed and specific toxic ingredients were isolated from herbal residues and patients' urine or serum. The clinical problems arising from the use of herbal medicines included the Aristolochia species causing acute renal failure (n = 1), aconite roots causing aconitine poisoning (n = 2), the Datura species causing anticholinergic poisoning (n = 1), and "yulan" (Stephania sinica) causing tetrahydropalmatine poisoning (n = 3). The 4 patients with acute renal failure and tetrahydropalmatine poisoning received these toxic herbs, which were not listed in the prescriptions, as a result of poor dispensing practice or for other reasons. Toxicological problems associated with the use of herbal medicines are complex and may be easily overlooked. A multidisciplinary team of experts should be made available to provide advice to frontline healthcare professionals.

Esquizofrénicos de larga evolución no institucionalizados / Long term follow-up of non institutionalized schizophrenics

Se hace el seguimiento de 53 esquizofrénicos con diez o más años de evolución de su enfermedad, controlados periódicamente por el propio autor. Se comentan las modalidades evolutivas, los niveles adaptativos del paciente a su medio, su nivel de autonomía y el grado de satisfacción personal, así como la aportación de los recursos públicos, asistenciales y psicosociales, en los casos que se han utilizado. El tratamiento de la información es puramente descriptivo y sólo afecta a un grupo de pacientes no representativo del universo de la esquizofrenia. Pretende únicamente, por tanto, invitar a la reflexión sobre realidades que el grupo estudiado nos ofrece. (AU)

Unexpected death related to restraint for excited delirium: a retrospective study of deaths in police custody and in the community.

BACKGROUND: Some people in states of excited delirium die while in police custody. Emerging evidence suggests that physical restraint in certain positions may contribute to such deaths. In this study the authors determined the frequency of physical restraint among people in a state of excited delirium who died unexpectedly. METHODS: The authors reviewed the records of 21 cases of unexpected death in people with excited delirium, which were investigated by the Office of the Chief Coroner for Ontario between 1988 and 1995. Eyewitness testimony, findings during postmortem examinations, clinical history, toxicological data and other official documents describing the events surrounding the deaths were analyzed. Specific reference was made to documented eyewitness testimony of restraint method, body position and use of capsicum oleoresin (pepper) spray. Because cocaine was detected in the blood of some of these people during the postmortem examination, the role of cocaine in excited delirium was examined by comparing the cocaine levels in these cases with levels in 2 control groups: 19 people who died from acute cocaine intoxication and 21 people who had used cocaine shortly before they died but who had died from other causes. RESULTS: In all 21 cases of unexpected death associated with excited delirium, the deaths were associated with restraint (for violent agitation and hyperactivity), with the person either in a prone position (18 people [86%]) or subjected to pressure on the neck (3 [14%]). All of those who died had suddenly lapsed into tranquillity shortly after being restrained. The excited delirium was caused by a psychiatric disorder in 12 people (57%) and by cocaine-induced psychosis in 8 (38%). Eighteen people (86%) were in police custody when they died. Four (19%) had been sprayed with capsicum oleoresin, and heart disease was found in another 4 at autopsy. The blood level of cocaine in those whose excited delirium was cocaine induced was similar to levels found in recreational cocaine users and lower than levels found in people who died from cocaine intoxication. INTERPRETATION: Restraint may contribute to the death of people in states of excited delirium, and further studies to test this hypothesis are recommended. Meanwhile, law enforcement authorities and others should bear in mind the potential for the unexpected death of people in states of excited delirium who are restrained in the prone position or with a neck hold.