Delirium is frequently underdiagnosed among older hospitalised patients despite available information in hospital medical records.

BACKGROUND: In-hospital delirium is associated with adverse outcomes and is underdiagnosed, limiting research and clinical follow-up. OBJECTIVE: To compare the incidence of in-hospital delirium determined by chart-based review of electronic medical records (D-CBR) with delirium discharge diagnoses (D-DD). Furthermore, to identify differences in symptoms, treatments and delirium triggers between D-CBR and D-DD. METHOD: The community-based cohort included 2,115 participants in the Hordaland Health Study born between 1925 and 1927. Between 2018 and 2022, we retrospectively reviewed hospital electronic medical records from baseline (1997-99) until death prior to 2023. D-DD and D-CBR were validated using The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for delirium. RESULTS: Of the 2,115 participants, 638 had in-hospital delirium. The incidence rate (IR) of D-CBR was 29.8 [95% confidence interval 28, 32] per 1,000 person-years, whereas the IR by D-DD was 3.4 [2.8, 4.2]. The IR ratio was 9.14 (P < 0.001). Patients who received pharmacological treatment for delirium (n = 121, odds ratio (OR) 3.4, [2.1, 5.4], P < 0.001), who were affected by acute memory impairment (n = 149, OR 2.8, [1.8, 4.5], P < 0.001), or change in perception (n = 137, OR 2.9, [1.8, 4.6] P < 0.001) had higher odds for D-DD. In contrast, post-operative cases (OR 0.2, [0.1, 0.4], P < 0.001) had lower odds for D-DD. CONCLUSION: Underdiagnosis of in-hospital delirium was a major issue in our study, especially in less severe delirium cases. Our findings emphasise the need for integrating systematic delirium diagnostics and documentation into hospital admission and discharge routines.

Cerebral ABC transporter-common mechanisms may modulate neurodegenerative diseases and depression in elderly subjects.

In elderly subjects, depression and dementia often coincide but the actual reason is currently unknown. Does a causal link exist or is it just a reactive effect of the knowledge to suffer from dementia? The ABC transporter superfamily may represent a causal link between these mental disorders. Since the transporters ABCB1 and ABCC1 have been discovered as major ß-amyloid-exporting molecules at the blood-brain barrier and ABCC1 was found to be directly activated by St. John's wort (SJW), depression and dementia certainly share an important pathophysiologic link. It was recognized that herbal anti-depressant formulations made from SJW are at least as effective for the treatment of unipolar depression in old age as classical pharmacotherapy, while having fewer side effects (Cochrane reports, 2008). SJW is known to activate various metabolizing and transport systems in the body, with cytochrome P450 enzymes and ABC transporters being most important. Does the treatment of depression in elderly subjects using pharmacological compounds or phytomedical extracts target a mechanism that also accounts for peptide storage in Alzheimer's disease and perhaps other proteopathies of the brain? In this review we summarize recent data that point to a common mechanism and present the first promising causal treatment results of demented elderly subjects with distinct SJW extracts. Insufficient trans-barrier clearance may indeed present a common problem in all the proteopathies of the brain where toxic peptides are deposited in a location-specific manner. Thus, activation of efflux molecules holds promise for future treatment of this large group of devastating disorders.

[Alzheimer's disease and genetics]. / Alzheimers sykdom og genetikk.

BACKGROUND: Alzheimer's disease is the most frequent cause of dementia. Recent knowledge reveals several new risk genes. We wish to summarise the knowledge of genetic factors related to Alzheimer's disease. METHOD: This article is based on findings in Alzgene, a database that summarises genetic association studies in Alzheimer's disease, a literature search in PubMed and the authors' own experience in dementia research. RESULTS: Several mutations of the genes APP, PSEN1 and PSEN2 are described. These cause around half of all cases of the rare early onset autosomal dominant form of Alzheimer's disease. Heritability, or how much of the development of the disease in an individual that is explained by genetics, is between 60 and 80% in the most common late onset form of Alzheimer's disease. APOE ε4 is the most robust risk gene for the development of this form of the disease, but recently ten new genes that increase the risk of developing Alzheimer's disease were identified by applying genome-wide association studies. These genes code for proteins that are central in the metabolism of cholesterol, activation of the immune system and synaptic cell membrane processes. INTERPRETATION: New hypotheses on the disease mechanisms for Alzheimer's disease are suggested based on the identification of new risk genes. These hypotheses partly replace and partly supplement the previously dominant amyloid pathway hypothesis. The new risk genes point to the potential for new biomarkers for specific disease processes and to possible new targets for future disease modifying therapies.

[Psychosis in Parkinson's disease]. / Psykose ved Parkinsons sykdom.

BACKGROUND: Psychosis is common in Parkinson's disease, and occurs with increasing frequency as the disease progresses. Assessment and treatment are often complicated and involve several clinical specialists in addition to the general practitioner. We describe the prevalence, form, causes and treatment of psychosis in Parkinson's disease. MATERIAL AND METHOD: The article is based on a literature search in PubMed for controlled pharmacological treatment studies and a discretionary selection of articles based on the authors' clinical and research experience. RESULTS: About 1 % of patients with newly diagnosed Parkinson's disease have psychotic symptoms. In later stages, complicated by dementia, these symptoms occur in about half of the patients. A false sense of presence, optical illusions and visual hallucinations occur most frequently, but delusions and hallucinations involving other senses have been reported. Various theories to explain the underlying etiology and pathology are explored. A further medical assessment is recommended when psychotic symptoms occur. Clozapine is still the only antipsychotic drug documented effective against psychotic symptoms in Parkinson's disease. INTERPRETATION: The prevalence of psychotic symptoms in various stages of Parkinson''s disease has been thoroughly documented. Non-pharmacological treatment is often effective, but the documentation is inadequate. Pharmacological treatment with clozapine has proved effective against psychosis in Parkinson's disease, but new drugs that are easier to administer are needed.

Mortality and Parkinson disease: A community based study.

OBJECTIVE: To compare the mortality of a community-based cohort of patients with carefully diagnosed Parkinson disease (PD) with the mortality in an age-matched population from the same study area and to investigate the possible influence of clinical features and diagnostic accuracy on survival in PD. METHODS: A total of 245 patients with PD were identified and included in the study. Patients were classified into groups of clinical definite, probable, and possible PD. The study period was 8 years. A total of 142 patients died. The mortality rates for the Norwegian population, which were available in 1-year intervals for all birth cohorts and both sexes during the study period, were used as controls. RESULTS: The standardized mortality ratio (SMR) for the total patient group was 1.52. The mortality rate was increased for both sexes (male SMR = 1.54, female SMR = 1.49) and in all age groups at disease onset (<60 years SMR = 1.92, 60 to 70 years SMR = 1.50, >70 years SMR = 1.41). The survival of patients with clinical definite PD was only modestly reduced (SMR = 1.35), whereas the SMR for possible PD was as high as 1.99. CONCLUSIONS: Our study gives evidence for increased mortality in PD despite modern treatment. The increase is not extensive in patients with a high probability for idiopathic PD.

[Cholinesterase inhibitors in Norway--effectiveness and side effects in clinical practice]. / Bruk av kolinesterasehemmere.

BACKGROUND: Naturalistic trials are needed to evaluate whether the results obtained in randomised trials of cholinesterase inhibitors (CEI) can be generalised to clinical practice. We conducted two studies in Norway to address this issue. MATERIAL AND METHODS: We included patients with dementia from 16 centres in Norway who had received treatment with a CEI until November 2001 (study 1, n = 1,167, retrospective case review) or who came to the first evaluation after onset of treatment (study 2; n = 252; prospective enrollment). Adverse events, global effectiveness, and Mini-Mental State Exam scores were recorded. RESULTS: In study 1, 56% of the patients were rated as mildly or markedly improved two to four months after onset of treatment. Side effects were recorded in 23%; 8% discontinued treatment due to side effects. In study 2, 49% were rated as mildly or markedly improved on at least one of the items cognition, psychiatric symptoms, activities of daily living or behaviour. Treatment was discontinued due to lack of effectiveness in 12%. INTERPRETATION: CEI were found to be useful in clinical practice in Norway. The open and uncontrolled design of the study limits the generalisability of the study.

[Dementia with Lewy bodies]. / Demens med Lewy-legemer.

BACKGROUND: Some 10%-15% of patients with dementia are diagnosed as dementia with Lewy bodies (DLB), a disorder characterised by the presence of Lewy bodies in the brainstem and cortex. MATERIAL AND METHODS: Review of pathology, clinical symptoms, pharmacological and nonpharmacological treatment, based on the literature and on personal experience. RESULTS: Neurochemical findings are marked cortical reduction of acetylcholine and nigrostriatal dopamine deficiency. Key features of the clinical syndrome are dementia, fluctuating consciousness, visual hallucinations and parkinsonism. There are pathological and clinical overlaps between DLB and Alzheimer's disease on the one hand, and between DLB and Parkinson's disease on the other; the relationship between these diseases awaits further elucidation. Clinical consensus criteria for DLB have been published and shown to have high sensitivity and specificity. Fluctuating consciousness may be difficult to detect, but diagnostic instruments exist that may help in the evaluation. Drug treatment of DLB is difficult. Cholinesterase inhibitors have been shown to improve cognition and psychiatric symptoms. Atypical antipsychotics may improve psychosis, but some patients develop severe sensitivity reactions. The effect of antiparkinson agents is unknown.