Unrecognised cognitive impairment in hospice patients: a pilot study.

The presence of cognitive impairment in patients who are receiving hospice care can affect numerous practical, ethical and legal aspects of their healthcare. A number of factors can contribute to cognitive impairment in these patients. Prevalence rates of cognitive impairment vary widely, but it remains under-recognised and under-treated. The aims of this pilot study were to evaluate the presence and nature of cognitive deficits in patients receiving inpatient hospice care who did not have a known current or past diagnosis of a cognitive disorder or any obvious cognitive impairments. A convenience sample of 30 patients receiving inpatient hospice care underwent bedside cognitive testing. A comprehensive battery of tests was used, including the Mini-Mental State Examination (MMSE) and standardised neuropsychological tests of pre-morbid intellectual functioning, immediate and delayed recall, digit span forward and backward, verbal reasoning and letter and category fluency. On average, subjects were impaired on the MMSE and on tests of learning, verbal reasoning and letter and category fluency. Furthermore, 12 of the 30 subjects met DSM-IV cognitive impairment criteria for dementia based on impaired performance in memory and at least one other cognitive domain on testing. The results of this pilot study suggest that a sizable proportion of patients receiving inpatient hospice care have undetected but clinically significant cognitive impairments. Assessing for and helping patients, families and caregivers deal with cognitive impairment might benefit patients' quality of life, relationships and overall care at the end of life. Future research in this population is needed to evaluate the causes and time course of cognitive impairment over time, as well as any relationship between cognitive impairment and decision-making capacity.

Multivariate predictors of social skills performance in middle-aged and older out-patients with schizophrenia spectrum disorders.

BACKGROUND: Cognitive impairment and negative symptoms are two of the primary features of schizophrenia associated with poor social functioning. We examined the relationships between clinical characteristics, specific cognitive abilities and social skills performance in middle-aged and older out-patients with schizophrenia and normal comparison subjects. METHOD: One hundred and ninety-four middle-aged and older schizophrenia out-patients and 60 normal comparison subjects were administered a standardized, performance-based measure of social skills using role-plays of various social situations [Social Skills Performance Assessment (SSPA)] and measures of current level of social contact (the Lehman Quality of Life Interview), psychiatric symptom severity [the Positive and Negative Syndrome Scale (PANSS) and the Hamilton Depression Rating Scale (HAMD)], insight [the Birchwood Insight Scale (IS)] and cognitive functioning [the Mattis Dementia Rating Scale (DRS)]. RESULTS: Patients demonstrated worse social skills compared with normal subjects. Better performance on the SSPA was associated with having less severe positive and negative symptoms, fewer social contacts, and better attention, initiation/freedom from perseveration, visuospatial ability, abstraction ability and memory. After controlling for demographic, clinical and insight-related factors, abstraction ability was the strongest predictor of social skills performance, followed by frequency of social contact. CONCLUSIONS: Social functioning (as measured through direct observation of social skills performance) was related to cognitive ability in out-patients with schizophrenia. Addressing such cognitive impairment may help to improve social functioning and result in greater overall quality of life.

Neurocognitive functioning in dually diagnosed middle aged and elderly patients with alcoholism and schizophrenia.

BACKGROUND: Alcohol abuse and dependence have important clinical implications for managing patients with schizophrenia. Alcoholism in schizophrenia patients can interfere with the course and prognosis of the schizophrenic illness. OBJECTIVE: The purpose of the present study was to compare the cognitive status, symptom profile and quality of life of middle aged and older patients (>44 years old) with schizophrenia and alcohol abuse/dependence vs those without alcohol abuse/dependence. We initially hypothesized that more males in this age group with schizophrenia would exhibit alcoholism. We also examined the characteristics of the 45-54 year age group with those of the > or = 55 year old group and hypothesized that comorbidity with alcohol would be associated with worse cognition and quality of life in later life. METHODS: Data were obtained from a database from the Center for Services and Interventions research at the University of California, San Diego. Patients had diagnoses of schizophrenia or schizoaffective disorder. Data collected included demographic characteristics, cognitive status (tested with the Mattis Dementia Rating Scale learning, the Figural and Story Memory Test of the Wechsler Memory Scale-Revised and the California Verbal Learning Test [CVLT]). In addition, patients had undergone psychopathologic assessment and were screened for quality of life using the Quality of Well Being scale. RESULTS: We demonstrated that the older aged patients with alcoholism had worse scores assessing cognition relative to the same aged group without alcoholism. In addition, they had worse cognitive scores relative to the younger group (45-54 year old) with alcoholism. There was no significant difference with regards to quality of life. In addition, more males than females exhibited alcoholism. CONCLUSION: The results are consistent with the premise that the higher cognitive function in the younger schizophrenia patients with alcoholism appear to mask the effects of alcohol use on cognition at that age. However, for the older group of schizophrenia patients, the effects of alcohol use on neuropsychological functioning appear to be deleterious.

Cognitive training in Alzheimer's disease: a meta-analysis of the literature.

OBJECTIVE: To systematically review the literature and summarize the effect of cognitive training (CT) for Alzheimer's disease (AD) patients on multiple functional domains. METHOD: Effect sizes (Cohen's d) were calculated for 17 controlled studies identified through a comprehensive literature review. RESULTS: An overall effect size of 0.47 was observed for all CT strategies across all measured outcomes. Mean effect sizes were higher for restorative (0.54) than for compensatory (0.36) strategies. Domain-specific effect sizes ranged from 2.16 (verbal and visual learning) to -0.38 (visuospatial functioning). Data are also presented on the relative impact of restorative and compensatory strategies for each domain of functioning. CONCLUSION: CT evidenced promise in the treatment of AD, with primarily medium effect sizes for learning, memory, executive functioning, activities of daily living, general cognitive problems, depression, and self-rated general functioning. Restorative strategies demonstrated the greatest overall effect on functioning. Several limitations of the published literature are discussed.

Pharmacologic management of psychosis in the elderly.

Antipsychotic medications are the pharmacologic agents of choice for treating psychosis in elderly persons. Age-related physiological changes make older persons more sensitive to the therapeutic and toxic effects of antipsychotics. There is a paucity of controlled studies on the efficacy of antipsychotic medications in older persons. Existing data suggest that atypical antipsychotics are at least as efficacious as and better tolerated than the conventional agents. For elderly persons, important adverse effects of antipsychotics include sedating, anticholinergic, and cardiovascular effects, extrapyramidal symptoms, and tardive dyskinesia. Some atypical antipsychotics appear to carry a risk of metabolic changes. Clinical recommendations include a thorough diagnostic evaluation followed by treatment with atypical antipsychotics at low dosages. It is essential that medication be combined with an appropriate psychosocial intervention in order to optimize its effect. Non-antipsychotic medications may provide useful adjunctive or alternative treatment and should be considered on a case-by-case basis.

Influence of Alzheimer pathology on clinical diagnostic accuracy in dementia with Lewy bodies.

OBJECTIVE: To determine whether AD neurofibrillary pathology influences clinical diagnostic accuracy in dementia with Lewy bodies (DLB). BACKGROUND: Pathologic diagnosis of DLB mandates Lewy bodies but also allows for AD pathology in the form of plaques and tangles. Because clinical diagnostic accuracy of DLB remains low, the authors questioned whether the severity of AD pathology in the form of tangles might affect the clinician's ability to correctly diagnose DLB in life. DESIGN/METHODS: Ninety-eight subjects with autopsy-proven DLB who had been evaluated annually at the University of California San Diego AD Research Center were identified. The clinical diagnosis used was the last diagnosis before death. Pathologic diagnosis of DLB was made according to Consensus guidelines, and Braak staging was used to assess the degree of neurofibrillary AD pathology. The clinical characteristics of subjects with DLB with low vs high Braak stages were compared and the clinical diagnostic accuracy for subjects stratified according to Braak stage was determined. RESULTS: Only 27% of the subjects with DLB demonstrated both visual hallucinations and spontaneous extrapyramidal signs (EPS). The low Braak stage (0 to 2, n = 24) subjects had a higher frequency of visual hallucinations (65%) than did subjects with DLB with higher (3 to 6, n = 66) Braak stages (33%, p = 0.008), and showed a slightly greater but not significant degree of EPS. Although clinical diagnostic accuracy for DLB was relatively low (49%), it was higher for subjects with low (75%) compared to high (39%) Braak stages (p = 0.0039). CONCLUSIONS: The degree of concomitant AD tangle pathology has an important influence on the clinical characteristics and, therefore, the clinical diagnostic accuracy of DLB.

Aging and outcome in schizophrenia.

OBJECTIVE: Controversy exists about long-term outcome of schizophrenia, but few studies have compared older out-patients to normal subjects. We sought to examine the relationship of age to clinical features, psychopathology, movement abnormalities, quality of well-being, and everyday functioning in schizophrenia out-patients and normal comparison subjects, and to further characterize these outcomes in elderly schizophrenia out-patients. METHOD: A total of 290 out-patients and 144 comparison subjects, aged 40-85 years, underwent comprehensive assessments. RESULTS: Among patients, aging was associated with decreased psychopathology, even after controlling for duration of illness. There was no accelerated aging-related decline on any measure in the patients. Yet, elderly patients were more impaired than comparison subjects on various measures. CONCLUSION: The course of schizophrenia in late life appears stable, but most elderly patients remain symptomatic and impaired. Our findings dispute notions of either progressive deterioration or marked improvement in aging schizophrenia out-patients.

Psychotic symptoms in Alzheimer disease: evidence for a distinct phenotype.

Though efforts to identify the genetic etiology of Alzheimer disease (AD) have made substantial progress, to date only some of the genes contributing to AD risk have been identified. Utilization of more etiologically homogeneous subphenotypes represents one strategy to facilitate the identification of novel risk genes in complex disorders. In this review, we evaluate the hypothesis that psychotic symptoms, such as delusions and hallucinations, define a suitable subphenotype in AD patients for gene-mapping efforts. Psychotic symptoms occur in 40-60% of patients with AD and are associated with more severe cognitive deficits and a more rapidly deteriorating course. The presence of psychotic symptoms in AD confers increased risk of similar symptoms to affected siblings. Candidate gene association analyses and initial linkage analysis have yielded significant results. We discuss possible genetic models of psychotic symptoms in AD, and suggest strategies for further investigation. Identification of such genetic factors may facilitate gene-mapping studies for both AD and idiopathic psychoses.

Ethical issues in psychosocial interventions research involving controls.

Psychiatric research is of critical importance in improving the care of persons with mental illness. Yet it may also raise difficult ethical issues. This article explores those issues in the context of a particular kind of research: psychosocial intervention research with control groups. We discuss 4 broad categories of ethical issues: consent, confidentiality, boundary violations, and risk-benefit issues. We believe that, despite the potential difficulties, psychosocial intervention research is vital and can be accomplished in an ethical manner. Further discussion and research into these issues are warranted.

Schizophrenia in homeless persons: a systematic review of the literature.

OBJECTIVE: This article systematically reviews studies of prevalence of schizophrenia in homeless persons. METHOD: Medline and PsychInfo were searched using the key words: homeless person, mental illness, psychosis, and schizophrenia. The bibliographies of identified articles were also reviewed. RESULTS: Study designs varied considerably. The rate of schizophrenia in homeless persons reported in the 33 published reports, representing eight different countries, ranged from 2 to 45%. In the 10 methodologically superior studies, the prevalence range was 4-16% and the weighted average prevalence was 11%. In addition, rates were higher in younger persons, women and the chronically homeless. Slightly less than half of the homeless persons with schizophrenia were not currently receiving treatment. CONCLUSION: Schizophrenia is much more prevalent among homeless persons than in the population at large. Future research should focus on better ways of meeting the mental health care needs of homeless people with schizophrenia.

Citalopram augmentation of antipsychotic treatment in older schizophrenia patients.

BACKGROUND: Depressive symptoms are common in older patients with schizophrenia; yet, few studies have examined the usefulness of antidepressants in this population. OBJECTIVE: We conducted a 10-week single-blind trial of citalopram (20-40 mg/day) vs no citalopram augmentation in 19 middle-aged and elderly patients with schizophrenia hospitalized for more than six of the last 12 months. At study-entry, the patients had been on stable doses of antipsychotics for at least two weeks, and had a 17-item Hamilton Depression Rating (HAM-D) scale score of 12 or greater. Nine patients were randomly assigned to citalopram augmentation, and 10 to no augmentation of antipsychotics. RESULTS: Patients in both groups improved on positive and negative symptoms, but the citalopram group had significantly greater improvement in HAM-D and Clinical Global Impression Scale scores than the control group. There were no major side effects. CONCLUSION: Larger double-blind studies are needed to follow up on these preliminary findings.

National Institute of Mental Health Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE): Alzheimer disease trial methodology.

The authors describe the development of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) protocol for Alzheimer disease (AD), a trial developed in collaboration with the National Institute of Mental Health (NIMH), assessing the effectiveness of atypical antipsychotics for psychosis and agitation occurring in AD outpatients. They provide an overview of the methodology utilized in the trial as well as the clinical-outcomes and effectiveness measures that were implemented.

Enhancing comprehension of consent for research in older patients with psychosis: a randomized study of a novel consent procedure.

OBJECTIVE: The ability of individuals with schizophrenia to provide informed consent for research has become the focus of public debate. The authors examined whether a novel consent procedure improved the comprehension of consent for older patients with psychosis. METHOD: Fifty outpatients with schizophrenia or other psychotic disorders and 19 normal comparison subjects aged 40-80 were randomly assigned to groups given either a routine or an enhanced consent procedure. The latter utilized a computerized presentation that included sequential bullet points and summaries of key information. A posttest measured comprehension of consent-relevant information. RESULTS: A significantly greater proportion of patients who received the enhanced consent procedure scored 100% on first and second trials of the posttest, compared to those receiving the routine procedure (trial 1: 42.3% versus 8.3%; trial 2: 80.8% versus 45.8%, respectively). CONCLUSIONS: The enhanced consent method improved comprehension of information relevant for consent in older patients with psychosis.

Relationship of gender and age at onset of schizophrenia to severity of dyskinesia.

The authors examined severity of dyskinesia in 119 men and 44 women, comparing by gender those with late-onset schizophrenia (LOS) versus early-onset schizophrenia (EOS). Women with LOS and men with EOS had more severe dyskinesia than men with LOS and women with EOS. Many factors, including the length of neuroleptic treatment, alcohol and smoking history, and menopausal status, may contribute to the severity of dyskinesia in older patients with schizophrenia.

Personality profiles among normal aged individuals as measured by the NEO-PI-R.

The revised Neuroticism (N), Extraversion (E), Openness (O) to experience Personality Inventory (NEO-PI-R) is a multidimensional measure of normal personality traits that is intended to assess five major personality dimensions or domains-N, E, O, Agreeableness (A), and Conscientiousness (C). Although several studies have been conducted examining N, E, and O factors in people 65 through to 85 years old, there has been little research examining all five-core domains of personality in individuals 85 and older. We compared the NEO-PI-R domains and facet traits in the middle-aged/young-old versus old-old normal subjects. Thirty-eight community-dwelling subjects (22 women, 16 men) free from major neuropsychiatric disorders were given the NEO-PI-R, a self-administered 240-item personality inventory, assessing 30 facet traits within the five domains. We compared the scores of 21 middle-aged and young-old (age 50-84) individuals, to those of 17 old-old (age 85-100) subjects. The personality profiles of the two groups were similar except that the old-old group had lower scores on Extraversion, and four of the 30 facet traits (warmth, positive emotions, impulsiveness, and order) compared to the middle-aged/young-old group. These results were limited by the cross-sectional design and small sample size. Nonetheless, the findings suggest that the middle-aged/young-old and the old-old normal subjects have fairly similar personality traits.

Anxiety disorders in older adults.

In the population of older adults, anxiety disorders are underdiagnosed and undertreated. Epidemiologic studies have generally found that the prevalence of anxiety disorders declines with age. Recognition of anxiety disorders in older adults is, however, complicated by several age-related factors including the presence of depression, cognitive impairment, and physical illness. A variety of medications have been used to treat anxiety disorders across the life span; however, few studies have evaluated their use specifically in older adults. Choice of medication requires consideration of the effects of aging on safety, tolerability, and adherence. Available data suggest that cognitive and behavioral treatments may be effective for anxiety disorders in older adults. Appropriate medical evaluation and psychosocial interventions are recommended prior to initiating pharmacotherapy. When pharmacologic treatment is warranted, antidepressant medications at low doses may be useful for late-life anxiety disorders; other agents may be considered for augmentation or second-line use in certain types of patients.

Health-related quality of well-being in chronically hospitalized patients with schizophrenia: comparison with matched outpatients.

Quantifying the functional consequences of illness in terms of quality of life can enhance our understanding of both mental and physical disorders. However, little is known about the quality of life among older inpatients vs. outpatients with schizophrenia. We present the results of health-related quality of life assessments in 54 middle-aged and elderly long-term inpatients with schizophrenia and a demographically matched outpatient sample. Assessments were performed using the Quality of Well-Being (QWB) scale, along with standard measures of psychopathology and global cognitive impairment. Compared with outpatients, the inpatients had a significantly lower health-related quality of life, as measured by the QWB. In the inpatient and outpatient groups, higher levels of positive symptoms were associated with lower health-related quality of life. Health-related quality of life remained fairly stable among the inpatients who remained hospitalized over 6 months. In both inpatients and outpatients, baseline cognitive status and psychopathology predicted QWB scores at the 6-month follow-up. These findings further support the use of the QWB in severely mentally ill populations; implications for improving health-related quality of life among older patients with schizophrenia are discussed.

A comparison of community-dwelling older schizophrenia patients by residential status.

OBJECTIVE: Differences in residential status may contribute to the diversity of findings observed in community-based samples of patients with schizophrenia. We compared older out-patients living independently with those in assisted-care facilities. METHOD: Two hundred and fifty-one out-patients with schizophrenia or schizoaffective disorder, aged 40-97 years, who had been referred to our Intervention Research Center were examined. RESULTS: Assisted living status was associated with an earlier age at onset of illness, longer illness duration, lower probability of having ever been married, more severe negative symptoms, worse cognitive impairment, and a poorer health-related quality of wellbeing. Independent living and assisted-care patients had similar levels of positive and depressive symptoms, and were on comparable doses of neuroleptic medication. Significant 'predictors' of residential status were marital status, cognitive impairment and quality of wellbeing. CONCLUSION: Among schizophrenia out-patients, one needs to consider residential status in evaluating heterogeneity in cognitive performance or quality of wellbeing.