'Auspicious liaisons'-evaluating the impact of a liaison geriatrician initiative on older adults psychiatric wards.

BACKGROUND: Although liaison services in acute hospitals are now the norm, the reverse is not usually available for patients in mental health trusts. Following the introduction of support from geriatricians to older people's mental health inpatient wards, we wanted to see if this intervention was effective and acceptable to clinicians. METHODS: We performed a retrospective cohort service evaluation on the impact of a liaison geriatrician, using routinely collected data, and assessed acceptability among medical staff by semi-structured interview. INTERVENTION: Our service introduced regular sessions from consultant community geriatricians across older adults psychiatric wards including a mixture of video conference and face-to-face input. RESULTS: There was no significant decrease in emergency transfers but there was a significant reduction in length of stay with an associated cost benefit for the service after the introduction of a liaison geriatrician. There was a significant increase in geriatrician consultations and a decrease in specialty consultations to other specialists. There was no change in discharge prescriptions or destination. There was a significant reduction in falls in the intervention arm but not in falls leading to emergency hospital admissions geriatricians gave confidence to psychiatrists of all grades to treat physical health care issues. CONCLUSIONS: A liaison geriatrician service may be a component in reducing length of stay (although there are many others) and improving continuity of care, although it confers no impact on emergency transfers. The intervention was highly acceptable to clinicians.

Impact of COVID-19 on mental health research: is this the breaking point?

There are many structural problems facing the UK at present, from a weakened National Health Service to deeply ingrained inequality. These challenges extend through society to clinical practice and have an impact on current mental health research, which was in a perilous state even before the coronavirus pandemic hit. In this editorial, a group of psychiatric researchers who currently sit on the Academic Faculty of the Royal College of Psychiatrists and represent the breadth of research in mental health from across the UK discuss the challenges faced in academic mental health research. They reflect on the need for additional investment in the specialty and ask whether this is a turning point for the future of mental health research.

How does carer management style influence the performance of activities of daily living in people with dementia?

INTRODUCTION: People with Dementia (PwD)'s performance of activities of daily living (ADLs) has been associated with apathy, cognitive deficits, carers' depression and burden. However, it is not known if the carers' management style affects ADL performance, particularly alongside PwD's cognitive deficits and apathy. Thus, the aim of this study was to explore the contribution of intrinsic (cognition, apathy) and extrinsic (carer management styles) dementia factors to ADL performance. METHODS: PwD (n = 143) were assessed on global cognition (ACE-III); apathy (CBI-R); ADLs (Disability Assessment for Dementia-DAD). Carers' (n = 143) criticism, encouragement and active-management styles were assessed with the Dementia Management Strategy Scale (DMSS). Multiple linear regression analysis investigated contributions of carer styles, cognition, apathy (independent variables) on ADLs (dependent variable). RESULTS: The best model explaining the variance of the DAD scores included cognition (ß = 0.413, t(142)  = 4.463, p = 0.001), apathy (ß = -0.365, t(142)  = -5.556, p = 0.001), carer criticism (ß = -0.326, t(142)  = -2.479, p = 0.014) and carer encouragement styles (ß = 0.402, t(142)  = 2.941, p = 0.004) accounting for 40% of the variance of the DAD scores. CONCLUSIONS: This novel study demonstrated that PwD's level of apathy and the carer's use of criticism negatively affected ADL performance while PwD's cognitive abilities and carer encouragement style improved ADL performance. These findings have critical implications for the development of novel multi-component non-pharmacological interventions to maintain function and delay disease progression in dementia, as well as direct relevance to current carers and families.

Investigation of risk of dementia diagnosis and death in patients in older people's secondary care mental health services.

OBJECTIVES: Previous studies have shown increased rates of death and dementia in older people in specific serious mental illnesses (SMI) such as bipolar disorder or depression. We examined the rates of death and dementia in older people referred into a secondary care psychiatric service across a range of SMIs. METHODS: We used an anonymised dataset across 6 consecutive years with 28,340 patients aged 65 years and older from a single secondary care psychiatric trust in the United Kingdom. We identified deaths and incident dementia in patients with bipolar disorder/mania, schizophrenia, recurrent depression and anxiety disorders. We compared mortality and dementia rates between these diagnostic groups and in different treatment settings. We also examined mortality rates and dementia rates compared with general population rates. RESULTS: Patients with schizophrenia showed the highest hazard rate for death compared to other groups with SMIs (hazard ratio, 1.58; 95% confidence interval (CI), 1.18-2.1, with anxiety group the reference). Survival was reduced in patients referred to liaison psychiatry services. There were no significant differences between the SMI groups in terms of rates of dementia. However, risks of death and dementia were significantly increased compared to the general population (standardized mortality rates with 95% CI, 2.6(2.0-3.3), 3.5(2.6-4.5), 2.5(2.0-3.0) and 1.8 (1.4-2.2) and standardized dementia incidence rates with 95% CI, 2.7(1.5-4.1), 2.9(1.5-4.7), 3.8(2.6-5.2) and 4.3 (3.0-5.7) for bipolar disorder/mania, schizophrenia, recurrent depression and anxiety disorders respectively. CONCLUSIONS: Older adults referred into an old age psychiatry service show higher rates of dementia and death than those reported for the general population.

Audit of memory clinic practice against CCG guidelines: West Suffolk Hospital.

INTRODUCTION: The memory service based in the West Suffolk has received increased funding to deliver a high quality service against standards set by the Clinical Commissioning Group (CCG). AIMS: This audit aims to examine if we are achieving the standards set by the local CCG and to identify areas to improve the quality of the service.We also aimed to assess information as to how many patients referred had dementia. If they had a dementia suitable for possible anti-dementia medication (such as dementia of Alzheimer's type, Alzheimer's mixed type or atypical or Lewy body/ Parkinson's dementia) to ascertain if they were being offered anti-dementia medication. METHODS: Retrospective analysis of 60 patients from the memory service were analysed. The first 10 patients referred in alternative months were selected for inclusion. Standards were based on targets set by the CCG in terms of time needed to assess, diagnose, communicate diagnosis to the GP and give post diagnostic advice. RESULTS: Patients in this memory service were being seen 37 days (on average) after referral. Most patients received a diagnosis at their initial assessment but some needed further investigation to establish the diagnosis or the specific type of diagnosis. The time for letters to be typed did not meet standards and letters were sent out on average 23 days after patients were being seen. Post diagnostic advice was delivered to most who received a diagnosis. CONCLUSIONS: Our service is offering timely diagnosis to those referred to the memory service in line with national guidelines.

Cut-off scores for mild and moderate dementia on the Addenbrooke's Cognitive Examination-III and the Mini-Addenbrooke's Cognitive Examination compared with the Mini-Mental State Examination.

AIMS AND METHOD: We aimed to establish cut-off scores to stage dementia on the Addenbrooke's Cognitive Examination-III (ACE-III) and the Mini-Addenbrooke's Cognitive Examination (M-ACE) compared with scores traditionally used with the Mini-Mental State Examination (MMSE). Our cross-sectional study recruited 80 patients and carers from secondary care services in the UK. RESULTS: A score ≤76 on the ACE-III and ≤19 on the M-ACE correlated well with MMSE cut-offs for mild dementia, with a good fit on the receiver operating characteristic analysis for both the ACE-III and M-ACE. The cut-off for moderate dementia had lower sensitivity and specificity. There were low to moderate correlations between the cognitive scales and scales for everyday functioning and behaviour. CLINICAL IMPLICATIONS: Our findings allow an objective interpretation of scores on the ACE-III and the M-ACE relative to the MMSE, which may be helpful for clinical services and research trials.

Efficacy of a dementia intensive support (DIS) service at preventing admissions to medical and psychiatric wards: qualitative and quantitative evaluation.

AIMS AND METHOD: To establish whether a dementia intensive support (DIS) service that is part of a crisis resolution and home treatment team for older people is preventing admissions to acute hospital and psychiatric wards. The number of referrals in 2017 to the DIS service was established and those admitted to hospital ascertained. Senior doctors examined 30 sets of notes in detail and reached a conclusion on whether DIS had contributed to admission prevention. This information was then re-examined in two meetings with at least eight senior psychiatrists present. A consensus opinion was then reached as to whether DIS had contributed to admission prevention in each case. RESULTS: Over 12 months, 30/171 patients (18%) referred were admitted to hospital. For the subset of 30 referrals examined in detail, DIS contributed to admission avoidance in 21 cases (70%). CLINICAL IMPLICATIONS: Our evaluation demonstrates that the DIS service is an effective way of preventing admission.

The neural basis of mood-congruent processing biases in depression.

BACKGROUND: Mood-congruent processing biases are among the most robust research findings in neuropsychological studies of depression. Depressed patients show preferential processing of negatively toned stimuli across a range of cognitive tasks. The present study aimed to determine whether these behavioral abnormalities are associated with specific neural substrates. METHODS: Ten depressed patients and 11 healthy control subjects underwent scanning during performance of an emotional go/no-go task using functional magnetic resonance imaging. The task allowed comparison among neural response to happy, sad, and neutral words, in the context of these words as targets (ie, stimuli to which subjects were required to make a motor response) or distractors (ie, stimuli to which the motor response was withheld). RESULTS: Depressed patients showed attenuated neural responses to emotional relative to neutral targets in ventral cingulate and posterior orbitofrontal cortices. However, patients showed elevated responses specific to sad targets in rostral anterior cingulate extending to anterior medial prefrontal cortex. Unlike controls, patients showed differential neural response to emotional, particularly sad, distractors in the lateral orbitofrontal cortex. CONCLUSIONS: These findings suggest a distinct neural substrate for mood-congruent processing biases in performance. The medial and orbital prefrontal regions may play a key role in mediating the interaction between mood and cognition in affective disorder.

A memory clinic v. traditional community mental health team service: comparison of costs and quality.

Aims and method To compare the cost and quality of a memory-clinic-based service (MCS) with a traditional community mental health team (CMHT) service. Using a retrospective case-note review, we studied two groups, each with 33 participants. Consecutive referrals for diagnostic 'memory' assessments over 4 months were evaluated. Participants were evaluated for up to 6 months. Results The MCS was less costly than the CMHT service but the difference was not statistically significant (mean cost for MCS was £742, mean cost for CMHT service was £807). The MCS offered more multidisciplinary and comprehensive care, including: pre- and post-diagnostic counselling, more systematic screening of blood for reversible causes of dementia, more use of structured assessment instruments in patients/carers, signposting to the third sector as well as more consistent copying of letters to patients/carers. Clinical implications An MCS service offered more comprehensive and multidisciplinary service at no extra cost to secondary care.

Abnormal ventral frontal response during performance of an affective go/no go task in patients with mania.

BACKGROUND: Patients with mania show a behavioral bias toward positive information in an emotional go/no go task. This is the converse of the bias toward negative information seen in unipolar depression that we have recently related to the abnormal function of ventral and medial prefrontal cortices (PFCs). The aim of this study was to investigate the neuronal basis of the bias toward positive information in manic patients. METHODS: During performance of an emotional go/no go task using functional magnetic resonance imaging, 8 manic patients and 11 healthy controls were scanned. The task allowed comparison between neural response to happy, sad, and neutral words in the context of these words being either targets or distracters. RESULTS: Manic patients showed attenuated orbitofrontal response when all the semantic conditions were compared with a control condition; however, they showed an enhanced response of the left ventrolateral PFC to emotional relative to neutral targets, as well as enhanced ventral and medial prefrontal response to emotional, particularly happy, distracters. CONCLUSIONS: These results suggest a critical role for ventral and medial dysfunction in the pathology of mania, which might underpin aspects of cognitive and clinical symptomatology.

The effects of tyrosine depletion in normal healthy volunteers: implications for unipolar depression.

RATIONALE: In recent years, there has been a growing interest in the role of dopamine (DA) both in the pathogenesis of unipolar depression and in motivated behaviour. The innovative technique of acute tyrosine depletion presents an opportunity to characterise further its function in these domains. OBJECTIVE: The present study examined the physiological, subjective and cognitive effects of acute tyrosine depletion in healthy volunteers. METHODS: A double-blind, placebo-controlled, parallel group design was employed. Half of the participants ingested a balanced amino-acid mixture (BAL) and the other half received an identical mixture except that tyrosine and phenylalanine were absent (TYR-free). Plasma amino acid concentrations and subjective ratings were monitored at both baseline (T(0)) and 5 h following consumption (T(5)) of the mixtures. A comprehensive neuropsychological test battery was also administered at T(5). RESULTS: Relative to the BAL group, the reduction in TYR availability to the brain was more marked in the TYR-free group. Employment of psychological rating scales revealed that, compared with the BAL group, the TYR-free group became less content and more apathetic. For the affective go/no-go task, whilst the BAL group exhibited a happy latency bias, the TYR-free group demonstrated a sad latency bias. Furthermore, in the decision-making task, the rate at which the TYR-free group increased their bets in response to more likely outcomes was lower than that of the BAL group. Taken together, these neuropsychological findings strikingly paralleled those reported in previous investigations of unipolar depression. The experimental groups could not be differentiated on any of the other neuropsychological measures, including more classical assessments of fronto-executive function. CONCLUSION: These findings are consistent with the hypothesis that dopaminergic factors are particularly involved in disrupted affect/reward-based processing characteristic of clinical depression.