The natural history of acute organic mental syndrome after bilateral electroconvulsive therapy.

Thirty-one patients undergoing electroconvulsive therapy (ECT) were followed prospectively for the development of acute organic mental syndrome (AOMS); 15 patients (48.4%) developed AOMS during ECT. For these 15 patients, the average number of ECTs before development of AOMS was 5.5 with average duration of AOMS being 20.1 days. Comparison of these 15 patients to the 16 patients who did not develop AOMS for diagnoses, demographic data, pre-ECT laboratory data, and medications, differed only in exposure to psychoactive medications and prior presence of major medical illness.

Use of THA in treatment of Alzheimer-like dementia: pilot study in twelve patients.

THA, a centrally acting anticholinesterase, was given intravenously in varying doses to 12 unselected cases of Alzheimer-like senile dementia. Significant improvement in memory testing occurred in 6 of 12 subjects; 9 of 12 improved in clinical staging. Analysis of results with respect to staging of dementia revealed that the degree of improvement was inversely related to the severity of dementia. Statistical analysis of these data by the Friedman test is detailed.

Drug modification of ECT: methohexital and diazepam. II.

A systematic comparison of methohexital and diazepam as anesthetics in the drug modification of ECT was done by holding atropinizaton, succinylcholine-depolarizing neuromuscular blockade, and resuscitation constant while monitoring four ECT in each of 24 patients. Each patient served as his own control, and two dosages of each drug (0.25 and 0.35 mg/kg diazepam, 0.9 and 1.1 mg/kg methohexital) were given each patient in all possible orderings (4! = 24) in a scheduled experimental design in which methohexital was given by very rapid (5 sec) and diazepam was given by the recommended slower (60 sec) infusion. The data revealed significant differences and methohexital was superior. Eight of 48 (17%) EKGs were abnormal post-ECT with methohexital, 18 of 48 (38%, phi = 5.3, p < 0.025) with diazepam. Five of 24 (21%) patients had an abnormal post-ECT EKG with methohexital, 15 of 24 (60%, phi 8.6, p < 0.005) with diazepam. Significantly more ventricular premature contractions (VPCs) occurred after diazepam. Diazepam records contained both more numerous and more extensive EKG abnormalities. Methohexital induction was clinically superior as well; there was little of the induction restlessness seen in seven treatments with diazepam (phi2 7.6, p < 0.01). The differences were less marked than in a previous study in which diazepam was given as rapidly as methohexital. Methohexital has been demonstrated to be the anexthesia of safety and choice for ECT when compared to diazepam.

Delirium after cataract surgery: review and two cases.

The authors define the delirium seen after cataract surgery on the basis of Dupuytren's original description and review studies using the criteria they set up on this basis. They then present prospective data on 2 patients with postcataractectomy delirium and 25 patients who did not experience this delirium. The data suggest that delirium after cataract surgery represents anticholinergic toxicity.

Psychiatric illness in a general urban emergency room: daytime versus nighttime population.

Two hundred adults presenting to the emergency room of an urban general hospital were interviewed by a standardized technique to evaluate the existence of a current or previous psychiatric illness. Half of the subjects presented between 8:00 a.m. and 4:00 p.m. (daytime group), and 100 presented between 12:00 a.m. and 8:00 a.m. (nighttime group). In the nighttime population 65% were judged to have current or past psychiatric illnesses. In the daytime population only 36% had current or past psychiatric illnesses. The differences between the 2 populations was highly significant. Fewer than 10% of the 200 patients presented with neuropsychiatric symptoms in their chief complaints.

The psychiatric physical examination - Part I: methodology.

The frequency of medical findings in psychiatric patients is quite high. Regardless, none of the responding psychiatrists in a recent survey do routine physical examinations. In response to this survey, the authors describe a method of rapid physical examination specifically designed for the psychiatric patient. The average duration of the examination in 75 patients was 16.9 minutes. There was no evidence of negative transference or countertransference. The level of competency required was that of a medical student, yet there were 8.2 physical findings per patient with 5.3 physical findings per patient being unknown previously.

The psychiatric physical examination - Part II: findings in 75 unselected psychiatric patients.

The psychiatric physical examination described in the previous paper was done on 75 new psychiatric inpatients. The examiners were one psychiatrist and two psychiatrist-internists. Results confirmed the high frequency of known and unsuspected medical illnesses previously reported in the literature. Additionally, the specific "psychiatric physical examination" confirmed the known psychiatric diagnoses in 76% of the patients and led to consideration of a second or other psychiatric diagnoses in 43% of the patients.

The general adult inpatient psychiatric assessment scale (GAIPAS).

The General Adult Inpatient Psychiatric Assessment Scale (GAIPAS) is a "here and now" testing instrument based on the general mental status examination. The unique features of the GAIPAS include high interrater reliability with minimal training, "forced choice" format, a scoring method for hostile patients, brief administration time, and a format that lends itself to direct key punch of data. The GAIPAS may be used to follow a symptom, a set of symptoms, or collapsed into a single number comparable to the Global Assessment Scale. Interrater reliability of GAIPAS by interviewer/observer design is given in detail. The GAIPAS is compared to the Brief Psychiatric Rating Scale (BPRS) and Global Assessment Scale (GAS) in the same population for interrater reliability.

Psychiatric sequelae to cardiotomy.

Eight of twenty-six subjects undergoing cardiotomy had a diagnosable psychiatric syndrome after surgery. No difference between psychiatric and non-psychiatric cases was noted with respect to demographic data, pre-operative medical psychiatric history, anesthesia time, serial laboratory studies, or environment. Post-operative psychiatric cases, however, did have significantly higher exposure to psychoactive drugs during the pre- and post-operative period.

Tacrine in the treatment of Alzheimer's disease. A clinical update and recent pharmacologic studies.

The initial report of the effectiveness of tacrine or tetrahydroaminoacridine (THA) in the treatment of some patients with Alzheimer's disease has been confirmed by further study of additional subjects and by preliminary reports from other investigators. The major side effect, elevation of liver enzymes, is shown to be reversible, dose-dependent and without significant hepatic pathology. Therapeutic serum concentrations of THA vary between 7 and 20 ng/ml. In addition to its presumed action as an acetylcholinesterase inhibitor, data are presented demonstrating marked effects on other brain neurotransmitters in animal models.

Alcohol use and psychiatric illness in emergency patients.

Screening for alcoholism and associated psychiatric disorders using preselected research criteria demonstrated an overall prevalence of alcoholism of 20% in 200 emergency department patients. The nighttime prevalence of alcoholism was 29%, while the daytime prevalence was 11%. The psychiatric disorders most frequently associated with alcoholism were primary affective disorder (depression) and antisocial personality. The alcoholics had chief complaints relating to trauma in 63% of the cases, vague neuropsychiatric complaints in 23% of the cases, and complaints directly related to alcohol in 8% of the cases. Screening for alcoholism and associated psychiatric illnesses is important in determining an overall treatment strategy for emergency patients.

Comparison of seven psychometric instruments used for evaluation of treatment effect in Alzheimer's dementia.

Standards of assessment of treatment effect in Alzheimer's disease have been wanting. We report here a comparison of seven methods of assessment of the severity of Alzheimer's disease used in demented subjects (n = 18) and in nondemented controls (n = 18). The instruments tested were the Names Learning test, the Orientation test, the Mini-Mental State Examination, the Alzheimer's Staging Scale (the AZSS), the Global Deterioration Scale, the Clinical Dementia Rating Scale, and the Alzheimer's Deficit Scale (ADS). Two examiners did the testing per telephone methodology, and test/retest design. Results showed all tests to be reliable. A ceiling and/or basement effect was noted in all but the AZSS and the ADS.

Oral tetrahydroaminoacridine in long-term treatment of senile dementia, Alzheimer type.

We treated 17 patients who had moderate to severe Alzheimer's disease with oral tetrahydroaminoacridine (THA), a centrally active anticholinesterase, in a three-phase study. In the nonblinded first phase of the study, significant improvement occurred in subjects who received the drug, as compared with their pretreatment status, on the global assessment (P = 0.001), the Orientation Test (P = 0.001), and the more sophisticated Names Learning Test (P = 0.001). During the second phase, the subjects served as their own controls in a double-blind, placebo-controlled, cross-over study in which the order of administration of the drug and placebo was randomly assigned. Among the 14 subjects completing Phase II, THA treatment produced significantly better results than placebo on the global assessment (P = 0.003), the Orientation Test (P = 0.004), the Alzheimer's Deficit Scale (P = 0.003), and the Names Learning Test (P = 0.001). Twelve subjects have entered Phase III, which involves long-term administration of oral THA. The average duration of treatment in these subjects at present is 12.6 months; symptomatic improvements have occurred, and no serious side effects attributable to THA have been observed. These encouraging initial results suggest that THA may be at least temporarily useful in the long-term palliative treatment of patients with Alzheimer's disease. We stress that further observations will be required before a clear assessment of the role of this agent can be made.

Isolation and the fluorometric, high-performance liquid chromatographic determination of tacrine.

Tacrine (THA; 1,2,3,4-tetrahydro-9-aminoacridine) is an anticholinesterase agent which has been used clinically, most recently in the treatment of Alzheimer-type dementias. This paper describes the methodology for the isolation and quantitation of THA at therapeutic levels in serum from human subjects. Using C18 Bond Elut columns and an HPLC/fluorometry system, this assay exhibits a considerable improvement in sensitivity over previous uv methods, and allows routine testing of THA levels in serum samples of reasonable volume from human subjects.