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Older At-Risk Adults Less Likely to Report Alcohol-Related Health Problems

Prior research has shown that while older adults (≥55 years of age) consume alcohol in amounts comparable to younger adults, their demographic is four times as likely to meet diagnostic criteria for alcohol dependence, with 8% to 15% reporting that they use alcohol in excess of National Institute of Alcohol Abuse and Alcoholism standards. Alcohol use for older adults has the potential to exacerbate symptoms attributed to old age, such as cognitive impairment, depression, disorientation, and insomnia as well as increase risk of falls. In addition, research has shown that patients ≥55 years of age are less likely to seek treatment for mental health problems.   

Faika Zanjani, PhD, of the Department of Gerontology at the University of Kentucky in Lexington, and colleagues, sought to identify health needs related to alcohol use among older adults through a primary care based, randomized, telephone disease management program. The researchers separated 205 patients in primary care at the Philadelphia Veterans Affairs Medical Center into telephone disease management and usual care groups. Usual care was defined as patients continuing to receive care from their primary care physician (PCP), and the telephone program paired care from PCPs with regular telephone assessments from a behavioral health specialist, who assessed patient rates of alcohol use and attitudes toward alcohol as well as presence of mental health disorders.

For study inclusion, patients must have been ≥18 years of age, met the diagnostic criteria for at-risk drinking (>21 standard drinks per week for men; >14 drinks per week for women; those ≥65 years of age), and not have a current diagnosis of alcohol or substance abuse.

Zanjani and colleagues found that among the >20 older adults receiving telephone assessments, 8% had major depressive disorder (MDD) and 12% had a past history of MDD, which are lower than rates for younger patients (58% of younger patients reported past MDD history). In addition, older adults were less likely to report problems related to their alcohol use despite rates of consumption similar to younger patients. Younger patients reported greater alcohol-related health problems and responded to negative symptomology related to alcohol abuse as a reason to restrict their use.

The authors concluded that older adults may experience alcohol-related problems, but attribute them to causes other than alcohol abuse. In addition, interventions focused on identifying negative symptoms related to alcohol abuse may also be ineffective with at-risk older adults because older study participants did not link alcohol consumption with negative consequences. Zanjani and colleagues added that further research is necessary to examine older adults’ attitudes regarding alcohol use and abuse. (2007 AAGP, Poster 3.46). —CP

Transcranial Magnetic Stimulation Effective for Major Depressive Disorder Treatment in Elderly Adults

Approximately 30% of primary care patients >65 years of age have been diagnosed with major depressive disorder (MDD). Pharmacotherapy is frequently used in conjunction with psychosocial treatment methods for MDD. Common first-line pharmacologic treatments include the use of selective serotonin reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors, and various other antidepressants United States Food and Drug Administration-approved for use in adults.

Electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) are options when psychotic or severe MDD does not respond to adequate trials of two antidepressants. TMS involves the application of electromagnetic currents to targeted areas of the brain through the placement of an electromagnetic wand directly on the scalp. TMS is less intrusive than ECT because it affects only a small portion of the brain and does not require anesthesia. In a recent study, researchers evaluated the efficacy of TMS in elderly patients with MDD.

Kenneth Trevino, BA, Shawn M. McClintock, PhD, Andrew Kozel, MD, of the University of Texas Southwestern Medical Center in Dallas, and colleagues, evaluated 301 patients in a double-blind, randomized, controlled study of TMS. For inclusion in the study, all participants had to meet Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for non-psychotic MDD. Of patients who enrolled in the trial, 92 were >55 years of age. Within the older adult subgroup, 44 patients received active TMS treatment and 48 received placebo treatment. TMS treatment was administered 5 times a week for 6 weeks, with an additional 6 TMS sessions as a taper period. Improvement in MDD symptoms was measured by the Montgomery-Asberg Depression Rating Scale, the 17-item and 24-item Hamilton Rating Scale for Depression, and the Inventory of Depressive Symptomatology. Global improvement symptoms was measured with the Clinical Global Impression Severity scale.

The authors found that active TMS significantly reduced MDD severity when compared to placebo treatment (25% of patients in the TMS treatment group showed response at 6 weeks, compared to 12.5% of patients receiving placebo treatment). Significant results were measured before or at the 6-week period. TMS was shown to be effective for all ages in the study, with no difference in findings between the older subgroup and the greater study population.

Trevino and colleagues also found that TMS was well tolerated among study participants. Few side effects were reported and were generally mild. The most frequent adverse event was application site pain (reported by 45% of patients receiving active TMS), muscle twitching (29%), facial pain (12.5%), and application site discomfort (10.4%). Of patients receiving active treatment, 8.3% reported neck pain and pain of skin, and 6.3% reported lacrimation (production and secretion of tears) increase.

The researchers concluded that, if approved by the FDA, TMS could present a safe and effective alternative to ECT and other treatments for MDD for clinicians treating elderly patients. (2007 AAGP, Poster 3.30). —RS

Previously Developed Alzheimer’s Disease Clinical Criteria Still Effective for Accurate Diagnosis

Criteria for the clinical diagnosis of Alzheimer’s disease was originally created in 1984. Since that time, reseachers in Alzheimer’s disease have made significant advances in the understanding of other dementia-based disorders. In addition, researchers have improved various neuropathologic techniques for the specific assessment of these differentiated dementia disorders. However, there are few studies that examine whether new dementia assessment techiques or specified disorders can more effectively diagnose Alzheimer’s disease than previously created clinical diagnoses.

Najeeb A. Ranginwala, MD, of the Department of Psychiatry at the University of Texas Southwestern Medical Center in Dallas, and colleagues, studied the original Alzheimer’s disease diagnoses of 324 patients from the Alzheimer’s Disease Center at the Southwestern Medical Center against more current neuropathic data available to determine if original diagnoses correctly identified the disorder in patients.

At initial diagnosis, all patients were independently evaluated by a neurologist, a geriatric psychiatrist, and a neuropsychologist. Other assessment information including clinical findings, lab results, and imaging studies, were later reviewed among the original healthcare providers and a diagnosis was reached by concensus. Initial evaluations were conducted between 1986 and 1993. Biopsies or postmortem neuropathic testing was conducted between 1998 and 2003. This diagnostic information was studied and patients were separated patients into two groups: (1) patients with probable Alzheimer’s disease; and (2) those with possible Alzheimer’s disease or Alzheimer’s with other diagnoses, such as Parkinson’s disease or Lewy body variant of Alzheimer’s disease. Lewy body disease is a condition that causes symptoms similar to Alzheimer’s disease, but is caused by brain damage.

The researchers found that 172 patients met criteria for probable Alzheimer’s disease and 60 met criteria for the disease with other diagnoses. Of the 172 patients with probable Alzheimer’s disease, 153 (89%) met histopathologic criteria for Alzheimer’s. However, Ranginwala and colleagues stated that due to a low negative prediction value (45%) for the probable diagnosis, many clinicians may miss Alzheimer’s disease in patients solely using this diagnosis. When possible Alzheimer’s disease patients and probable patients were examined together, 201 patients (86.6%) met Alzheimer’s disease criteria. With a higher negative prediction value (62%) and a positive prediction value (88%) similar to prior studies, the authors concluded that clinicians using the combination of both diagnoses will accurately identify Alzheimer’s disease in most patients despite the advanced technology.

Diffuse Lewy Body disorder was most commonly mistaken for Alzheimer’s disease, accounting for 47% of false positives in the probable group and 32% of false positives in the possible group, while other disorders, such as frontotemporal dementia, were also mistaken for Alzheimer’s disease. Postmortem neurological studies identified neocortical Lewy bodies and presence of frontotemporal dementia.

Ranginwala and colleagues concluded that Alzheimer’s disease diagnostic criteria developed >20 years earlier continues to be effective in Alzheimer’s disease diagnosis, with more recent neurologic tests not discovering high rates of misdiagnosis. The researchers also noted that while this analysis focused on initial diagnosing of patients, follow-up research shows that many patients were correctly diagnosed with probable or possible Alzheimer’s disease or another disorder during the course of treatment or when disorder symptoms became more apparent.

Funding for this research was provided by the National Institute on Aging and the Winspear Center for Research on the Neuropathology of Alzheimer’s Disease. (2007 AAGP, Poster 2.66). —CP

Communication and Quality of Care for Older Schizophrenic Patients

Medical illness is a leading cause of death in schizophrenia patients. In addition, many patients report social stigma due to the disease. A recent study suggests that a disparity between psychiatrists and primary care physicians (PCPs) may be affecting overall quality of care in older schizophrenia patients, possibly contributing to the mortality rate.

Sarah M. Jones, BA, Ipsit Vahia, MD, Carl I. Cohen, MD, of the Department of Psychiatry at the State University of New York Downstate Medical Center in New York City, and colleagues, investigated three hypotheses in order to explain this disparity in schizophrenia care: (1) the attitude of PCPs toward older patients; (2) PCP behavior is influenced by patients’ symptom presentation, which may affect diagnosis as well as treatment; (3) and poor communication between psychiatrists and PCPs has an effect.

The researchers presented a 20-item questionnaire to a sample of 24 PCPs and 27 psychiatrists who regularly treat schizophrenia patients 55 years of age, which gathered data on beliefs, experiences, and procedures in treating medical illnesses in older schizophrenic patients. Attitude toward schizophrenia patients was also measured, with an 11-item scale.

Jones and colleagues found that PCPs and psychiatrists had similar attitudes about older schizophrenic patients, although psychiatrists considered schizophrenic patients to be significantly less healthy than other patients.

PCPs and psychiatrists differed significantly in their reaction to patient presentation of positive schizophrenia symptoms. Using their own clinical vignette, the authors found that PCPs were significantly more likely to feel uncomfortable and prematurely end the visit, and that psychiatrists were more likely to react to positive symptoms.

Finally, there was also a lack of information sharing between PCPs and psychiatrists.

“We found that >50% of both PCPs and psychiatrists report that they do not receive information from the other collaborating physician >50% of the time,” Ms. Jones said. “More importantly, there was a significant difference between the amount of time that psychiatrists reported they sent information to PCPs and the amount of time PCPs received such information.”

In addition to these questionnaires, several open-ended questions were posed to study participants, such as “How can we improve communication between psychiatrists and PCPs?” Jones and colleagues found that such questions elicited varied responses from PCPs and psychiatrists.

“Many people believe that even with the emergence of electronic medical records and healthcare managers, the Health Insurance Portability Accounting Act will prevent this communication from ever being resolved,” Ms. Jones said.

However, as many physicians interviewed suggested, increased verbal communication between PCPs and psychiatrists may be “the best way to maintain adequate care of your patients,” Ms. Jones said.

The study demonstrated that patients with schizophrenia may experience shorter visits with their PCPs due to physician discomfort, which may contribute to lack of adequate care of these patients. In addition, there are deficiencies in the communication between PCPs and psychiatrists. The researchers suggest that taking measures to enhance this communication may greatly improve the physical well-being of older adults with schizophrenia.

Funding for this research was provided by the National Institute of General Medical Sciences. (2007 AAGP, Poster 2.43). —LS

FDA Requests Label Changes for All Sleep Disorder Medications

In March, the United States Food and Drug Administration issued a request that asked manufacturers of sedative-hypnotic drug products to change their product labeling information to include stronger language regarding the potential risks involving the usage of these products. The FDA also requested that all manufacturers send letters to healthcare providers that would immediately notify them of these updated warnings.

Risks the FDA has asked be included in the product labelings include anaphylaxis, angioedema, and complex sleep-related behaviors, such as making phone calls, preparing and eating food, and driving while asleep. Patients who have taken a sedative-hypnotic medication and experienced such sleep-related behavior have no memory of the event.

Lastly, the FDA has asked all manufacturers to create Patient Medication Guides for these products. The goal of these guides is to inform consumers about the risks of taking these products and advises them of precautions that can be taken.

For more information, please visit the FDA Web site. (www.fda.gov). —CN


Psychiatric Dispatches is written by Christopher Naccari, Carlos Perkins, Jr., Lonnie Stoltzfoos, and Rebecca Sussman.