Biomedical subjects
Publications and source records attributed to B S Meyers.
Delusional depression frequently is encountered in the treatment of older psychiatric patients. Although the pathogenesis of this disorder and its relationship to organic brain lesions remains unclear, somatic treatment, especially with ECT, leads to initial recovery in the majority of cases. High rates of relapse and the possibility of increased mortality in these patients argue for studies of the effectiveness of maintenance treatments.
Performance on a verbal memory task and affective state were assessed in geriatric major depressives before and during 6 weeks of treatment with nortriptyline (NT) in a fixed-dose design study. Higher plasma NT concentration was associated with poorer free recall but better affective outcome. In contrast, higher plasma Z-10-hydroxynortriptyline (Z-10-OH-NT) concentration was associated with more efficient free recall. Concentration-effect relationships were noted in patients later classified as cognitively unimpaired using the Dementia Rating Scale after optimal treatment, rather than in those with residual cognitive impairment.
The effects of nortriptyline (NTL) on memory were compared with those of placebo (PBO), in elderly subjects after recovery from a major depression. Subjective and objective memory was assessed using a repeated-measures discontinuation design. Average immediate, but not delayed, free recall, on a 20-item selective reminding test was adversely affected by medication. Free recall on placebo was stable over four learning trials and at delay. A different pattern of responses occurred on nortriptyline: Performance dropped off significantly on learning Trial 2, remained worse than placebo through Trial 4, but improved after a 15-min delay. Performance on measures of immediate and delayed recognition memory were comparable on nortriptyline and placebo. Discontinuation of nortriptyline resulted in significant improvement on a subset of nine memory self-assessment items. On questions addressing ability to retrieve recently learned information, subjects reported the greatest improvement while on placebo compared with nortriptyline.
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Depression in later life can present unique clinical and therapeutic challenges. Phenomenology is often atypical and the concurrence of physical illness can confound both diagnosis and treatment. A review of current knowledge about epidemiology, pathogenesis, clinical features, and therapeutic issues is presented.
Clinical and biologic studies of geriatric depression are reviewed to evaluate the role of age of onset as a distinguishing parameter. The findings suggest that late-onset depressives have a different presentation, more frequent relapses, and a greater association with medical disorders, dementia, and aging-related biologic changes than early-onset geriatric depressives. Careful clinical evaluation and follow-up of late-onset depressives are suggested. Longitudinal investigations of geriatric depressed patients are needed in order to study the frequency and time of occurrence of various clinical outcomes and identify predictors of outcome in late- and early-onset geriatric depression.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
A comparison of the prevalence of delusions was made between early-onset (less than age 60) and late-onset (greater than or equal to age 60) primary endogenous depressives. Depressives with onset after age 60 had delusions more frequently than those with earlier onset. Fourteen of 16 late-onset depressives but only 5 of 18 earlier onset patients were delusional (p less than .005). Within the early onset group, those with delusions tended to be older at index episode than those without delusions (.05 less than p less than .10). This correlation between age of onset of depression and the tendency to be delusional is of heuristic and possibly pathogenetic interest.
In a prospective study of all geriatric patients treated with tricyclic antidepressants over an 18-month period, a lower incidence of adverse psychiatric reactions than literature based on chart reviews has suggested was found. In only three of the 43 patients studied (7%) did a picture consistent with toxic delirium develop. None of the seven patients with senile dementia of the Alzheimer type suffered an adverse psychiatric reaction despite having achieved therapeutic blood levels of medication. Difficulties in determining the type and pathogenesis of untoward reactions that do occur as a source of error in establishing frequency are emphasized. The relationship of such reactions to the neurobiology of aging, the central anticholinergic syndrome, and the putative role of acetylcholine in contributing to the clinical picture of senile dementia of the Alzheimer type is discussed.
A preliminary exploration of psychiatric residents' thinking on the subject of psychotherapy fees revealed a pattern of inconsistencies in attitudes and a divergence between attitudes and practice. The author discusses these findings in the light of theoretical considerations and the effect of such attitudes on clinic administration and patient treatment. He emphasizes education about and discussion of fees as important aspects of residency training.
A study of 161 consecutively admitted elderly major depressives with a mean age of 71.7 +/- 6.6 revealed that 72 patients (45%) were delusional. Delusional depressives were significantly older than nondelusionals at onset (62.4 +/- 15.5 + 17.2), but were of comparable age at admission. Utilizing the median age of onset (60) as a cut-off, a sex difference was identified: an association between lateness of onset and delusions was only apparent in women. The presence of a concurrent medical or neurologic disorder or hearing deficit did not increase the association. The importance of investigating samples of elderly patients to identify age effects that only occur in late-life is emphasized.
Recovery from lithium-induced neurotoxicity can take much longer than the 2 to 3 weeks previously reported. Contributing factors could include advanced age and underlying clinical or subclinical brain disease. However, the occurrence of lithium-induced neurotoxicity does not preclude reinstitution of lithium treatment. We report three case histories that illustrate these points.
Retrospective analysis of the phenomenology and the diagnostic process of 112 consecutive psychogeriatric admissions revealed the majority (61%) were suffering from affective illness. In 53 percent, the reason for admission was depression and 8 percent were in the manic phase of a bipolar disorder. Dementia was diagnosed in 32 percent, with a third of these patients having an associated depression. The remaining 7 percent had a schizophrenic or paranoid disorder. Ninety-two patients (82%) were found to have at least one coexisting medical and/or neurological disorder(s) requiring early intervention. Associated acute organic brain syndromes were common (18%) and often difficult to diagnose. The AOBS was at times the only sign of an underlying active medical condition. The diagnosis of this condition often required serial observations for fluctuations in mental status accompanied by appropriate laboratory investigations. These findings underscore the complexity of the diagnostic process in psychogeriatric patients suffering from concomitant medical and psychiatric disorders. High index of awareness is recommended for the need to search for coexisting delirium, which may be masked at times by the major psychiatric disorder.
A study of 112 psychogeriatric admissions identified seventy patients sufficiently depressed to require biologic treatment. Twenty-four patients completed a primary treatment trial with TCA's and seventeen with ECT. ECT proved to be more effective, (81.4% versus 62.5%), even though overtly psychotic and medically unstable patients preferentially received this treatment. The ECT response rate is comparable to other reports of its efficacy in the treatment of delusional depression. A higher morbidity rate of 27 percent in the TCA-treated group was observed. The authors conclude that ECT is a highly beneficial treatment modality for the carefully selected elderly patient with major depressive illness. They found that a higher number of ECT treatments than expected were required in their psychogeriatric patients, but did not find a higher morbidity other than increased confusion with more treatments. Careful repeated assessment of response to treatment combined with readiness for assertiveness, in spite of the advanced age of the patient, seem to be indicated. Conversely, excessive hesitance when caring for the elderly patient may lead to a premature termination of treatment, causing the patient to remain in a chronic mentally compromised state.