Biomedical subjects
Publications and source records attributed to C A Shamoian.
During the past decade geriatric psychiatry has progressed from syndrome identification at a general level to the more sophisticated typological studies of the etiology, diagnosis, course, and pharmacologic treatment of illnesses such as Alzheimer's disease, depression, depression in dementia, and geriatric mania. The authors review recent findings of studies of these disease states.
Recent advances in the methodology of longitudinal investigations have permitted the identification of predictors of chronicity and relapse of depression. However, findings from mixed-age populations may not be directly applicable to geriatric depression. The effects of medical illness, cognitive dysfunction, and neuroradiological abnormalities on the outcome of geriatric depression merit further evaluation. Late-onset depression requires special attention, since medical and neurological disorders may be particularly important factors in these cases.
The effect of oral clonidine challenge on cortisol secretion was evaluated in seven patients with primary degenerative dementia and in seven patients with major depression. Postclonidine cortisol levels were decreased in all depressed patients and in demented patients with hypercortisolemia at baseline. Demented patients with normal cortisol levels at baseline developed increased post-clonidine cortisol levels. These preliminary findings suggest differences in noradrenergic regulation of cortisol secretion among patients with primary degenerative dementia.
The Cornell Scale for Depression in Dementia is introduced. This is a 19-item clinician-administered instrument that uses information from interviews with both the patient and a nursing staff member, a method suitable for demented patients. The scale has high interrater reliability (kw = 0.67), internal consistency (coefficient alpha: 0.84), and sensitivity. Total Cornell Scale scores correlate (0.83) with depressive subtypes of various intensity classified according to Research Diagnostic Criteria.
The Cornell scale is a 19-item clinician-administered scale of depression that uses information from interviews with both patients and their caregivers. The Cornell scale has been validated in demented patients. In this study, the Cornell scale was psychometically tested in nondemented geriatric subjects by administering it to 15 depressed patients, 15 patients with other psychiatric diagnoses, and 15 normal control subjects. The Cornell scale had high interrater reliability (Cohen's kappa = 0.74), internal consistency (Kuder-Richardson's coefficient = 0.98), and sensitivity, and correlated significantly (Spearman's r = 0.81) with Research Diagnostic Criteria psychiatric diagnoses associated with various intensity of depression. To our knowledge, the Cornell scale is the only depression-rating instrument that has been validated in both demented and nondemented geriatric subjects.
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.
The authors studied platelet MAO activity in psychiatrically hospitalized geriatric patients with depression and dementia. Platelet MAO activity was higher in demented patients with and without depression and in depressed patients with reversible dementia than in nondemented depressed patients. The data suggest that abnormally high platelet MAO activity may reflect a predisposition to the development of a dementia syndrome.
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Depression with reversible dementia occurs frequently in the elderly and may be a diagnostic problem. The 1-mg dexamethasone suppression test (DST) was performed in 175 elderly psychiatric patients. Abnormal DSTs occurred in both patients with primary degenerative dementia (n = 43, 34.9%) and those with major depression without cognitive dysfunction (n = 59, 66.1%). This finding suggests the presence of common hypothalamic abnormalities in these two disorders. There was no difference in the incidence of abnormal DSTs among depressives with a reversible dementia (n = 28, 78.6%), cognitively intact depressives (n = 59, 66.2%), and depressives who also had primary degenerative dementia (n = 24, 70.8%). An abnormal DST is not clinically useful in predicting the outcome of dementia in depressed patients with cognitive dysfunction.
Among 18 elderly depressed patients given ECGs before and during nortriptyline treatment, plasma E-10-hydroxynortriptyline and the sum of E-10-hydroxynortriptyline and nortriptyline distinguished the group with conduction/repolarization effects. Plasma nortriptyline, age, drug dose, and baseline cardiovascular status did not.
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Plasma concentrations of nortriptyline (NT) and of unconjugated E-10-hydroxynortriptyline (E-10-OH-NT) were measured under steady-state conditions in elderly (60 yr and older) and young adult (40 yr and younger) patients treated with NT. The two groups received equivalent doses of NT. Plasma NT concentrations of the two groups did not differ, but plasma E-10-OH-NT concentrations were higher in the elderly. The plasma E-10-OH-NT/NT ratios were twice as high in the elderly group. Plasma E-10-OH-NT/NT ratios varied 2000% between individuals in the elderly group but were stable within individuals. Plasma E-10-OH-NT/NT ratios correlated positively but weakly with serum creatinine concentrations.
A 75-year-old depressed woman treated with the monoamine oxidase inhibitor (MAOI) phenelzine developed a parkinsonian syndrome that remitted after discontinuation of the drug. The authors discuss possible explanations for this unusual phenomenon.
Platelet monoamine oxidase (MAO) activity was assayed in 38 elderly depressed women and 16 matched controls. The depressed women whose illness began at age 55 or earlier (N = 19) had significantly lower MAO activity than patients with later onset (N = 19) or controls.
The authors describe a patient who developed congestive heart failure and had a high plasma concentration of 10-hydroxynortriptyline. They discuss the need for further research to define the contribution of antidepressants' active metabolites to toxic and therapeutic effects.
Many elderly manifest "functional" psychiatric symptoms that are not necessarily associated with a dementing process. The vast majority of these psychiatric syndromes are amenable to treatment if it is instituted early. Early treatment may prevent institutionalization. Of all age groups, the elderly have the highest suicide rate. The possibility of suicide must be evaluated and openly discussed. Drug abuse and alcoholism should also be considered. The elderly respond to much smaller doses of psychopharmacologic agents and are very sensitive to the side effects of these drugs. Polypharmacy, decreased compliance, and drug-drug interactions are common occurrences in the elderly. Not all psychiatric reactions of the elderly require pharmacologic intervention. Many respond to psychotherapy, which should be used more frequently than has been the practice in the past.