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Biomedical subjects

K I Shulman

Publications and source records attributed to K I Shulman.

At least 37 records · Page 2Linked to original sources
PubMed1996

Late-onset Huntington's disease: a geriatric psychiatry perspective.

Late-onset Huntington's disease is more common than has been generally appreciated and is associated with a wide range of psychiatric symptoms and syndromes. Geriatric psychiatrists have an important role to play in establishing the diagnosis and providing guidance to elderly patients and their families as they struggle with difficult management decisions. An illustrative case report and selective literature review are presented that highlight the genetic and clinical aspects of the condition.

Aged↗
PubMed1996

The making of a user friendly MAOI diet.

BACKGROUND: Many monoamine oxidase inhibitor (MAOI) diets are considered to be excessively restrictive and founded on poor scientific evidence. We present a safe and practical MAOI diet based on the related clinical and analytic data. METHOD: We used a critical review of the literature and our own tyramine assay results to categorize foods to be restricted absolutely, taken in moderation only, or unrestricted. RESULTS: We recommend that users avoid aged cheese; aged or cured meats (e.g., air-dried sausage); any potentially spoiled meat, poultry, or fish; broad (fava) bean pods; Marmite concentrated yeast extract; sauerkraut; soy sauce and soy bean condiments; and tap beer. Wine and domestic bottled or canned beer are considered safe when consumed in moderation. Other foods not mentioned are considered unrestricted. CONCLUSION: The concerns about perpetuating an overly restrictive MAOI diet include the avoidance by prescribers of a potentially useful treatment option, excessive limitations on lifestyle for patients, and increased risk to patients secondary to noncompliance with the diet. We propose an MAOI diet that has a solid scientific and clinical basis and that is, above all, practical.

Acute Disease↗
PubMed1994

First-episode mania in late life.

Among 14 elderly patients (mean age = 74.6 years) with first-episode mania who were followed for 3 to 10 years, men had a higher risk of mortality. Compared to 36 elderly patients with multiple episodes of mania, patients with first-episode mania were twice as likely to have a comorbid neurological disorder (71% [N = 10] versus 28% [N = 10]). Mania in the elderly appears to be a heterogeneous disorder.

Age of Onset↗
PubMed1994

The future of geriatric psychiatry.

The author first reviews some of the main forces and historical developments that have shaped the young specialty of geriatric psychiatry. Emphasis is placed on the integrative and collaborative nature of the psychiatry of old age. This includes its relationship with the parent field of psychiatry, geriatric medicine and the broader field of gerontology. An outline of the future for the field is presented which highlights the need for academic credibility and responsiveness to service delivery issues. Because future trends in mental health delivery are likely to continue to give priority to the severely mentally ill and to emphasize cost-effectiveness, geriatric psychiatrists are well poised to meet the challenges of the coming generation. However, a strong future depends ultimately on the ability of the field to recruit bright young psychiatrists who bring inquisitiveness, enthusiasm and a social commitment to a vulnerable elderly population.

Aged↗
PubMed1994

Unipolar mania reconsidered: evidence from an elderly cohort.

Earlier studies have failed to differentiate the unipolar manic subtype from bipolar patients with both manic and depressive episodes. This retrospective cohort study of 50 elderly manic in-patients identified six patients (12%) who met strict criteria for a course of unipolar mania. Significant differences emerged in age at onset, with a mean of 41.2 years for unipolar mania compared with 64.7 years for the others. Consequently, clinical course was significantly longer, 27.7 v. 7.4 years. Elderly patients pursuing a unipolar manic course are among the very few elderly 'bipolars' whose illness begins early in life. Recent neuroradiological investigations and data from geriatric studies suggest that the concept of unipolar mania is worthy of further investigation.

Aged↗
PubMed1994

Hypertensive episode associated with phenelzine and tap beer--a reanalysis of the role of pressor amines in beer.

A case report of a hypertensive crisis resulting from the ingestion of tap beer in a patient on an irreversible monamine oxidase inhibitor (MAOI; phenelzine) stimulated the investigation of different kinds of beer for tyramine concentration. The objective was to determine the tyramine concentration in tap and bottled beers. A total of 98 beer samples (79 different brands of beer) were analyzed by high-performance liquid chromatography for tyramine. Of these 98 beers, 49 were bottled or canned beers and 49 were beers on tap. All of the bottled beers analyzed had safe tyramine concentrations (< or = 10 mg/liter; range, 0 to 3.16 mg/liter) and, thus, do not require restriction in patients receiving MAOIs. Therefore, the consumption of canned or bottled beer, including dealcoholized beer, in moderation (fewer than four bottles or cans; 1.5 liters within a 4-hour period) appears to be safe and does not require restriction in patients receiving MAOIs. Only 4 of 98 beer samples studied were found to have a dangerous (> 10 mg/liter) tyramine concentration, one of which was the index beer. The tyramine concentration in these four beers ranged from 26.34 to 112.91 mg/liter. All four of these beers were tap beers produced by bottom fermentation (lagers) and brewed by a secondary fermentation process. Although we did not find any visible bacterial growth in the tap beers with high tyramine content, this finding does not preclude the possibility that bacterial contamination, bacterial growth, production of tyramine, and eventually bacterial death occurred at some earlier time. Therefore, to err on the side of caution, it is recommended that patients on irreversible MAOIs avoid beers on tap.

Adult↗
PubMed1993

Factors determining the decision to institutionalize dementing individuals: a prospective study.

This longitudinal study of 196 caregiver/care receiver dyads was undertaken to determine the variables predictive of caregiver decision to institutionalize a dependent with dementia. Seven variables (use of services, enjoyment of caregiving, caregiver burden and health, caregiver rating and reaction to care receiver behavior and memory problems, and presence of troublesome behaviors) predicted the decision to institutionalize. Six variables (caregiver health and burden, use of services, care receiver cognitive function and troublesome behaviors, and caregiver reaction to behaviors) predicted actual institutionalization at 18 months.

Aged↗
PubMed1992

Mania compared with unipolar depression in old age.

OBJECTIVE: The goal of this study was to clarify the meaning and importance of mania in old age. METHOD: The authors conducted a retrospective study of 50 elderly patients consecutively admitted to a private mental hospital with an index episode of mania. As a comparison group, they used 50 age- and sex-matched patients with unipolar depression. They reviewed the charts of the 100 patients for family history, clinical course, and neurological disorders. Outcome was determined by contacting patients, families, physicians, institutional settings, and vital statistics records. Survival analysis compared mortality rates. RESULTS: The manic patients had a greater familial predisposition to affective disorder and were younger at first psychiatric hospitalization. For the 20 manic patients whose first affective episode was depression, an average of 15 years elapsed before mania became manifest. Eighteen of the manic patients, compared with only four of the depressed patients, had neurological disorders. The manic patients had a significantly higher mortality rate than the depressed patients; by the end of the follow-up, 25 of the manic patients, compared with 10 of the depressed patients, had died. CONCLUSIONS: Mania appears to have a poorer prognosis and to be a more severe form of affective illness than unipolar depression. The 18 manic patients with neurological disorders seemed to have "secondary mania." Subtle cerebral changes due to aging may have been responsible for the conversion to mania in the 20 patients who experienced a long latency from first depression to onset of mania. The low frequency of early-onset mania in this study group highlights the need to differentiate early- from late-onset mania.

Adult↗
PubMed1992

Intensive early exposure to geriatric psychiatry in residency training: impact on career choice and practice.

The authors examined the impact of intensive early exposure to geriatric psychiatry on the career choice of trainees. All psychiatrists who had completed a six month inpatient rotation on a general hospital psychogeriatric unit as part of their first year of residency were interviewed three to 12 years later with a questionnaire designed to elicit practice patterns, prior interest in geriatrics, and the major influences of the rotation. Nine of 16 trainees had spent more than 50% of their time since graduation treating elderly patients. Those surveyed who were not practicing geriatrics spontaneously reported positive influences of the rotation on psychiatry training in general. The nature of geriatric psychiatry and the clinical issues, as well as the supervisors and educational activities were rated as the most important influences of the rotation. Early experience in psychogeriatrics seems valuable for subspecialty recruitment as well as general psychiatry training.

Attitude of Health Personnel↗
PubMed1991

Regionalization of psychiatric services for the elderly.

This overview addresses issues related to psychiatric services for the elderly in Canada. The author reviews the developments in the United Kingdom that have led to the establishment of guiding principles which may be applied to the Canadian health care system. These include the clear definition of a target population, a comprehensive approach to services, availability and accessibility, and clear accountability. A model for the establishment of regionalized psychiatric services is proposed, including the integration of hospital-based and community-based services with clearly defined areas of responsibility. In light of the changing demographics in Canada and the prevalence of psychiatric illness in the elderly, this is a matter of growing urgency for the health care system.

Canada↗
PubMed1989

Dietary restriction, tyramine, and the use of monoamine oxidase inhibitors.

The aim of this study is to provide clearer guidelines for rational, safe, and practical dietary restriction for use with monoamine oxidase inhibitors. Tyramine levels were assayed in over 100 of the controversial foods that have been associated with hypertensive reactions or reported to contain high levels of tyramine. Only a very limited number of foods appear to require absolute restriction. These include all aged cheeses, concentrated yeast extracts (e.g., Marmite), sauerkraut, and broad bean pods. Alcoholic beverages, including Chianti wine consumed in moderation, appear to be safe. Some aged meats contain relatively high levels of tyramine and require closer investigation.

Food Analysis↗
PubMed1989

Conceptual problems in the assessment of depression in old age.

This paper challenges the traditional conceptualization of depression as a primary mood disorder. Clinical and biological research findings support the hypothesis that 'depression' in old age is a final common pathway of central nervous system dysregulation. This accounts for the varied clinical presentations, cognitive changes and diverse neurobiological abnormalities found in the depressed elderly. Clarification of the concept of depression in old age will help to improve clinical management and have heuristic value in developing better research strategies.

Aged↗
PubMed1987

The clinical use of lithium carbonate in old age: a review.

The authors review the available data concerning the pharmacokinetics and clinical use of lithium carbonate in old age. Guidelines for lithium prophylaxis are provided including a recommendation to maintain 12 hour blood levels at approximately 0.5 mmol/l using a single bedtime dosing regimen. The value of a specialized clinic to manage and monitor elderly patients maintained on lithium is discussed. Empirical clinical findings on the use of lithium may help to elucidate issues of classification in the affective disorders of old age. Increasing clinical data supports a spectrum theory of affective disorder.

Aged↗
PubMed1987

Community psychiatric services for the elderly: the Sunnybrook experience.

This paper describes the first three years of a community outreach service for psychogeriatric assessment and treatment, provided by a multidisciplinary team in an urban area. As one component of a comprehensive geriatric psychiatry service within a general hospital, this program provides a long-term link between patient, family, community agencies and hospital. The paper describes the functioning of the team, including its relationships with other hospital and community services. An overview is given of patient characteristics, referral sources, services provided, and outcomes at discharge from the program. Educational opportunities for students and staff in various health professions and settings are discussed.

Aged↗
PubMed1987

Pharmacokinetics of lithium in the elderly.

The disposition and elimination of lithium was examined in nine female geriatric patients (aged 67 to 80 years) maintained on lithium carbonate as a once daily dose (300 to 600 mg) for the treatment of recurrent depression. Following the morning lithium dose (0.21 +/- 0.06 mmol/kg/day, mean +/- standard deviation), a peak steady state serum concentration of 0.83 +/- 0.25 mmol/liter was achieved at 2.2 +/- 1.2 hours. The mean distribution half-life (alpha-t1/2) was 2.7 +/- 1.2 hours, with distribution being complete at 10.6 +/- 3.0 hours. The mean terminal elimination half-life (beta-t1/2), the mean apparent oral clearance (Cl), and the mean apparent volume of distribution (Varea) were 26.9 +/- 5.5 hours, 15.6 +/- 4.0 ml/min, and 0.64 +/- 0.16 liter/kg, respectively. Compared to a younger adult cohort (35 +/- 10 years), the lithium Cl and Varea were significantly reduced and the alpha- but not beta-t1/2 prolonged in the elderly (p less than 0.05). Based on these pharmacokinetic differences, geriatric patients may require one-third to one-half less lithium than younger adults. The 12-hour standard serum lithium concentration remained a value of minimal intersubject variability when lithium was administered once daily. However, the therapeutic concentration range based on this 12-hour standard serum lithium concentration needs to be redefined for the prophylaxis of unipolar disorders in the elderly.

Adult↗
PubMed1986

Geriatric psychiatry in the general hospital: the integration of services and training.

This article describes the development of a new psychiatric service for the elderly based in a university general hospital. The service aims to provide and coordinate comprehensive psychiatric care for a defined population and also to serve as a tertiary care unit with academic responsibilities. As part of the Department of Psychiatry, this specialized service is fully integrated into all the major clinical and teaching components of the department. As the demand for more geriatric psychiatry services and training increases over the next decade, innovative ways of responding to this need will have to be developed. This integrative model in a general hospital setting has enhanced the quality of health care delivery to the elderly at the same time as improving training and recruitment.

Aftercare↗
PubMed1986

Desipramine plasma concentration and therapeutic response in elderly depressives: a naturalistic pilot study.

This naturalistic pilot study of desipramine hydrochloride treatment in elderly DSM III diagnosed depressives demonstrated that therapeutic response was related to desipramine plasma levels and that a desipramine plasma concentration of 200 nmol/l significantly differentiated responders from non-responders. Plasma concentrations of 2-Hydroxydesipramine were not related to therapeutic response. This finding suggests that monitoring of desipramine plasma levels has utility in certain clinical situations. Further fixed dosage studies are necessary to confirm these initial results.

Aged↗