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Biomedical subjects

L Ganzini

Publications and source records attributed to L Ganzini.

At least 37 records · Page 2Linked to original sources
PubMed1997

Neuropsychiatric adverse effects of antiparkinsonian drugs. Characteristics, evaluation and treatment.

Parkinson's disease (PD) is a progressive neurological condition that causes considerable disability in the elderly. Drugs used to treat PD, such as levodopa, offer symptomatic relief but often have neuropsychiatric adverse effects, most prominently psychosis and delirium. Aged patients and those with dementia are particularly vulnerable to these adverse effects. Evaluating PD patients with drug-induced neuropsychiatric adverse effects is made difficult by their complex clinical presentations. The treatment of drug-induced psychosis and delirium begins with manipulating the antiparkinsonian drug regimen, but this frequently worsens motor function. Atypical antipsychotics such as clozapine have been successfully employed to treat the psychosis without worsening the motor disability. Patient intolerance of clozapine therapy has prompted open-label studies with newer agents such as risperidone, remoxipride, zotepine, mianserin and ondansetron.

Aging↗
PubMed1996

Legalizing assisted suicide--views of physicians in Oregon.

BACKGROUND: Since the Oregon Death with Dignity Act was passed in November 1994, physicians in Oregon have faced the prospect of legalized physician-assisted suicide. We studied the attitudes and current practices of Oregon physicians in relation to assisted suicide. METHODS: From March to June 1995, we conducted a cross-sectional mailed survey of all physicians who might be eligible to prescribe a lethal dose of medication if the Oregon law is upheld. Physicians were asked to complete and return a confidential 56-item questionnaire. RESULTS: Of the 3944 eligible physicians who received the questionnaire, 2761 (70 percent) responded. Sixty percent of the respondents thought physician-assisted suicide should be legal in some cases, and nearly half (46 percent) might be willing to prescribe a lethal dose of medication if it were legal to do so; 31 percent of the respondents would be unwilling to do so on moral grounds. Twenty-one percent of the respondents have previously received requests for assisted suicide, and 7 percent have complied. Half the respondents were not sure what to prescribe for this purpose, and 83 percent cited financial pressure as a possible reason for such requests. The respondents also expressed concern about complications of suicide attempts and doubts about their ability to predict survival at six months accurately. CONCLUSIONS: Oregon physicians have a more favorable attitude toward legalized physician-assisted suicide, are more willing to participate, and are currently participating in greater numbers than other surveyed groups of physicians in the United States. A sizable minority of physicians in Oregon objects to legalization and participation on moral grounds. Regardless of their attitudes, physicians had a number of reservations about the practical applications of the act.

Adult↗
PubMed1996

Oregon emergency physicians' experiences with, attitudes toward, and concerns about physician-assisted suicide.

OBJECTIVE: To determine emergency physicians' (EPs') attitudes toward physician-assisted suicide (PAS), factors associated with those attitudes, current experiences with attempted suicides in terminally ill persons, and concerns about the impact of legalizing PAS on emergency medicine practice. METHODS: A cross-sectional, anonymous mailed survey was taken of EPs in the state of Oregon. RESULTS: Of 356 eligible physicians, 248 (70%) returned the survey. Of the respondents, 69% indicated that PAS should be legal, 65% considered PAS consistent with the physician's role, and 19% believed that it is immoral. The respondents were concerned that patients might feel pressure if they perceived themselves to be either a care burden on others (82%) or a financial stress to others (69%). Only 37% indicated that the Oregon initiative has enough safeguards to protect vulnerable persons. Support for legalization was not associated with gender, age, or practice location. Respondents with no religious affiliation were most supportive of PAS (p < 0.001), and Catholic respondents were least suppportive (p = 0.03). A majority (58%) had treated at least 1 terminally ill patient after an apparent overdose. Most respondents (97%) indicated at least 1 circumstance for which they would sometimes be willing to let a terminally ill patient die without resuscitation after PAS if the Oregon initiative becomes law: if verified with an advance directive from the patient (81%), with documentation in writing from the physician (73%), after speaking to the primary physician (64%), if a competent patient verbally confirmed intent (60%), or if the family verbally confirmed intent (52%). CONCLUSIONS: Although the majority of Oregon EPs favor the concept of legalization of PAS, most have concerns that safeguards in the Oregon initiative are inadequate to protect vulnerable patients. These physicians would consider not resuscitating terminally ill patients who have attempted suicide under the law's provisions, only in the setting of documentation of the patient's intent.

Adult↗
PubMed1996

Attitudes of Oregon psychiatrists toward physician-assisted suicide.

OBJECTIVE: After passage, in November 1994, of Oregon's ballot measure legalizing physician-assisted suicide for terminally ill persons, the authors surveyed psychiatrists in Oregon to determine their attitudes toward assisted suicide, the factors influencing these attitudes, and how they might both respond to and follow up a request by a primary care physician to evaluate a terminally ill patient desiring assisted suicide. METHOD: An anonymous questionnaire was sent to all 418 Oregon psychiatrists. RESULTS: Seventy-seven percent of psychiatrists (N = 321) returned the questionnaire. Two-thirds endorsed the view that a physician should be permitted, under some circumstances, to write a prescription for a medication whose sole purpose would be to allow a patient to end his or her life. One-third endorsed the view that this practice should never be permitted. Over half favored Oregon's assisted suicide initiative becoming law. Psychiatrists' position on legalization of assisted suicide influenced the likelihood that they would agree to evaluate patients requesting assisted suicide and how they would follow up an evaluation of a competent patient desiring assisted suicide. Only 6% of psychiatrists were very confident that in a single evaluation they could adequately assess whether a psychiatric disorder was impairing the judgment of a patient requesting assisted suicide. CONCLUSIONS: Psychiatrists in Oregon are divided in their belief about the ethical permissibility of assisted suicide, and their moral beliefs influence how they might evaluate a patient requesting assisted suicide, should this practice be legalized. Psychiatrists' confidence in their ability to determine whether a psychiatric disorder such as depression was impairing the judgment of a patient requesting assisted suicide was low.

Attitude of Health Personnel↗
PubMed1996

When patients ask about assisted suicide. A viewpoint from Oregon.

The passage of the Oregon Death With Dignity Act has profound implications for the prevailing model of care for dying patients. Patients are already asking for assisted suicide. Most physicians have not been trained in evaluating these requests in a therapeutic way. We discuss the issues around the needs of dying patients and, regardless of the legal status, what to do when patients ask for a lethal dose of medication. With the tools to explore the meaning of these requests, physicians will be better able to understand and meet the needs of their dying patients.

Humans↗
PubMed1995

An interdisciplinary mental health consultation team in a nursing home.

The Mental Health Consultation Team (MHCT) at the Portland Veterans Affairs Medical Center nursing home is an interdisciplinary group of mental health professionals and primary care providers established to triage mental health consultations, improve communication between consultants and primary care providers, help staff translate consultants' recommendations into patient care, and furnish education in the management of mental health problems. The MHCT has decreased the demands for formal psychiatry and psychology consultations while increasing mental health services through innovative use of existing staff.

Activities of Daily Living↗
PubMed1995

Screening for alcohol use disorders in the nursing home.

OBJECTIVES: To determine the prevalence of Alcohol Use Disorders (AUDs) among residents of a Veterans Affairs (VA) nursing home (NH) using DSM-III-R criteria for alcohol abuse and dependence, and to examine the demographic variables associated with AUDs among NH residents. A third objective was to assess the sensitivity, compared with DSM-III-R criteria, of three screening tests for AUDs in the NH: the CAGE, the MAST-G, and the two-question instrument developed by Cyr and Wartman. DESIGN: A cross-sectional design, with DSM-III-R criteria determined by the alcohol module of the Diagnostic Interview Schedule (DIS) as the criterion standard. PATIENTS: Patients older than age 50 admitted consecutively to a VA NH, n = 117. MAIN OUTCOME MEASURES: Sensitivities, specificities, positive predictive values for the CAGE, MAST-G, and Cyr and Wartman Screening questionnaires; receiver operating characteristic (ROC) curves for the CAGE and MAST-G. MAIN RESULTS: Forty-nine percent of study participants met DSM-III-R criteria for lifetime alcohol abuse or dependence (18% active, 31% inactive). The sensitivities and specificities of the three screening questionnaires were as follows: CAGE-82% and 90%; MAST-G-93% and 65%; Cyr and Wartman-70% and 92% respectively. The area under the ROC curve was 0.94 for the CAGE and 0.90 for the MAST-G. CONCLUSIONS: The prevalence of lifetime alcohol abuse and dependence was high in this VA NH population. Both the CAGE and MAST-G are sensitive to AUDs in this setting. The areas under the ROC curves were not significantly different and indicate both tests discriminated well between NH residents with and without AUDs.

Aged↗
PubMed1994

The effect of recovery from depression on preferences for life-sustaining therapy in older patients.

BACKGROUND: This study compared older veterans' preferences about life-sustaining therapy before and after treatment for depression in order to determine whether recovery from depression is associated with an increase in the desire for these interventions. METHODS: Medical inpatients over 65 years of age were eligible. Depressed subjects scored > 14 on the Geriatric Depression Scale and were independently diagnosed by a psychiatrist as depressed. A questionnaire quantified preferences regarding potentially life-sustaining interventions currently, and in four hypothetical scenarios of illness. RESULTS: Initial interviews were completed on 50 depressed and 50 nondepressed subjects. Within 6 months, 34 (68%) depressed and 40 (80%) control subjects were reevaluated. Preferences did not change significantly from initial to final interview, regardless of whether subjects had recovered from depression or remained depressed. With the exception of cardiopulmonary resuscitation, however, control subjects' preferences were more stable than depressed subjects' choices. CONCLUSIONS: This study demonstrated that treatment of mild-to-moderate depression does not necessarily result in an increased desire for life-sustaining medical therapy. Because depressed patients exhibit less consistency in their preferences over time, we advise careful and repeated discussions with the depressed patient regarding these decisions.

Aged↗
PubMed1994

The effect of depression treatment on elderly patients' preferences for life-sustaining medical therapy.

OBJECTIVE: This study was undertaken 1) to test the hypothesis that remission of depression results in an increase in desire for life-sustaining medical therapy and 2) to characterize patients whose desire for life-sustaining treatment increases substantially following depression therapy. METHOD: Elderly patients, suffering from major depression, were interviewed on admission to a psychiatric inpatient unit and at discharge about their desire for specific medical therapies in their current state of health and in two hypothetical scenarios of medical illness. A psychiatrist rated the impact of depressive thinking on the subject's response to these questions. Forty-three subjects completed the study, and 24 were in remission from depression at the time of discharge. RESULTS: In the majority of patients, remission of depression did not result in an increase in desire for life-sustaining medical therapy. However, a clinically evident increase in desire for life-sustaining medical therapies followed treatment of depression in subjects (N = 11 [26%]) who had been initially rated as more severely depressed, more hopeless, and more likely to overestimate the risks and to underestimate the benefits of treatment. CONCLUSIONS: In major depression of mild to moderate severity, a patient's desire to forgo life-sustaining medical treatment is unlikely to be altered by depression treatment. On the other hand, severely depressed patients, particularly those who are hopeless, overestimate the risks of treatment, or underestimate the benefits of treatment, should be encouraged to defer advance treatment directives. In these patients decisions about life-sustaining therapy should be discouraged until after treatment of the depression.

Advance Directives↗
PubMed1993

The prevalence of metoclopramide-induced tardive dyskinesia and acute extrapyramidal movement disorders.

BACKGROUND: Metoclopramide hydrochloride, a neuroleptic dopamine receptor antagonist used to treat gastric ailments, is reported to cause extrapyramidal movement disorders. The goals of this study were (1) to determine the prevalence and severity of tardive dyskinesia and acute extrapyramidal movement syndromes including akathisia, acute dystonia, and drug-induced parkinsonism in metoclopramide-treated patients and (2) to compare the prevalence and severity of tardive dyskinesia in metoclopramide-treated diabetics and nondiabetics. METHODS: From a list of metoclopramide-treated patients received from the Portland (Ore) Veterans Affairs Medical Center pharmacy, 53 patients met inclusion criteria and 51 (96%) agreed to participate. Controls consisted of a convenience sample drawn from the Portland Veterans Affairs Medical Center Outpatient Clinic who were matched to subjects on age (+/- 10 years), gender, and presence or absence of diabetes. Of 61 potential controls contacted, 51 (84%) agreed to participate. Metoclopramide-treated subjects and controls were seen by a rater who was "blind" to all diagnoses and treatments. The rater performed a standardized examination used to elicit signs and symptoms of tardive dyskinesia and acute extrapyramidal movement syndromes. RESULTS: The relative risk for tardive dyskinesia was 1.67 (95% confidence interval, 0.93 to 2.97), and the relative risk for drug-induced parkinsonism was 4.0 (95% confidence interval, 1.5 to 10.5). Metoclopramide-treated patients had significantly greater severity of tardive dyskinesia, drug-induced parkinsonism, and subjective akathisia than controls. Use of metoclopramide was associated with impairment in ambulation and increased use of benzodiazepines. Metoclopramide-treated diabetics had significantly greater severity of tardive dyskinesia than metoclopramide-treated nondiabetics. CONCLUSIONS: Metoclopramide use is associated with a significantly increased prevalence and severity of several extrapyramidal movement disorders.

Adult↗
PubMed1993

The PSDA and treatment refusal by a depressed older patient committed to the state mental hospital.

Since 1991, the Patient Self-Determination Act (PSDA) has required all health care institutions that receive Federal funds to inform patients upon admission of their rights to make decisions about medical care and to execute advance directives. Implementation of the PSDA presents a special challenge for state mental hospitals. The relevance and possible negative therapeutic impact of discussing end of life decisions at the time of an acute psychiatric admission has recently been raised in the literature. Other ethical dilemmas arising from the interplay between mental illness and informed consent for medical treatment, particularly for older patients committed to state mental hospitals, have been highlighted by the PSDA. In this article we discuss some of the issues raised by implementation of the PSDA in this setting.

Advance Directives↗
PubMed1992

Depression in the elderly: effect on patient attitudes toward life-sustaining therapy.

OBJECTIVE: To determine the effect of depression on preferences for life-sustaining therapy in older persons. DESIGN: A survey comparing depressed, older veterans and a similar, but non-depressed, control group. SETTING: A 490-bed Veterans Affairs teaching hospital. PATIENTS: Medical inpatients over 65 years of age were potential subjects. Patients who were in intensive care, cognitively impaired, unable to communicate, abusing alcohol or drugs, or unable to return for outpatient care were excluded. Ninety-five eligible subjects (29%) refused to participate. Depressed subjects scored >14 on the Geriatric Depression Scale (GDS) and were diagnosed as depressed by a psychiatrist who was blind to the GDS results. Complete data were collected on 50 depressed and 50 control subjects. MAIN OUTCOME MEASURES: A self-administered questionnaire quantified patients' preferences regarding life-saving interventions in their current state of health and in four hypothetical scenarios of serious illness. RESULTS: Depressed subjects desired fewer interventions than control subjects in their current health and in hypothetical scenarios with a good prognosis (P < or = 0.05). There were no differences between groups in poor prognosis scenarios. However, depression did not explain more than 5% of the variance in decision-making in any situation. In good prognosis scenarios, subjects' assessment of quality of life was the most powerful predictor of desire for life-saving interventions, accounting for 9%-17% of the variance (P <0.01). CONCLUSIONS: These results suggest that depression is associated with treatment refusal in situations with a good medical prognosis. Depression, however, is only a weak predictor of treatment refusal. Further research is needed to define which patients would accept medical treatment if effectively treated for depression.

Activities of Daily Living↗
PubMed1992

Do-not-resuscitate orders for depressed psychiatric inpatients.

Many patients, especially those who are elderly and who have chronic medical illnesses, choose to forgo cardiopulmonary resuscitation (CPR) in case of cardiac arrest. The right of mentally competent patients to refuse CPR is supported by ethicists, the courts, and medical associations. Psychiatrists are increasingly presented with dilemmas about resuscitation preferences of elderly psychiatric inpatients whose decision-making capacity may be impaired because of mental illness such as depression. The authors discuss justifications for patients' refusing resuscitation, the role of advance directives in communicating patients' preferences, and the use of do-not-resuscitate orders for depressed psychiatric inpatients. Survival rates after CPR among elderly patients with chronic medical illnesses are low. Patients and their families need accurate information about the risks and benefits of CPR and about the consequences of refusing the procedure.

Aged↗
PubMed1992

Tardive dyskinesia and diabetes mellitus.

Two studies examine the prevalence of tardive dyskinesia (TD) in neuroleptic-treated diabetic patients. Study 1 compared 38 diabetic patients with 38 nondiabetic patients treated for psychotic disorders with low to moderate doses of neuroleptics (mean chlorpromazine equivalents = 300 mg/day) for an average of 18 years. Study 2 compared 24 diabetic and 27 nondiabetic patients treated for an average of 2.6 years with a mean 31 mg/day of metoclopramide for gastrointestinal disease. Patients were examined for TD using standardized scales by raters blind to all treatment and illness variables. In both studies, there were no differences between the diabetic and nondiabetic groups in age, sex, type of psychiatric illness, and dose and duration of neuroleptic treatment or severity of parkinsonism. In both studies, the diabetic patients had significantly greater prevalence and severity of TD. No measures of diabetes severity were associated with TD in either study. Possible pathophysiologic mechanisms for the increased prevalence of TD in neuroleptic-treated patients with diabetes will be discussed.

Adult↗