- Email: [email protected]
HEALTH CARE PROXY IN OLDER PSYCHIATRIC OUTPATIENTS
AAGP 12th Annual Meeting as measured by the Simpson-Angus Scale, the Abnormal Involuntary Movement Scale, or the Barnes Akathisia Scale. P71
DOPAMINE RECEPTOR GENETIC VARIATION AND MOTIVATIONAL DISTURBANCE IN ALZHEIMER’S DISEASE. Channamalappa Umapathy, M.D.; Robert A. Sweet, M.D.; Vishwajit L. Nimgoankar, M.D.; M. Ilyas Kamboh, Ph.D.; Oscar L. Lopez, M.D.; Steven T. DeKosky, M.D.; Supported in Part by USPHS Grants MH00153, MH53459, AG13672, AG05133
B
ackground: Behavioral syndromes are reported to occur in over 80% of patients with AD. Motivational disturbance (MD) varyingly characterized by loss of interest, fatigue, motor retardation, affective blunting, anhedonia, and social withdrawal occurs as frequently as aggression or psychosis and is as important a source of caregiver distress. Although the pathophysiology of MD in AD is not known, there are several reasons to suspect an underlying hypodopaminergic state. Among these are uncontrolled studies indicating benefit of the dopaminergic agent methylphenidate in the treatment of MD. Method: The authors examined whether MD was associated with genetic variation in the dopamine-1 (DRD1), DRD2, DRD3, and DRD4 receptors in patients diagnosed with probable AD. Severity of MD was rated using the CERAD Behavioral rating scale for dementia (items 10,11,12, and 33) at the time of initial presentation to the Alzheimer’s Disease Research Center of the University of Pittsburgh. A total of 193 patients were available for analysis. Results: There was no association of MD with age, race, or gender. Severity of MD was correlated with increased measures of depression (Ham-D) and impaired cognition (MATTIS). MD was significantly more severe in subjects with a psychotic or depressed syndrome but not in subjects with aggression. After controlling for the effects of cognitive impairment, psychosis, and depression, MD was significantly more severe in individuals with long alleles of the DRD4 exon III repeat sequence. No association with DRD1, DRD2, or DRD3 were seen. Conclusion: The authors found increased severity of MD in AD subjects with DRD4 long alleles. These results must be considered preliminary pending independent replication. DRD4 may represent a site of action for dopaminergic treatment of MD in AD subjects. P43
PROTON MR SPECTROSCOPY OF THE FRONTAL CORTEX IN COGNITIVELY NORMAL SUBJECTS: EFFECT OF AGE. Suman Vidyarthi; Molly Fortner; K. Ranga Krishnan M.D.; Jean Smith; Daniel Barboriak M.D.; H. Cecil Charles Ph.D.; P. Murali Doraiswamy M.D.; Duke University Medical Center
I
ntroduction: Proton magnetic resonance spectroscopy (MRS) allows the noninvasive assessment of metabolites in discrete brain regions. The characterization of norma-
62
tive changes of these metabolites with age would facilitate the application of MRS to the study of disorders of aging such as Alzheimer’s disease. Methods: 145 volunteers (55– 86 years, 74 women) free of significant neuropsychiatric disorders underwent proton MRS using PROBE (GE Medical Systems) technique. MRS data from a frontal cortical voxel was analyzed using the LCModel method. Reference normalized concentrations of N-acetylaspartate (NAA), myo-inositol (MI), choline moieties (Cho), and creatine (Cr) as well as ratios of NAA, MI, and Cho to Cr were calculated. All subjects were cognitively intact (MMSE 25–30) and free of dementia. Pearson correlations and linear regression models were used to analyze the data. Results: Age was inversely correlated with frontal lobe NAA (P⬍0.0003), Cho (P⬍0.05) and Cr (P⬍0.02). Age was not correlated with MI. Age was however positively correlated with MI/NAA ratio (P⬍0.03) but was not significantly correlated with NAA/Cr or Cho/Cr ratios. Conclusions: There is an age-related decrease in frontal lobe NAA, Cr, and Cho attributable most likely to neuronal loss, atrophy, alterations in neuronal function, or energetics. There is also an age-related decrease in NAA relative to MI. The use of NAA/ Cr ratios may be less sensitive than the use of MI/NAA ratios to the study of age-related degenerative disorders. P37
HEALTH CARE PROXY IN OLDER PSYCHIATRIC OUTPATIENTS. Kathleen A. Warren, R.N.; Hoang Nguyen, M.D.; Laurie A. Lindamer, Ph.D.; Dilip V. Jeste, M.D.
I
ntroduction: The Patient Self-Determination Act (PSDA) of 1991 called for the use of written advance directives to guide medical care in patients who have lost decisionmaking capacity. The authors investigated the frequency of such healthcare proxy among patients attending a geriatric psychiatry clinic. Methods: A retrospective chart review was conducted for 565 middle age and elderly patients attending geriatric psychiatry clinic. All the patients were seen by a geriatric psychiatrist and met the DSM-IIIR or DSM-IV criteria for dementia such as Alzheimer’s disease or vascular dementia, a mood disorder such as major depression or bipolar affective disorder, or a psychotic disorder such as schizophrenia or psychosis not otherwise specified. There were 280 (50%) patients in the dementia group, 219 (38.8%) patients in the mood disorder group, and 66 (11.7%) patients in the psychosis group. Results: Healthcare proxy was completed by significantly more patients in the dementia group (n⳱48; 17.1%), than in the mood disorder group (n⳱6; 2.7%) or the psychosis group (n⳱2; 3%) (P⬍0.001, chi-square). The dementia patients with proxy did not differ from those without proxy in terms of age, race, gender, marital status, or total MMSE
Am J Geriatr Psychiatry Supplement, Fall 1999
Abstracts scores. Conclusion: A relationship between healthcare proxy completion and diagnosis was noted, with dementia patients most likely to have completed written advance directives. One potential explanation is the urgency of legal documentation in the dementia group. Nonetheless, a large majority of the middle age and elderly psychiatric patients did not have a healthcare proxy. The current push to comply with the PSDA will have to work for a more consistent advance care planning for all psychiatric patients. P64
DEVELOPING A STATEWIDE MEASURE FOR THE EFFECTIVENESS OF GERIATRIC INPATIENT TREATMENT OF DEPRESSION. James Westphal, M.D.; Ronald Horswell, Ph.D.
P
urpose: The purpose of this study was to develop a statewide statistical measure of the effectiveness of inpatient treatment of geriatric depression. Methodology: A Kaplan Mier survival curve for all Louisiana over age 65 Medicare admissions for depression in fiscal year 1995 was constructed using the HCFA MedPro database. ECT-treated patients were treated as a separate group. A literature search was performed to find a suitable comparison group. Results: Survival rates at 1 year were 67% without statistically significant differences for ECT vs. other inpatient treatments. The literature search found minimal studies reporting on geriatric depression rehospitalization rates. Only two studies were found that reported rehospitalization rates at one year in geriatric depression populations. The studies reported 1-year survival rates of (77% and 72%) with smaller sample sizes and more homogenus treatment populations. Conclusion: Rehospitalization rates may be a useful measure of inpatient geriatric depression treatment effectiveness. In this study, the statewide rehospitalization rate was comparable to a smaller group of geriatric patients treated in a single academic medical center. The next step in the development of this measure will be to calculate provider rehospitalization rates and measure the amount of systemic variation. P8
THE LOUISIANA MEDICARE ECT QUALITY IMPROVEMENT PROJECT. James Westphal, M.D.;, Kenneth Sauyke, M.D.;, Jill Rush, M.D.; Sanjaya Kumar, M.D., M.P.H.
T
he first collaborative state-wide psychiatric quality improvement project, initiated by Louisiana Health Care Review, Inc., focused on the practice of inpatient ECT among Medicare patients. Data from the project indicated that the majority of Medicare patients receiving ECT were Caucasian females living at home, in good physical health, in their seventies with a diagnosis of major depression or
Am J Geriatr Psychiatry Supplement, Fall 1999
major depression with psychotic features. The quality indicators for the project included: (documentation of) monitoring of cognitive side effects, monitoring of depressive target symptoms, ECT appropriateness, electrode placement, anesthesia evaluation, and dental examination. An additional indictor (administration of possibly detrimental medication during ECT) was developed based on the recommendation by the study group. At project conclusion, significant improvement occurred in all project indicators. ECT as practiced in the participating hospitals was effective and appropriate. Appropriateness was determined as depression refractory to two medication trails or an emergency due to severe suicidality or physical decompensation secondary to malnourishment. Transient hypertension (13%) and cardiac dysrhythmias (3.5%) which resolved in the recovery period were the most frequent complications. P7
STATEWIDE GEOGRAPHIC VARIATION IN GERIATRIC PSYCHIATRIC ADMISSIONS. James Westphal, M.D.; Ron Horswell, Ph.D.
P
urpose: The study of geographic practice variation in medicine and surgery has caused significant changes in health care policy and the regulation of clinical practice, but studies of psychiatric practice variation are minimal. The purpose of this study was to determine the major sources of statewide geographic variation in geriatric psychiatric admissions. Methodology: The Louisiana 1995 fiscal year Medicare over 65 psychiatric admission rates were calculated from the HCFA MEDPRO database and analyzed using six variables: prospective payment stays (PPS), psychiatric hospital vs. acute general hospital stays, first admissions vs. readmissions, depression admissions, substance abuse admissions, transfers after medical/surgical admissions. Results: High admission rate areas were associated with psychiatric hospitalizations after a medical/surgical hospitalization, the use of acute general hospitals, the use of non PPS stays, and depression admissions. Readmissions and substance abuse admissions were not statistically related to high admission areas. Conclusions: The strongest association with higher geographic admission rates was the use of non-PPS beds in acute general hospitals. This finding in geriatric psychiatric admissions is consistent with the small area analysis literature on medical and surgical admissions. P6
LIFE SATISFACTION IN INSTITUTIONALIZED CENTENARIANS. Marc Zisselman, M.D.; Terri A CutilloSchmitter, M.S.N, R.N.C.S.
O
bjective: To assess life satisfaction among centenarians residing in a long-term care facility. Second, to determine if a simple weekly interpersonal intervention
63
DOPAMINE RECEPTOR GENETIC VARIATION AND MOTIVATIONAL DISTURBANCE IN ALZHEIMER’S DISEASE. Channamalappa Umapathy, M.D.; Robert A. Sweet, M.D.; Vishwajit L. Nimgoankar, M.D.; M. Ilyas Kamboh, Ph.D.; Oscar L. Lopez, M.D.; Steven T. DeKosky, M.D.; Supported in Part by USPHS Grants MH00153, MH53459, AG13672, AG05133
B
ackground: Behavioral syndromes are reported to occur in over 80% of patients with AD. Motivational disturbance (MD) varyingly characterized by loss of interest, fatigue, motor retardation, affective blunting, anhedonia, and social withdrawal occurs as frequently as aggression or psychosis and is as important a source of caregiver distress. Although the pathophysiology of MD in AD is not known, there are several reasons to suspect an underlying hypodopaminergic state. Among these are uncontrolled studies indicating benefit of the dopaminergic agent methylphenidate in the treatment of MD. Method: The authors examined whether MD was associated with genetic variation in the dopamine-1 (DRD1), DRD2, DRD3, and DRD4 receptors in patients diagnosed with probable AD. Severity of MD was rated using the CERAD Behavioral rating scale for dementia (items 10,11,12, and 33) at the time of initial presentation to the Alzheimer’s Disease Research Center of the University of Pittsburgh. A total of 193 patients were available for analysis. Results: There was no association of MD with age, race, or gender. Severity of MD was correlated with increased measures of depression (Ham-D) and impaired cognition (MATTIS). MD was significantly more severe in subjects with a psychotic or depressed syndrome but not in subjects with aggression. After controlling for the effects of cognitive impairment, psychosis, and depression, MD was significantly more severe in individuals with long alleles of the DRD4 exon III repeat sequence. No association with DRD1, DRD2, or DRD3 were seen. Conclusion: The authors found increased severity of MD in AD subjects with DRD4 long alleles. These results must be considered preliminary pending independent replication. DRD4 may represent a site of action for dopaminergic treatment of MD in AD subjects. P43
PROTON MR SPECTROSCOPY OF THE FRONTAL CORTEX IN COGNITIVELY NORMAL SUBJECTS: EFFECT OF AGE. Suman Vidyarthi; Molly Fortner; K. Ranga Krishnan M.D.; Jean Smith; Daniel Barboriak M.D.; H. Cecil Charles Ph.D.; P. Murali Doraiswamy M.D.; Duke University Medical Center
I
ntroduction: Proton magnetic resonance spectroscopy (MRS) allows the noninvasive assessment of metabolites in discrete brain regions. The characterization of norma-
62
tive changes of these metabolites with age would facilitate the application of MRS to the study of disorders of aging such as Alzheimer’s disease. Methods: 145 volunteers (55– 86 years, 74 women) free of significant neuropsychiatric disorders underwent proton MRS using PROBE (GE Medical Systems) technique. MRS data from a frontal cortical voxel was analyzed using the LCModel method. Reference normalized concentrations of N-acetylaspartate (NAA), myo-inositol (MI), choline moieties (Cho), and creatine (Cr) as well as ratios of NAA, MI, and Cho to Cr were calculated. All subjects were cognitively intact (MMSE 25–30) and free of dementia. Pearson correlations and linear regression models were used to analyze the data. Results: Age was inversely correlated with frontal lobe NAA (P⬍0.0003), Cho (P⬍0.05) and Cr (P⬍0.02). Age was not correlated with MI. Age was however positively correlated with MI/NAA ratio (P⬍0.03) but was not significantly correlated with NAA/Cr or Cho/Cr ratios. Conclusions: There is an age-related decrease in frontal lobe NAA, Cr, and Cho attributable most likely to neuronal loss, atrophy, alterations in neuronal function, or energetics. There is also an age-related decrease in NAA relative to MI. The use of NAA/ Cr ratios may be less sensitive than the use of MI/NAA ratios to the study of age-related degenerative disorders. P37
HEALTH CARE PROXY IN OLDER PSYCHIATRIC OUTPATIENTS. Kathleen A. Warren, R.N.; Hoang Nguyen, M.D.; Laurie A. Lindamer, Ph.D.; Dilip V. Jeste, M.D.
I
ntroduction: The Patient Self-Determination Act (PSDA) of 1991 called for the use of written advance directives to guide medical care in patients who have lost decisionmaking capacity. The authors investigated the frequency of such healthcare proxy among patients attending a geriatric psychiatry clinic. Methods: A retrospective chart review was conducted for 565 middle age and elderly patients attending geriatric psychiatry clinic. All the patients were seen by a geriatric psychiatrist and met the DSM-IIIR or DSM-IV criteria for dementia such as Alzheimer’s disease or vascular dementia, a mood disorder such as major depression or bipolar affective disorder, or a psychotic disorder such as schizophrenia or psychosis not otherwise specified. There were 280 (50%) patients in the dementia group, 219 (38.8%) patients in the mood disorder group, and 66 (11.7%) patients in the psychosis group. Results: Healthcare proxy was completed by significantly more patients in the dementia group (n⳱48; 17.1%), than in the mood disorder group (n⳱6; 2.7%) or the psychosis group (n⳱2; 3%) (P⬍0.001, chi-square). The dementia patients with proxy did not differ from those without proxy in terms of age, race, gender, marital status, or total MMSE
Am J Geriatr Psychiatry Supplement, Fall 1999
Abstracts scores. Conclusion: A relationship between healthcare proxy completion and diagnosis was noted, with dementia patients most likely to have completed written advance directives. One potential explanation is the urgency of legal documentation in the dementia group. Nonetheless, a large majority of the middle age and elderly psychiatric patients did not have a healthcare proxy. The current push to comply with the PSDA will have to work for a more consistent advance care planning for all psychiatric patients. P64
DEVELOPING A STATEWIDE MEASURE FOR THE EFFECTIVENESS OF GERIATRIC INPATIENT TREATMENT OF DEPRESSION. James Westphal, M.D.; Ronald Horswell, Ph.D.
P
urpose: The purpose of this study was to develop a statewide statistical measure of the effectiveness of inpatient treatment of geriatric depression. Methodology: A Kaplan Mier survival curve for all Louisiana over age 65 Medicare admissions for depression in fiscal year 1995 was constructed using the HCFA MedPro database. ECT-treated patients were treated as a separate group. A literature search was performed to find a suitable comparison group. Results: Survival rates at 1 year were 67% without statistically significant differences for ECT vs. other inpatient treatments. The literature search found minimal studies reporting on geriatric depression rehospitalization rates. Only two studies were found that reported rehospitalization rates at one year in geriatric depression populations. The studies reported 1-year survival rates of (77% and 72%) with smaller sample sizes and more homogenus treatment populations. Conclusion: Rehospitalization rates may be a useful measure of inpatient geriatric depression treatment effectiveness. In this study, the statewide rehospitalization rate was comparable to a smaller group of geriatric patients treated in a single academic medical center. The next step in the development of this measure will be to calculate provider rehospitalization rates and measure the amount of systemic variation. P8
THE LOUISIANA MEDICARE ECT QUALITY IMPROVEMENT PROJECT. James Westphal, M.D.;, Kenneth Sauyke, M.D.;, Jill Rush, M.D.; Sanjaya Kumar, M.D., M.P.H.
T
he first collaborative state-wide psychiatric quality improvement project, initiated by Louisiana Health Care Review, Inc., focused on the practice of inpatient ECT among Medicare patients. Data from the project indicated that the majority of Medicare patients receiving ECT were Caucasian females living at home, in good physical health, in their seventies with a diagnosis of major depression or
Am J Geriatr Psychiatry Supplement, Fall 1999
major depression with psychotic features. The quality indicators for the project included: (documentation of) monitoring of cognitive side effects, monitoring of depressive target symptoms, ECT appropriateness, electrode placement, anesthesia evaluation, and dental examination. An additional indictor (administration of possibly detrimental medication during ECT) was developed based on the recommendation by the study group. At project conclusion, significant improvement occurred in all project indicators. ECT as practiced in the participating hospitals was effective and appropriate. Appropriateness was determined as depression refractory to two medication trails or an emergency due to severe suicidality or physical decompensation secondary to malnourishment. Transient hypertension (13%) and cardiac dysrhythmias (3.5%) which resolved in the recovery period were the most frequent complications. P7
STATEWIDE GEOGRAPHIC VARIATION IN GERIATRIC PSYCHIATRIC ADMISSIONS. James Westphal, M.D.; Ron Horswell, Ph.D.
P
urpose: The study of geographic practice variation in medicine and surgery has caused significant changes in health care policy and the regulation of clinical practice, but studies of psychiatric practice variation are minimal. The purpose of this study was to determine the major sources of statewide geographic variation in geriatric psychiatric admissions. Methodology: The Louisiana 1995 fiscal year Medicare over 65 psychiatric admission rates were calculated from the HCFA MEDPRO database and analyzed using six variables: prospective payment stays (PPS), psychiatric hospital vs. acute general hospital stays, first admissions vs. readmissions, depression admissions, substance abuse admissions, transfers after medical/surgical admissions. Results: High admission rate areas were associated with psychiatric hospitalizations after a medical/surgical hospitalization, the use of acute general hospitals, the use of non PPS stays, and depression admissions. Readmissions and substance abuse admissions were not statistically related to high admission areas. Conclusions: The strongest association with higher geographic admission rates was the use of non-PPS beds in acute general hospitals. This finding in geriatric psychiatric admissions is consistent with the small area analysis literature on medical and surgical admissions. P6
LIFE SATISFACTION IN INSTITUTIONALIZED CENTENARIANS. Marc Zisselman, M.D.; Terri A CutilloSchmitter, M.S.N, R.N.C.S.
O
bjective: To assess life satisfaction among centenarians residing in a long-term care facility. Second, to determine if a simple weekly interpersonal intervention
63