Generalized anxiety disorder in the

elderly y otros temas

Autore:
Dada, F; Sethi, S; Grossberg, GT;
Abstract
The thought of growing older is anxiety provoking because of associated loss of
health, financial security relationships, and mental faculties. As with depression
in the elderly geriatric anxiety is commonly disguised and presents with varied
symptoms, especially physical ones. Geriatric anxiety disorders most
commonly begin in early adulthood, tend to be chronic and interspersed with
remissions and relapses of varying degrees, and usually continue into old age.
This article outlines the clinical, diagnostic, and therapeutic issues that are
pertinent to generalized anxiety disorder in geriatric patients, including clinical
features, epidemiology, neurobiology, and nonpharmacologic and
pharmacologic therapies.
Behavioral and psychological symptoms of dementia as a risk factor
for nursing home placement
Autore:
Balestreri, L; Grossberg, A; Grossberg, GT;
DIAGNOSIS AND TREATMENT OF PSYCHOTIC SYMPTOMS IN ELDERLY
PATIENTS
Autore:
LAKE JT; RAHMAN AH; GROSSBERG GT
Abstract
The diagnosis and treatment of psychotic symptoms in elderly patients requires
more than extrapolation from studies of similar symptoms in the adult
population. In comparison with early-onset psychosis, late-onset psychosis is
characterized by differences in both its risk factors and typical signs and
symptoms. Diagnosis may include psychotic disorders, mood disorders,
delusional disorder, dementia or delirium. Several medications have also been
associated with the development of psychotic symptoms in the elderly. There is

a paucity of literature concerning psychotic symptoms specifically in elderly

patients, and this complicates management.
Treatment involves the resolution of any causative general medical condition,
and/or symptomatic management with antipsychotic medication. The highpotency antipsychotics are typically better tolerated in the elderly than their
low-potency counterparts. In addition, the newer atypical antipsychotics such
as clozapine have shown early promise. It is important to consider the higher
incidence of adverse effects and tardive dyskinesia in the elderly when
choosing a drug and its dosage. Consideration of psychosocial factors
completes the appropriate management of psychotic symptoms in older
patients.
:
THE TREATMENT OF PSYCHOSIS IN LATE-LIFE
Autore:
ZAYAS EM; GROSSBERG GT;
Abstract
The authors emphasize the need for careful differential diagnosis when
symptoms of psychosis arise in patients over the age of 65 years. Prevalence of
psychotic disorders in the elderly ranges from 0.2%-4.7% in community-based
samples to 10% in a nursing home population and as high as 63% in a study of
Alzheimer's patients.
Risk factors associated with the development of psychotic symptoms and
common causes of delirium are reviewed. Because age-related changes affect
the pharmacokinetics of neuroleptics, the authors' treatment
recommendations, which include the use of traditional and novel
antipsychotics, take into account the higher risk of side effects in the elderly.
ESTROGEN AS A PSYCHOTHERAPEUTIC AGENT
Autore:
RODRIGUEZ MM; GROSSBERG GT;
Abstract
This article provides information on the effects of estrogen as a
psychotherapeutic agent. Estrogen has a positive effect on several
neurotransmitter systems that are assumed to be involved in regulation of
affect, behavior, and cognition.

Clinical studies suggest that an important cause of non-responsiveness to

antidepressants in postmenopausal women may be inadequate hormone
replacement. Potential uses of estrogen as a mood stabilizer or mood enhancer
also are described in this article.
In the area of behavior, estrogen regulates aggressivity, sexual drive,
impulsivity, and hostility. In terms of cognition, evidence suggests the
importance of estrogen in the prevention and treatment of Alzheimer's-type
dementia. At the end of the article, future research directions are discussed.
EPIDEMIOLOGY OF PSYCHOTHERAPEUTIC DRUG-USE IN OLDER ADULTS
Autore:
GROSSBERG GT; GROSSBERG JA;
Abstract
Those over 65 years of age constitute nearly 13% of the United States
population. This age group, however, consumes three times their number of
prescribed and over-the-counter remedies. In fact, nearly 30% of all
prescriptions and 40% of over-the-counter remedies are consumed by older
adults. This is also the population most sensitive to the side effects of drugs
and, in particular, to the mood-or mind-altering properties of commonly
prescribed and over-the-counter remedies. This article discusses medication
usage among older adults with a special focus on various classes of
psychotherapeutic agents-their uses, potential abuses, and special hazards.
G.T. Grossberg e J.T. Lake, "THE ROLE OF THE PSYCHIATRIST IN ALZHEIMERSDISEASE", The Journal of clinical psychiatry, 59, 1998, pp. 3-6

Abstract
Psychiatrists are uniquely qualified to provide a variety of important services to
patients with Alzheimer's disease and their families andprofessional caregivers.
This paper highlights the role of the psychiatric physician in the differential
diagnosis of dementing illnesses. Psychiatrists are also uniquely trained to
evaluate and treat the psychiatric symptoms and problem behaviors in
Alzheimer's disease. The psychiatrist may be asked to utilize and monitor
antidementia compounds as well as to orchestrate functional and competency
evaluations. As theleader of the mental health team, the psychiatrist serves as
educatorand resource provider to patients and their families. Lately, the
psychiatrist works closely with caregivers to monitor for and prevent burnout
and depression.

B.C. Jost e G.T. Grossberg, "THE EVOLUTION OF PSYCHIATRIC-SYMPTOMS IN

ALZHEIMERS-DISEASE - A NATURAL-HISTORY STUDY", Journal of the American
Geriatrics Society, 44(9), 1996, pp. 1078-1081

Abstract
OBJECTIVE: To characterize the natural history of Alzheimer's Disease (AD); in
particular, to determine the prevalence and time of onset of psychiatric
symptoms. DESIGN: Retrospective medical records review.
SETTING: Regional brain bank operated by a university hospital.
PARTICIPANTS: One hundred randomly selected autopsy-confirmed AD
patients. MEASUREMENTS: The presence of psychiatric symptoms (e.g.,
anxiety, wandering, agitation) was documented, and the time of onset relative
to diagnosis was measured.
RESULTS:

Irritability, agitation, and aggression were documented in 81 patients

(81%) an average of 10 months after diagnosis.
A total of 72% of patients experienced depression, changes in mood,
social withdrawal, and suicidal ideation more than 2 years before
diagnosis (26.4 months).
Hallucinations, paranoia, accusatory behavior, and delusions were
documented around the time of diagnosis (0.1 months after diagnosis) in
45% of patients.
Patients with early-onset disease, more years of formal education, and
male gender experienced psychiatric symptoms later, relative to
diagnosis, than their counterparts.

CONCLUSIONS: Psychiatric manifestations of depression may herald a diagnosis

of AD, as such behaviors occurred more than 2 years before diagnosis, on
average, in this cohort. Psychotic symptoms manifested around the time of
diagnosis, perhaps even prompting diagnosis, whereas agitative symptoms
occurred in the first year after diagnosis. The evolution of psychiatric
symptoms in this cohort differed according to age at onset of disease, years of
formal education, and gender.
E.M. Zayas e G.T. Grossberg, "TREATING THE AGITATED ALZHEIMER
PATIENT", The Journal of clinical psychiatry, 57, 1996, pp. 46-54

Abstract
Dementia is a syndrome that consists of cognitive, psychiatric, and behavioral
changes.
Studies report from 42% to 62% of nursing home residents and at least 50% of
outpatients with dementia exhibit behavioral disturbances.
Agitation is a frequent behavioral disturbance associated with dementia. The
Omnibus Budget Reconciliation Act (OBRA) regulations have made it imperative
that physicians review and be familiar with alternative treatment options. We
review and present strategies for the evaluation and treatment of agitation in
demented patients.

B.C. Jost e G.T. Grossberg, "THE NATURAL-HISTORY OF ALZHEIMERS-DISEASE - A

BRAIN BANK STUDY", Journal of the American Geriatrics Society, 43(11), 1995,
pp. 1248-1255

Abstract
OBJECTIVE: To define the natural history of Alzheimer's Disease (AD),from time
of clinical (presumptive) diagnosis and/or onset of symptoms to death and to
describe demographic and clinical characteristics of patients with AD. DESIGN:
Retrospective medical records review.
SETTING: Regional brain bank operated by a university hospital.
PARTICIPANTS: One-hundred randomly selected, autopsy-confirmed Alzheimer's
Disease patients.
MEASUREMENTS: All information pertaining to family and clinical history
(diagnoses, office visits, hospitalizations), medication use, nutritional status,
and clinical testing (laboratory testing, imaging, diagnostics, and psychometric
testing) was abstracted. Time of onset for behavioral symptoms (e.g., anxiety,
wandering, agitation) and deficits in cognitive function (e.g., recent memory,
concentration, language) and activities of daily living (ADL) were also
abstracted. Data was collected on-site using a laptop computer and a series of
customized data entry spreadsheets. Upon completion of the data abstraction
process, data was converted to a database program for query and analysis.

RESULTS: A complete natural history timeline was constructed based on the

mean values observed in order to demonstrate important clinical endpoints,
namely, diagnosis, institutionalization, and death. The mean time between
onset of symptoms and clinical diagnosis was 32.1 months (standard deviation
= 37.9 months).
The interval between symptom onset and AD diagnosis was longer for patients
who were less than 65 at time of diagnosis (mean = 37.6 months), female
patients (mean = 34.9 months), and patients with a positive family history of
dementia (mean = 37.5 months).
The mean age at diagnosis was 74.7 years (standard deviation = 8.6 years),
with a range of 52 to 89 years. Most patients were diagnosed between the ages
of 70 and 79. Males were diagnosed at an earlier age, 72.8 years, on average,
than females, 75.4 years.
The mean time to institutionalization from time of clinical diagnosis was 23.9
months (standard deviation = 33.6 months). The average age at
institutionalization was 77.6 years, with a minimum of 60 years and a
maximum of 92.5 years. Institutionalization occurred 56.5 months after
symptom onset, on average. This interval was shorter among patients with a
negative family history (mean = 53.1 months) and patients diagnosed after
age 65 (mean = 51.6 months).
Patients diagnosed before age 65 experienced a significantly greater average
time to institutionalization, 94 months (P = .01). Disease duration was
measured as time from symptom onset until death. Mean disease duration was
101.3 months, or nearly 8.5 years (standard deviation = 59.2 months).
Subgroup analysis showed that disease duration was prolonged in younger
onset patients (mean = 129.1 months), females (mean = 107.9 months), and
patients with a positive family history of dementia (mean = 106.3 months).
CONCLUSIONS: These data suggest that the typical AD patient is diagnosed 32
months after symptom onset, at the age of 75 years. This patient is
institutionalized 25 months after diagnosis, or approximately 57 months after
symptom onset at age 78. The patient remains institutionalized for 44 months
or, in actuality, until death. Total disease duration for this typical AD patient is
just over 101 months or approximately 8.5 years.
Epidemiology of and risk factors for psychosis of Alzheimer's disease:
a review of 55 studies published from 1990 to 2003.
Ropacki SA1, Jeste DV.
Author information
Abstract

OBJECTIVE:
The authors reviewed studies published between 1990 and 2003 that reported
the prevalence, incidence, and persistence of, as well as the risk factors
associated with, psychosis of Alzheimer's disease.
METHOD:
PubMed and PsycINFO databases were searched by using the terms "psychosis
and Alzheimer disease" and "psychosis and dementia." Empirical investigations
presenting quantitative data on the epidemiology of and/or risk factors for
psychotic symptoms in Alzheimer's disease were included in the review. A total
of 55 studies, including a total of 9,749 subjects, met the inclusion criteria.
RESULTS:
Psychosis was reported in 41% of patients with Alzheimer's disease, including
delusions in 36% and hallucinations in 18%. The incidence of psychosis
increased progressively over the first 3 years of observation, after which the
incidence seemed to plateau. Psychotic symptoms tended to last for several
months but became less prominent after 1 year. African American or black
ethnicity and more severe cognitive impairment were associated with a higher
rate of psychosis. Psychosis was also associated with more rapid cognitive
decline. Some studies found a significant association between psychosis and
age, age at onset of Alzheimer's disease, and illness duration. Gender,
education, and family history of dementia or psychiatric illness showed weak or
inconsistent relationships with psychosis.
CONCLUSIONS:
Psychotic symptoms are common and persistent in patients with Alzheimer's
disease. Improved methods have advanced the understanding of psychosis in
Alzheimer's disease, although continued research, particularly longitudinal
studies, may unveil biological and clinical associations that will inform
treatments for these problematic psychological disturbances.
PMID:
16263838
[PubMed - indexed for MEDLINE]
The evolution of psychiatric symptoms in Alzheimer's disease: a
natural history study.
Jost BC1, Grossberg GT.

Author information
Abstract
OBJECTIVE:
To characterize the natural history of Alzheimer's Disease (AD); in particular, to
determine the prevalence and time of onset of psychiatric symptoms.
DESIGN:
Retrospective medical records review.
SETTING:
Regional brain bank operated by a university hospital.
PARTICIPANTS:
One hundred randomly selected autopsy-confirmed AD patients.
MEASUREMENTS:
The presence of psychiatric symptoms (e.g., anxiety, wandering, agitation) was
documented, and the time of onset relative to diagnosis was measured.
RESULTS:
Irritability, agitation, and aggression were documented in 81 patients (81%) an
average of 10 months after diagnosis. A total of 72% of patients experienced
depression, changes in mood, social withdrawal, and suicidal ideation more
than 2 years before diagnosis (26.4 months). Hallucinations, paranoia,
accusatory behavior, and delusions were documented around the time of
diagnosis (0.1 months after diagnosis) in 45% of patients. Patients with earlyonset disease, more years of formal education, and male gender experienced
psychiatric symptoms later, relative to diagnosis, than their counterparts.
CONCLUSIONS:
Psychiatric manifestations of depression may herald a diagnosis of AD, as such
behaviors occurred more than 2 years before diagnosis, on average, in this
cohort. Psychotic symptoms manifested around the time of diagnosis, perhaps
even prompting diagnosis, whereas agitative symptoms occurred in the first
year after diagnosis. The evolution of psychiatric symptoms in this cohort
differed according to age at onset of disease, years of formal education, and
gender.
Comment in

Some "depressive" symptoms may not imply depression. [J Am Geriatr

Soc. 1997]

Neuropsychiatric Symptoms of Dementia in the Elderly

Clinical Overview
Scope of the Problem
Neuropsychiatric symptoms have been observed in between 60% and 98% of
patients with dementia, are more evident in the moderate to severe stages,
and are a major trigger for nursing home placement. These symptoms,
including agitation, aggression, delusions, and hallucinations, among others,
are associated with heightened caregiver stress and burden. Thus,
interventions (both non pharmacologic and pharmacologic) aimed at treating
neuropsychiatric symptoms are sorely needed.
While typically thought of as indicative of late-stage disease,
behavioral/neuropsychiatric symptoms can appear early in the course of the
disease, well before clinical diagnosis. These symptoms can include social
withdrawal, depression, paranoia, and mood changes, among others. As the
disease advances, symptoms such as anxiety, irritability, and agitation become
more pronounced. Nearly 90% of patients with AD develop behavioral
symptoms during their illness; as many as 40% suffer from symptoms of mild
depression, and up to 66% experience anxiety.
The behavioral aspects of AD are highly distressing for the patient. Symptoms
of agitation (including inappropriate motor activity), apathy, and psychosis
(such as hallucinations) are common and are exacerbated in the presence of
the patients existing disabilities. More distressing symptoms, such as agitation,
violence, incontinence, and wandering, often prompt nursing home placement.
Behavioral symptoms are also a major source of stress for the caregiver.
Behavioral disturbances have been shown to be a strong predictor of caregiver
burden and are associated with increased financial hardship for the caregiver.
Indeed, caregivers for patients with AD often consider behavioral and
psychiatric symptoms to be the most challenging and distressing effects of the
disease.
Selected References:
Sink KM, Holden KF, Yaffe K. Pharmacologic treatment of neuropsychiatric
symptoms of dementia. JAMA. 2005;293:596-608.
Jost BC, Grossberg GT. The evolution of psychiatric symptoms in Alzheimer's
disease: a natural history study. J Am Geriatr Soc. 1996; 44: 1078-81.

Mega MS, Cummings JL, Fiorello, et al. The spectrum of behavioral changes in
Alzheimer's disease. Neurology. 1996; 46: 130-5.
Levy ML, Cummings JL, Kahn-Rose R. Neuropsychiatric symptoms and
cholinergic therapy for Alzheimer's disease. Gerontology. 1999; 45(suppl 1): 1522.

Burnout En Cuidadores Principales De Pacientes Con

Alzheimer, El Sndrome Del Asistente Desasistido
Fecha de publicacin:
1998 Digitum : Depsito de la Universidad de
Murcia >
Editor/es:
Murcia: Universidad de Murcia, Servicio de Publicacione
Enfermedad de Alzheimer,
Estrs profesional
Resumen: En este trabajo se describen los efectos emocionales que sufren
los familiares que asumen el papel de cuidadores principales de enfermos de
Alzheimer, y en especial el sndrome denominado Burnout. Este trastorno se
manifiesta mediante un complejo sndrome afectivo y motivacional, que acaece
en quienes desempean tareas de ayuda a los dems, caracterizado por la
presencia de sntomas de agotamiento emocional, despersonalizacin en el
trato e inadecuacin con la tarea que se realiza. El cuidado y atencin
constante que los familiares deben prestar al enfermo a lo largo de todas las
fases de la enfermedad, asistiendo en calidad de testigos impotentes del
deterioro progresivo e irreversible de su familiar, justifica frecuentemente la
aparicin de este sndrome. En este trabajo se describen las variables que
influyen en su aparicin, desde el mbito social, familiar y personal, modulando
la relacin entre cuidador y enfermo. Posteriormente se pone de manifiesto la
ausencia de programas de prevencin e intervencin para paliar los efectos del
sndrome. Por ltimo, se concluye la necesidad de implementar programas de
intervencin psicolgica que provean pautas adaptativas de afrontamiento y
control emocional a lo largo de las distintas fases de la enfermedad.