Quality improvement toward decreasing high-risk medications for older veteran outpatients.

Objectives: To examine the effectiveness of a quality improvement program to decrease prescribing of high-risk medications.

Design: Single cohort, pre- and postintervention.

Setting: Regional network of Department of Veterans Affairs medical facilities.

Antidepressant treatment of veterans with Parkinson's disease and depression: analysis of a national sample.

We examined the impact of comorbid Parkinson's disease (PD) on depression treatment. Using national Veterans Affairs (VA) databases, fiscal year 2002 data were examined for 283 273 elderly males seen for depression. We compared 2 matched depression groups, one with (N = 7868) and one without (N = 7868) PD.

Depression in veterans with Parkinson's disease: frequency, co-morbidity, and healthcare utilization.

Objective: To determine the frequency of depression in Parkinson's disease (PD) in routine clinical care, and to examine its association with co-morbid psychiatric and medical conditions and healthcare utilization.

Methods: Depression diagnoses and healthcare utilization data for all male veterans with PD age 55 or older seen in fiscal year 2002 (n = 41,162) were analyzed using Department of Veterans Affairs (VA) national databases. Frequencies of co-morbid disorders and healthcare utilization were determined for depressed and non-depressed patients; associations with depression were examined using multivariate logistic regression models.

Race and depression: does race affect the diagnosis and treatment of late-life depression?

While it is recognized that medical and neurological comorbidities complicate the accurate diagnosis and treatment of late-life depression, the possibility that patient race or even gender may affect management decisions is less discussed. This article reviews the current literature on racial differences in the diagnosis and treatment of late-life depression, including recent studies on physician contribution to disparities.

Rates of clinical depression diagnosis, functional impairment, and nursing home placement in coexisting dementia and depression.

Objective: Depression is commonly found as a coexisting condition in dementia. An earlier retrospective study by the authors found that patients with coexisting dementia and depression (CDD) were high utilizers of inpatient and nursing home care. The current prospective study was designed to investigate specific factors that might contribute to outcomes such as nursing home placement by examining the detection and course of CDD subjects as compared with subjects with either disorder alone.

Race, gender, and psychiatrists' diagnosis and treatment of major depression among elderly patients.

Objective: This study examined psychiatrists' contributions to racial and gender disparities in diagnosis and treatment among elderly persons.

Methods: Psychiatrists who volunteered to participate in the study were randomly assigned to one of four video vignettes depicting an elderly patient with late-life depression. The vignettes differed only in terms of the race of the actor portraying the patient (white or African American) and gender.

Effect of race and sex on primary care physicians' diagnosis and treatment of late-life depression.

Objectives: To examine primary care physician (PCP) contributions toward racial and sex differences in the diagnosis and treatment of late-life depression.

Design: Survey using a computerized instrument incorporating video interviews and text, with volunteer PCPs randomly assigned to one of four standardized video vignettes of an elderly patient depicting late-life depression. Vignettes differed only in the patient/actor's race (white/African-American) or sex.

Cerebrovascular disease and late-life depression.

Depression may occur as a result of vascular disease in a significant subpopulation of elderly persons. Indirect support for vascular disease as an underlying etiology of late-life depression includes the high rate of depression in patients with vascular disease, the frequency of "silent stroke" and white-matter hyperintensities in late-life depression, and the lower frequency of positive family histories of depression in such patients. The authors evaluate the associations of late-life depression with cerebrovascular disease by reviewing the existing pathophysiological, prognosis, and treatment-outcomes studies.

Herbal products and other supplements: use by elderly veterans with depression and dementia and their caregivers.

The use of herbal products and other "natural" supplements among the US population is on the rise. Limited data suggest that such use among the elderly may correlate with higher education levels as well as psychiatric symptoms. The authors examined herbal/supplement use among elderly veterans with depression and/or dementia (n = 82) and their primarily elderly caregivers (n = 56).

Treatment of agitation in AD: a randomized, placebo-controlled clinical trial.

Background: Treatment of agitation is a crucial problem in the care of patients with AD. Although antipsychotic and antidepressant medications and behavior management techniques (BMT) have each been used to treat agitation, clinical trials of these treatments have been characterized by small sample sizes and uncontrolled treatment designs.

Objective: To compare haloperidol, trazodone, and BMT with placebo in the treatment of agitation in AD outpatients.

Race, psychiatric diagnosis, and mental health care utilization in older patients.

To evaluate the impact of race on mental health care utilization among older patients within given clinical psychiatric diagnoses, the authors examined a retrospective sample of 23,718 elderly veterans treated in Department of Veterans Affairs inpatient facilities in 1994. Significant racial differences in mental health care utilization found over a subsequent 2-year period were related to outpatient (but not inpatient) care; for instance: 1) African American patients with psychotic disorders had significantly fewer outpatient psychiatric visits; and 2) African American patients with substance abuse disorders had significantly more psychiatric visits than Caucasian patients in their respective groups. Although inpatient utilization appeared to be similar among races, findings related to outpatient utilization may be associated with such factors as compliance, treatment efficacy, access to health care, or possible clinician bias.

Serotonin dysregulation in adolescents with major depression: hormone response to meta-chlorophenylpiperazine (mCPP) infusion.

This study examined central serotonin disturbance, as reflected by neuroendocrine hormones, among adolescents with major depression. Prolactin, cortisol, and growth hormone were measured following the infusion of a serotonin agonist, meta-chlorophenylpiperazine (mCPP). Twelve (M=6, F=6) medication-free adolescents with major depression (MDD) were compared with 12 (M=6, F=6) matched normal control subjects, ranging in age from 13 to 17 years.

Race and inpatient psychiatric diagnoses among elderly veterans.

Objective: Limited data exist on differential rates of psychiatric diagnoses between ethnocultural groups in the elderly population. The purpose of this study was to examine more closely the issue of race and rates of psychiatric diagnoses among elderly inpatients.

Methods: The national sample included 23,758 veterans age 60 or over admitted in 1994 to acute inpatient units in Department of Veterans Affairs (VA) hospitals.

The efficacy, safety, and tolerability of antipsychotics in the elderly.

Antipsychotic medications are among the most widely prescribed class of medications for elderly patients. Despite their high use, few studies document the efficacy, safety, and tolerability of these agents in this patient population. This is unfortunate because, as a group, the elderly are exceptionally sensitive to the adverse effects associated with antipsychotics, in particular, the extrapyramidal side effects (EPS).

Health care utilization by older patients with coexisting dementia and depression.

Objective: Few studies have examined the course of coexisting dementia and depression. The purpose of this study was to compare elderly patients who had coexisting dementia and depression with elderly patients who had either disorder alone in terms of their utilization of inpatient and outpatient services.

Method: The study group included 7,115 veterans aged 60 years or older who had been discharged from Department of Veterans Affairs inpatient units in 1992 with diagnoses of major depression, dementia, or both.

Psychiatric diagnosis and intervention in older and younger patients in a primary care clinic: effect of a screening and diagnostic instrument.

Objectives: To determine whether patient age is associated with psychiatric diagnosis or provider intervention in a busy primary care clinic, and, if so, whether a screening and diagnostic tool, the PRIME-MD, modifies age-related differences.

Design, Setting, And Participants: PRIME-MD use, psychiatric diagnosis, and provider interventions for psychiatric conditions were recorded for eligible patients attending a Veterans Affairs Medical Center primary care clinic. Data from 952 younger (<65 years) and 1135 older patients (> or =65 years) were analyzed to determine whether there were age-related differences in diagnosis/intervention and if use of the PRIME-MD modified these differences.

Differential trace amine alterations in individuals receiving acetylenic inhibitors of MAO-A (clorgyline) or MAO-B (selegiline and pargyline).

Marked, dose-dependent elevations in the urinary excretion of phenylethylamine, para-tyramine, and meta-tyramine were observed in depressed patients treated for three or more weeks with 10, 30, or 60 mg/day of the partially-selective inhibitor of MAO-B, selegiline (l-deprenyl). In comparative studies with other, structurally similar acetylenic inhibitors of MAO, pargyline, an MAO-B > MAO-A inhibitor used in doses of 90 mg/day for three or more weeks, produced elevations in these trace amines which were similar to those found with the highest dose of selegiline studied. Clorgyline, a selective inhibitor of MAO-A used in doses of 30 mg/day for three or more weeks (a dose/time regimen previously reported to reduce urinary, plasma, and cerebrospinal fluid 3-methoxy-4-hydroxyphenylethyleneglycol (MHPG) > 80%, indicating a marked inhibitory effect on MAO-A in humans in vivo) produced negligible changes in trace amine excretion.

Cognitive, behavioral, and motor effects of the NMDA antagonist ketamine in Huntington's disease.

Background: Excitotoxicity may contribute to neuronal degeneration in Huntington's disease (HD). N-methyl-D-aspartate (NMDA) receptor antagonists can prevent neuronal degeneration caused by excitotoxicity, but their effects in HD patients are not known.

Methods: We investigated the acute cognitive, behavioral, and motor effects of the NMDA-receptor antagonist ketamine in HD patients.

Management of treatment resistance in the depressed geriatric patient.

The treatment of depression in geriatric patients is challenging on all levels. Recognition, compliance, medical comorbidity, tolerance of drug regimens, and accessibility of the patient to therapy all represent major clinical problems. Treating depression in elderly, disabled patients requires patience, keen observation skills, and much flexibility.

High-dose selegiline in treatment-resistant older depressive patients.

Background: We examined the effect of high-dose selegiline in 16 treatment-resistant older depressive patients. We hypothesized that selegiline, at a dosage of 60 mg/d, would be at least partially effective but that the higher doses would not maintain the monoamine oxidase B selectivity observed with the lower doses of selegiline.

Methods: Sixteen treatment-resistant subjects (mean [+/- SD] age, 65.

Sodium valproate in the treatment of behavioral disturbance in dementia.

Management of the behavioral complications of dementia, including agitation and aggression, presents a tremendous challenge to families and caregivers of afflicted patients. Most previous pharmacotherapies have shown minimal efficacy and significant side effects. We report our initial, open-label experience using the anticonvulsant sodium valproate in four dementia patients with severe behavioral disturbance.