American Association for Geriatric Psychiatry (AAGP)

WASHINGTON – One-fourth of older adults with schizophrenia shifted between remission and nonremission status in the first-ever large-scale longitudinal outcome study of older adults with schizophrenia spectrum disorder living in the community.

The 4-year longitudinal data revealed a lower persistent remission rate than had been suggested by earlier cross-sectional studies. "Our findings suggest that in addition to the increasingly recognized difficulties that older adults with schizophrenia face with respect to physical health, there is substantially more psychiatric instability than previously believed," said Dr. Carl I. Cohen, professor of psychiatry and director of the division of geriatric psychiatry at the State University of New York Downstate, Brooklyn.

Schizophrenia typically develops in the second or third decade of life, and increasing numbers of patients are surviving into old age with the disorder. Between 80% and 85% of people aged 55 years and over with schizophrenia developed it prior to age 45, with prevalence estimates for schizophrenia in adults aged between 45 and 60 of about 0.6% to 1%.

However, over the next two decades, there will be a doubling of the number of people aged 55 years and over with schizophrenia, from about 550,000 in 2005 to 1.1 million in 2025. By that time, about one-fourth of people with schizophrenia will be in this older age bracket. And in contrast to previous decades, most of these individuals are living in the community rather than in institutional settings, Dr. Cohen noted at the annual meeting of the American Association for Geriatric Psychiatry.

Recent cross-sectional studies of older adults have found remission rates of 49% (Am. J. Geriatr. Psychiatry 2008;16:966-73), 47% (J. Int. Neuropsychol. Soc. 2008;14:479-88), and 29% (Schizophr. Res. 2011;126:237-44). In longitudinal studies of remission and associated predictors in younger persons with schizophrenia, rates of clinical remission after an initial clinical episode ranged from 17% to 88% (Curr. Opin. Psychiatry 2011;24:114-21). On follow-up, the percentage of patients maintaining remission ranged from 50% to 89% (Rev. Epidemiol. Sante Publique 2009;57:25-32 and Schizophr. Res. 2009;115:58-66), with remission occurring in some of the originally nonremitted patients over time.

There have been no previous longitudinal studies in older adults, he said.

Dr. Cohen and his associates previously conducted a cross-sectional study of 198 community-dwelling adults with schizophrenia aged 55 years and over, and found that that 49% met the clinical criteria for remission, 66% met the Positive and Negative Syndrome Scale (PANSS) criteria of 3 or fewer of 8 domains, and 83% had had no hospitalizations in the past year (Am. J. Geriatr. Psychiatry 2008;16:966-73). Thus, "the study showed that symptom remission is a realistic goal for many patients," Dr. Cohen said.

In that study, four variables were associated with remission: fewer total network contacts, a greater proportion of intimates, fewer lifetime traumatic events, and higher Dementia Rating Scale scores. Type of residence, use of mental health services, and use of psychotropic medication had no significant association with remission, he said.

In the current longitudinal study, a total of 104 patients aged 55 years and older with schizophrenia spectrum disorders participated in follow-up interviews. They were followed for a mean of 52 months (range, 12-116 months). They had a mean age of 61 years, 55% were men, and 55% were white. Two-thirds (65%) lived in supported residences, while the other 35% lived independently or with family members.

To meet the criteria of remission, subjects had to score 3 or below on 8 symptom domains derived from the PANSS, and were required to have no hospitalizations during the previous year. The PANSS domains used were P1 (delusions), P2 (conceptual disorganization), P3 (hallucinatory behavior), N1 (blunted affect), N4 (passive/apathetic social withdrawal), N6 (lack of spontaneity and flow of conversation), G5 (mannerisms and posturing), and G9 (unusual thought content).

On follow-up, there were nonsignificant changes in the percentages meeting the outcomes of remission, including no hospitalizations in the past year (49% at baseline, 40% at follow-up), overall symptom remission (56% at baseline, 47% at follow-up), positive-type symptom remission (66% at baseline, 72% at follow-up), and negative-type symptom remission (64% at baseline, 68% at follow-up).

"If you look cross sectionally, you don’t see much change," Dr. Cohen noted.

However, a great deal of movement occurred between groups. Just 25% met remission criteria at both assessments, and an additional 35% did not meet remission criteria at either assessment. Another 25% went from meeting remission criteria at time 1 to not meeting remission criteria at time 2, and 16% went from not meeting remission criteria at T1 to meeting remission criteria at T2.

"Notably, half the persons in remission at time 1 were not in remission at time 2. These findings suggest that sustained remission is much less than suggested by cross-sectional studies, and optimism regarding outcome may need to be tempered.

"Secondly, [the results] suggest that symptoms in later life are not stagnant and that there is considerable flux in symptoms," he commented.

In bivariate analysis, 7 of 12 of the baseline predictor variables were significant at T1: baseline remission, total number of intimates, community integration, residential status, self-esteem score, number of psychiatric medications, and number of entitlements. Significant loss in the past 5 years at T2 also proved to be a significant predictor.

However, on logistic regression analysis, only 3 of the baseline predictors were found to predict readmission at follow-up: a higher community integration score (8.8 vs. 7.3; odds ratio, 1.52), higher number of entitlements (3.9 vs. 3.3; OR, 1.57), and a lower number of psychiatric medications (1.6 vs. 2.3; OR, 0.63). After network size at T1 was controlled for, remission at T1 was significantly correlated with network size at T2 (10.3 vs. 6.5 contacts for persons in remission at T1 vs. nonremission at T2). Baseline remission did not predict any other clinical or social variables at T2, after their baseline levels were controlled for.

"The fact that community integration can impact on subsequent clinical remission suggests that social interventions can be very important in older adults with respect to both clinical and social well-being. The significance of entitlements in this population underscores the need for older adults to secure and maintain various safety net supports as they grow older and more physically frail," Dr. Cohen said.

The finding that more psychotropic medications at baseline were associated with lower remission rates at follow-up is probably attributable to greater symptoms among the nonremission group, rather than the medications making patients worse. However, "it does suggest that the medications may not be as powerful in the older age group," he noted.

Post hoc analysis revealed that compared with the 36 patients who remained in nonremission, the 16 who improved showed higher Instrumental Activities of Daily Living scores at baseline (24.3 vs. 21.9), had a greater number of physical disorders at baseline (2.3 vs. 1.0), and had more persons in their network who could be counted on (7.3 vs. 4.6). When the investigators compared the 25 patients who remained in remission with the 25 who went from remission at baseline to nonremission at follow-up, they found that those who worsened showed lower rates of community integration scores (7.8 vs. 8.9), he said.

There were no significant changes in positive symptom remission (65% at baseline vs. 72% at follow-up), with 51% in remission at both assessments, 15% not in remission at either assessment, 14% going from remission to nonremission, and 20% from nonremission to remission. There were also no significant changes in negative symptom remission (64% at baseline vs. 68% at follow-up), with 54% in remission at both assessments, 23% not in remission at either assessment, 10% going from remission to nonremission, and 14% from nonremission to remission.

"Little is known about the factors that predict the movement from remission to nonremission status and vice versa. Our preliminary data – with a fairly small subsample – suggest that social and functional factors are important," Dr. Cohen concluded. "More studies are needed to identify those factors that move persons toward remission."

Dr. Cohen’s research was funded in part by a grant from the National Institute of General Medical Sciences. He reported no other disclosures.

WASHINGTON – One-fourth of older adults with schizophrenia shifted between remission and nonremission status in the first-ever large-scale longitudinal outcome study of older adults with schizophrenia spectrum disorder living in the community.

The 4-year longitudinal data revealed a lower persistent remission rate than had been suggested by earlier cross-sectional studies. "Our findings suggest that in addition to the increasingly recognized difficulties that older adults with schizophrenia face with respect to physical health, there is substantially more psychiatric instability than previously believed," said Dr. Carl I. Cohen, professor of psychiatry and director of the division of geriatric psychiatry at the State University of New York Downstate, Brooklyn.

Schizophrenia typically develops in the second or third decade of life, and increasing numbers of patients are surviving into old age with the disorder. Between 80% and 85% of people aged 55 years and over with schizophrenia developed it prior to age 45, with prevalence estimates for schizophrenia in adults aged between 45 and 60 of about 0.6% to 1%.

However, over the next two decades, there will be a doubling of the number of people aged 55 years and over with schizophrenia, from about 550,000 in 2005 to 1.1 million in 2025. By that time, about one-fourth of people with schizophrenia will be in this older age bracket. And in contrast to previous decades, most of these individuals are living in the community rather than in institutional settings, Dr. Cohen noted at the annual meeting of the American Association for Geriatric Psychiatry.

Recent cross-sectional studies of older adults have found remission rates of 49% (Am. J. Geriatr. Psychiatry 2008;16:966-73), 47% (J. Int. Neuropsychol. Soc. 2008;14:479-88), and 29% (Schizophr. Res. 2011;126:237-44). In longitudinal studies of remission and associated predictors in younger persons with schizophrenia, rates of clinical remission after an initial clinical episode ranged from 17% to 88% (Curr. Opin. Psychiatry 2011;24:114-21). On follow-up, the percentage of patients maintaining remission ranged from 50% to 89% (Rev. Epidemiol. Sante Publique 2009;57:25-32 and Schizophr. Res. 2009;115:58-66), with remission occurring in some of the originally nonremitted patients over time.

There have been no previous longitudinal studies in older adults, he said.

Dr. Cohen and his associates previously conducted a cross-sectional study of 198 community-dwelling adults with schizophrenia aged 55 years and over, and found that that 49% met the clinical criteria for remission, 66% met the Positive and Negative Syndrome Scale (PANSS) criteria of 3 or fewer of 8 domains, and 83% had had no hospitalizations in the past year (Am. J. Geriatr. Psychiatry 2008;16:966-73). Thus, "the study showed that symptom remission is a realistic goal for many patients," Dr. Cohen said.

In that study, four variables were associated with remission: fewer total network contacts, a greater proportion of intimates, fewer lifetime traumatic events, and higher Dementia Rating Scale scores. Type of residence, use of mental health services, and use of psychotropic medication had no significant association with remission, he said.

In the current longitudinal study, a total of 104 patients aged 55 years and older with schizophrenia spectrum disorders participated in follow-up interviews. They were followed for a mean of 52 months (range, 12-116 months). They had a mean age of 61 years, 55% were men, and 55% were white. Two-thirds (65%) lived in supported residences, while the other 35% lived independently or with family members.

To meet the criteria of remission, subjects had to score 3 or below on 8 symptom domains derived from the PANSS, and were required to have no hospitalizations during the previous year. The PANSS domains used were P1 (delusions), P2 (conceptual disorganization), P3 (hallucinatory behavior), N1 (blunted affect), N4 (passive/apathetic social withdrawal), N6 (lack of spontaneity and flow of conversation), G5 (mannerisms and posturing), and G9 (unusual thought content).

On follow-up, there were nonsignificant changes in the percentages meeting the outcomes of remission, including no hospitalizations in the past year (49% at baseline, 40% at follow-up), overall symptom remission (56% at baseline, 47% at follow-up), positive-type symptom remission (66% at baseline, 72% at follow-up), and negative-type symptom remission (64% at baseline, 68% at follow-up).

"If you look cross sectionally, you don’t see much change," Dr. Cohen noted.

However, a great deal of movement occurred between groups. Just 25% met remission criteria at both assessments, and an additional 35% did not meet remission criteria at either assessment. Another 25% went from meeting remission criteria at time 1 to not meeting remission criteria at time 2, and 16% went from not meeting remission criteria at T1 to meeting remission criteria at T2.

"Notably, half the persons in remission at time 1 were not in remission at time 2. These findings suggest that sustained remission is much less than suggested by cross-sectional studies, and optimism regarding outcome may need to be tempered.

"Secondly, [the results] suggest that symptoms in later life are not stagnant and that there is considerable flux in symptoms," he commented.

In bivariate analysis, 7 of 12 of the baseline predictor variables were significant at T1: baseline remission, total number of intimates, community integration, residential status, self-esteem score, number of psychiatric medications, and number of entitlements. Significant loss in the past 5 years at T2 also proved to be a significant predictor.

However, on logistic regression analysis, only 3 of the baseline predictors were found to predict readmission at follow-up: a higher community integration score (8.8 vs. 7.3; odds ratio, 1.52), higher number of entitlements (3.9 vs. 3.3; OR, 1.57), and a lower number of psychiatric medications (1.6 vs. 2.3; OR, 0.63). After network size at T1 was controlled for, remission at T1 was significantly correlated with network size at T2 (10.3 vs. 6.5 contacts for persons in remission at T1 vs. nonremission at T2). Baseline remission did not predict any other clinical or social variables at T2, after their baseline levels were controlled for.

"The fact that community integration can impact on subsequent clinical remission suggests that social interventions can be very important in older adults with respect to both clinical and social well-being. The significance of entitlements in this population underscores the need for older adults to secure and maintain various safety net supports as they grow older and more physically frail," Dr. Cohen said.

The finding that more psychotropic medications at baseline were associated with lower remission rates at follow-up is probably attributable to greater symptoms among the nonremission group, rather than the medications making patients worse. However, "it does suggest that the medications may not be as powerful in the older age group," he noted.

Post hoc analysis revealed that compared with the 36 patients who remained in nonremission, the 16 who improved showed higher Instrumental Activities of Daily Living scores at baseline (24.3 vs. 21.9), had a greater number of physical disorders at baseline (2.3 vs. 1.0), and had more persons in their network who could be counted on (7.3 vs. 4.6). When the investigators compared the 25 patients who remained in remission with the 25 who went from remission at baseline to nonremission at follow-up, they found that those who worsened showed lower rates of community integration scores (7.8 vs. 8.9), he said.

There were no significant changes in positive symptom remission (65% at baseline vs. 72% at follow-up), with 51% in remission at both assessments, 15% not in remission at either assessment, 14% going from remission to nonremission, and 20% from nonremission to remission. There were also no significant changes in negative symptom remission (64% at baseline vs. 68% at follow-up), with 54% in remission at both assessments, 23% not in remission at either assessment, 10% going from remission to nonremission, and 14% from nonremission to remission.

"Little is known about the factors that predict the movement from remission to nonremission status and vice versa. Our preliminary data – with a fairly small subsample – suggest that social and functional factors are important," Dr. Cohen concluded. "More studies are needed to identify those factors that move persons toward remission."

Dr. Cohen’s research was funded in part by a grant from the National Institute of General Medical Sciences. He reported no other disclosures.

WASHINGTON – One-fourth of older adults with schizophrenia shifted between remission and nonremission status in the first-ever large-scale longitudinal outcome study of older adults with schizophrenia spectrum disorder living in the community.

The 4-year longitudinal data revealed a lower persistent remission rate than had been suggested by earlier cross-sectional studies. "Our findings suggest that in addition to the increasingly recognized difficulties that older adults with schizophrenia face with respect to physical health, there is substantially more psychiatric instability than previously believed," said Dr. Carl I. Cohen, professor of psychiatry and director of the division of geriatric psychiatry at the State University of New York Downstate, Brooklyn.

Schizophrenia typically develops in the second or third decade of life, and increasing numbers of patients are surviving into old age with the disorder. Between 80% and 85% of people aged 55 years and over with schizophrenia developed it prior to age 45, with prevalence estimates for schizophrenia in adults aged between 45 and 60 of about 0.6% to 1%.

However, over the next two decades, there will be a doubling of the number of people aged 55 years and over with schizophrenia, from about 550,000 in 2005 to 1.1 million in 2025. By that time, about one-fourth of people with schizophrenia will be in this older age bracket. And in contrast to previous decades, most of these individuals are living in the community rather than in institutional settings, Dr. Cohen noted at the annual meeting of the American Association for Geriatric Psychiatry.

Recent cross-sectional studies of older adults have found remission rates of 49% (Am. J. Geriatr. Psychiatry 2008;16:966-73), 47% (J. Int. Neuropsychol. Soc. 2008;14:479-88), and 29% (Schizophr. Res. 2011;126:237-44). In longitudinal studies of remission and associated predictors in younger persons with schizophrenia, rates of clinical remission after an initial clinical episode ranged from 17% to 88% (Curr. Opin. Psychiatry 2011;24:114-21). On follow-up, the percentage of patients maintaining remission ranged from 50% to 89% (Rev. Epidemiol. Sante Publique 2009;57:25-32 and Schizophr. Res. 2009;115:58-66), with remission occurring in some of the originally nonremitted patients over time.

There have been no previous longitudinal studies in older adults, he said.

Dr. Cohen and his associates previously conducted a cross-sectional study of 198 community-dwelling adults with schizophrenia aged 55 years and over, and found that that 49% met the clinical criteria for remission, 66% met the Positive and Negative Syndrome Scale (PANSS) criteria of 3 or fewer of 8 domains, and 83% had had no hospitalizations in the past year (Am. J. Geriatr. Psychiatry 2008;16:966-73). Thus, "the study showed that symptom remission is a realistic goal for many patients," Dr. Cohen said.

In that study, four variables were associated with remission: fewer total network contacts, a greater proportion of intimates, fewer lifetime traumatic events, and higher Dementia Rating Scale scores. Type of residence, use of mental health services, and use of psychotropic medication had no significant association with remission, he said.

In the current longitudinal study, a total of 104 patients aged 55 years and older with schizophrenia spectrum disorders participated in follow-up interviews. They were followed for a mean of 52 months (range, 12-116 months). They had a mean age of 61 years, 55% were men, and 55% were white. Two-thirds (65%) lived in supported residences, while the other 35% lived independently or with family members.

To meet the criteria of remission, subjects had to score 3 or below on 8 symptom domains derived from the PANSS, and were required to have no hospitalizations during the previous year. The PANSS domains used were P1 (delusions), P2 (conceptual disorganization), P3 (hallucinatory behavior), N1 (blunted affect), N4 (passive/apathetic social withdrawal), N6 (lack of spontaneity and flow of conversation), G5 (mannerisms and posturing), and G9 (unusual thought content).

On follow-up, there were nonsignificant changes in the percentages meeting the outcomes of remission, including no hospitalizations in the past year (49% at baseline, 40% at follow-up), overall symptom remission (56% at baseline, 47% at follow-up), positive-type symptom remission (66% at baseline, 72% at follow-up), and negative-type symptom remission (64% at baseline, 68% at follow-up).

"If you look cross sectionally, you don’t see much change," Dr. Cohen noted.

However, a great deal of movement occurred between groups. Just 25% met remission criteria at both assessments, and an additional 35% did not meet remission criteria at either assessment. Another 25% went from meeting remission criteria at time 1 to not meeting remission criteria at time 2, and 16% went from not meeting remission criteria at T1 to meeting remission criteria at T2.

"Notably, half the persons in remission at time 1 were not in remission at time 2. These findings suggest that sustained remission is much less than suggested by cross-sectional studies, and optimism regarding outcome may need to be tempered.

"Secondly, [the results] suggest that symptoms in later life are not stagnant and that there is considerable flux in symptoms," he commented.

In bivariate analysis, 7 of 12 of the baseline predictor variables were significant at T1: baseline remission, total number of intimates, community integration, residential status, self-esteem score, number of psychiatric medications, and number of entitlements. Significant loss in the past 5 years at T2 also proved to be a significant predictor.

However, on logistic regression analysis, only 3 of the baseline predictors were found to predict readmission at follow-up: a higher community integration score (8.8 vs. 7.3; odds ratio, 1.52), higher number of entitlements (3.9 vs. 3.3; OR, 1.57), and a lower number of psychiatric medications (1.6 vs. 2.3; OR, 0.63). After network size at T1 was controlled for, remission at T1 was significantly correlated with network size at T2 (10.3 vs. 6.5 contacts for persons in remission at T1 vs. nonremission at T2). Baseline remission did not predict any other clinical or social variables at T2, after their baseline levels were controlled for.

"The fact that community integration can impact on subsequent clinical remission suggests that social interventions can be very important in older adults with respect to both clinical and social well-being. The significance of entitlements in this population underscores the need for older adults to secure and maintain various safety net supports as they grow older and more physically frail," Dr. Cohen said.

The finding that more psychotropic medications at baseline were associated with lower remission rates at follow-up is probably attributable to greater symptoms among the nonremission group, rather than the medications making patients worse. However, "it does suggest that the medications may not be as powerful in the older age group," he noted.

Post hoc analysis revealed that compared with the 36 patients who remained in nonremission, the 16 who improved showed higher Instrumental Activities of Daily Living scores at baseline (24.3 vs. 21.9), had a greater number of physical disorders at baseline (2.3 vs. 1.0), and had more persons in their network who could be counted on (7.3 vs. 4.6). When the investigators compared the 25 patients who remained in remission with the 25 who went from remission at baseline to nonremission at follow-up, they found that those who worsened showed lower rates of community integration scores (7.8 vs. 8.9), he said.

There were no significant changes in positive symptom remission (65% at baseline vs. 72% at follow-up), with 51% in remission at both assessments, 15% not in remission at either assessment, 14% going from remission to nonremission, and 20% from nonremission to remission. There were also no significant changes in negative symptom remission (64% at baseline vs. 68% at follow-up), with 54% in remission at both assessments, 23% not in remission at either assessment, 10% going from remission to nonremission, and 14% from nonremission to remission.

"Little is known about the factors that predict the movement from remission to nonremission status and vice versa. Our preliminary data – with a fairly small subsample – suggest that social and functional factors are important," Dr. Cohen concluded. "More studies are needed to identify those factors that move persons toward remission."

Dr. Cohen’s research was funded in part by a grant from the National Institute of General Medical Sciences. He reported no other disclosures.

WASHINGTON – More than one in 10 admissions to an acute psychiatric inpatient geriatric psychiatry service was associated with an alcohol or drug use disorder in a retrospective examination of admissions for 1,788 patients over age 65 who were seen from 2001 to 2011.

"With more than 1 in 10 elderly patients meeting criteria for a substance use diagnosis in this population, clinicians should increase surveillance at all patient encounters in an effort to reduce the associated morbidity and mortality and improve functional status and quality of life for these individuals," Dr. Dennis Dombrowski said in an interview.

The total group had a mean age of 75.45 years and an average length of stay of 13.91 days. Of all 1,788 admissions, 11.7% (210) were associated with at least one substance abuse diagnosis. The most common was alcohol abuse, identified in 73% of the 210. Other substance abuse diagnoses included sedative hypnotic abuse/dependence in 11%, opiate abuse/dependence in 3%, cannabis use in 1%, tobacco use disorder in 1%, and unspecified drug-induced disorders/withdrawal in 39%. (The total is greater than 100% because some patients had more than one diagnosis.)

Compared with the psychiatric patients without substance abuse diagnoses, those who had at least one were significantly younger, were more likely to be male, had shorter lengths of stay, were readmitted less frequently, and were more likely to be divorced, he reported in a poster presentation at the annual meeting of the American Association for Geriatric Psychiatry.

Although the primary reason for admission could not be ascertained because of the limitations of the database, the most frequent Axis I comorbid diagnoses were recurrent major depression in 26%, bipolar disorder type 1 in 10.5%, vascular dementia in 10%, Alzheimer’s-type dementia in 7%, adjustment disorder in 7%, delirium in 5%, and generalized anxiety disorder in 3%.

Dr. Dombrowski of the University of Virginia, Charlottesville, said that these findings most likely underrepresent the problem. Although substance abuse history is routinely solicited from all new admissions, "substance abuse is likely grossly underappreciated in this population secondary to reluctance of self report, inaccuracy of self report, health care provider attitudes, and also the different social circumstances of elderly patients as compared to younger substance abusers who might be more easily identified secondary to declining occupational or social functioning," he noted.

Moreover, there is a relative dearth of validated screening tools for identifying substance abuse in this patient population. Although they are probably underrecognized clinically, high morbidity and mortality are associated with substance abuse in the older population, including increased risk of falls, delirium, and suicide, he said.

Dr. Dombrowski has no disclosures

WASHINGTON – More than one in 10 admissions to an acute psychiatric inpatient geriatric psychiatry service was associated with an alcohol or drug use disorder in a retrospective examination of admissions for 1,788 patients over age 65 who were seen from 2001 to 2011.

"With more than 1 in 10 elderly patients meeting criteria for a substance use diagnosis in this population, clinicians should increase surveillance at all patient encounters in an effort to reduce the associated morbidity and mortality and improve functional status and quality of life for these individuals," Dr. Dennis Dombrowski said in an interview.

The total group had a mean age of 75.45 years and an average length of stay of 13.91 days. Of all 1,788 admissions, 11.7% (210) were associated with at least one substance abuse diagnosis. The most common was alcohol abuse, identified in 73% of the 210. Other substance abuse diagnoses included sedative hypnotic abuse/dependence in 11%, opiate abuse/dependence in 3%, cannabis use in 1%, tobacco use disorder in 1%, and unspecified drug-induced disorders/withdrawal in 39%. (The total is greater than 100% because some patients had more than one diagnosis.)

Compared with the psychiatric patients without substance abuse diagnoses, those who had at least one were significantly younger, were more likely to be male, had shorter lengths of stay, were readmitted less frequently, and were more likely to be divorced, he reported in a poster presentation at the annual meeting of the American Association for Geriatric Psychiatry.

Although the primary reason for admission could not be ascertained because of the limitations of the database, the most frequent Axis I comorbid diagnoses were recurrent major depression in 26%, bipolar disorder type 1 in 10.5%, vascular dementia in 10%, Alzheimer’s-type dementia in 7%, adjustment disorder in 7%, delirium in 5%, and generalized anxiety disorder in 3%.

Dr. Dombrowski of the University of Virginia, Charlottesville, said that these findings most likely underrepresent the problem. Although substance abuse history is routinely solicited from all new admissions, "substance abuse is likely grossly underappreciated in this population secondary to reluctance of self report, inaccuracy of self report, health care provider attitudes, and also the different social circumstances of elderly patients as compared to younger substance abusers who might be more easily identified secondary to declining occupational or social functioning," he noted.

Moreover, there is a relative dearth of validated screening tools for identifying substance abuse in this patient population. Although they are probably underrecognized clinically, high morbidity and mortality are associated with substance abuse in the older population, including increased risk of falls, delirium, and suicide, he said.

Dr. Dombrowski has no disclosures

WASHINGTON – More than one in 10 admissions to an acute psychiatric inpatient geriatric psychiatry service was associated with an alcohol or drug use disorder in a retrospective examination of admissions for 1,788 patients over age 65 who were seen from 2001 to 2011.

"With more than 1 in 10 elderly patients meeting criteria for a substance use diagnosis in this population, clinicians should increase surveillance at all patient encounters in an effort to reduce the associated morbidity and mortality and improve functional status and quality of life for these individuals," Dr. Dennis Dombrowski said in an interview.

The total group had a mean age of 75.45 years and an average length of stay of 13.91 days. Of all 1,788 admissions, 11.7% (210) were associated with at least one substance abuse diagnosis. The most common was alcohol abuse, identified in 73% of the 210. Other substance abuse diagnoses included sedative hypnotic abuse/dependence in 11%, opiate abuse/dependence in 3%, cannabis use in 1%, tobacco use disorder in 1%, and unspecified drug-induced disorders/withdrawal in 39%. (The total is greater than 100% because some patients had more than one diagnosis.)

Compared with the psychiatric patients without substance abuse diagnoses, those who had at least one were significantly younger, were more likely to be male, had shorter lengths of stay, were readmitted less frequently, and were more likely to be divorced, he reported in a poster presentation at the annual meeting of the American Association for Geriatric Psychiatry.

Although the primary reason for admission could not be ascertained because of the limitations of the database, the most frequent Axis I comorbid diagnoses were recurrent major depression in 26%, bipolar disorder type 1 in 10.5%, vascular dementia in 10%, Alzheimer’s-type dementia in 7%, adjustment disorder in 7%, delirium in 5%, and generalized anxiety disorder in 3%.

Dr. Dombrowski of the University of Virginia, Charlottesville, said that these findings most likely underrepresent the problem. Although substance abuse history is routinely solicited from all new admissions, "substance abuse is likely grossly underappreciated in this population secondary to reluctance of self report, inaccuracy of self report, health care provider attitudes, and also the different social circumstances of elderly patients as compared to younger substance abusers who might be more easily identified secondary to declining occupational or social functioning," he noted.

Moreover, there is a relative dearth of validated screening tools for identifying substance abuse in this patient population. Although they are probably underrecognized clinically, high morbidity and mortality are associated with substance abuse in the older population, including increased risk of falls, delirium, and suicide, he said.

Dr. Dombrowski has no disclosures

WASHINGTON – Proposed DSM-5 criteria for sleep-wake disorders include dropping the DSM-IV’s "primary insomnia" diagnosis in favor of "insomnia disorder," and decreasing use of the term "not otherwise specified."

The changes reflect a move away from the need to make causal attribution between coexisting disorders and also the overall DSM-5 shift toward more data-driven diagnostic criteria, said Dr. Charles F. Reynolds III, professor of geriatric psychiatry, neurology, and neuroscience at the University of Pittsburgh.

"Sleep-wake disorders" is one of 13 diagnostic categories that are undergoing revision from the DSM-IV to the DSM-5, slated for publication in May 2013. Dr. Reynolds is chair of the seven-member Sleep-Wake Disorders Work Group that devised the proposed diagnostic criteria, which – along with the rest of the DSM-5 proposed criteria – will be open for a third and final round of comments from visitors beginning this spring. As before, comments will be systematically reviewed by each of the work groups for consideration of additional changes.

The proposed criteria are meant to be used by nonpsychiatrists and psychiatrists who are not sleep specialists. "We are trying very much to propose a classification and a set of criteria that are friendly [and] clinically useful for the general mental health clinician and to the general medical clinician, because very few users will have specific expertise in sleep disorders medicine," said Dr. Reynolds, also professor of behavioral and community health sciences at the university’s graduate school of public health. "We don’t think such expertise will be necessary. At the same time, our hope is that with these criteria and with the accompanying text, that the general user will feel more confident about when to consult a sleep disorder specialist."

Sleep disorders per se are frequently accompanied by depression, anxiety, and other cognitive mental status changes that must be addressed in treatment planning and management. The differential diagnosis of complaints such as insomnia and daytime sleepiness necessitates consideration of coexisting medical and neurologic conditions, and requires a multidimensional approach. "Coexisting clinical conditions are the rule, not the exception," he noted.

Proposed Terminology Changes

The proposed DSM-5 criteria replace terminology that causally attributes coexisting conditions with a simple listing of the comorbidities. This was done to underscore that the patient has a sleep disorder warranting independent clinical attention in addition to the psychiatric and medical disorders also present. In addition to the switch from "primary insomnia" to "insomnia disorder," the diagnoses of "sleep disorder related to another mental disorder" and "sleep disorder related to a general medical condition" also are proposed to be dropped in favor of "insomnia disorder" or "hypersomnia disorder," along with specification of clinically comorbid medical and psychiatric conditions.

This approach acknowledges bidirectional or interactive effects between sleep disorders and coexisting psychiatric conditions such as depression. It also has implications for treatment. For example, a patient who has persistent insomnia even after adequate treatment for depression might be at increased risk for relapse of the depression, or for worsening of cognitive impairment, and might therefore require independent evaluation of the sleep problem, Dr. Reynolds noted.

In an effort to improve diagnostic precision, use of "insomnia not otherwise specified" is proposed to be reduced by elevating both "REM sleep behavior disorder" and "restless leg syndrome" to full-fledged diagnoses. This recommendation is based on a large amount of epidemiologic, pathophysiologic, genetic, and controlled clinical trial data, he said.

Another proposal is to further subtype circadian rhythm sleep disorders into delayed sleep phase type; advanced sleep phase type; and irregular sleep–wake type, –free-running type, –jet lag type, and –shift work type. Yet another proposal would subtype breathing-related sleep disorder into obstructive vs. central in order to inform treatment planning.

Other Proposed Modifications

Other major proposed changes include distinguishing narcolepsy/hypocretin deficiency from other forms of hypersomnia disorder, which illustrates the increased emphasis on using biomarkers in the DSM-5 where doing so would be scientifically appropriate and clinically practical, he noted.

An example of the effort to move away from expert opinion to evidence-based diagnostic criteria is the proposed "primary hypersomnia/narcolepsy without cataplexy" category. In the DSM-IV, the criteria are "unexplained hypersomnia (excessive sleep) or/and hypersomnolence (sleepiness in spite of sufficient nocturnal sleep), for at least 3 months, occurring 3 or more times per week," with "hypersomnia" defined by a prolonged nocturnal sleep episode or daily sleep amounts (more than 9 hours/day).

In the proposed DSM-5 revision, the definition of hypersomnia includes thresholds: Excessive sleepiness that occurs three or more times per week, for 3 or more months, despite a main sleep lasting 7 hours or longer. Evidence supporting this comes from a recent cross-sectional telephone survey of 15,929 individuals who were representative of the adult general population of 15 U.S. states. A total of 27.8% reported "excessive sleepiness," and 15.6% had recurrent periods of irrepressible need to sleep or to nap within the same day (13.2%); recurrent naps within the same day (1.9%); a nonrestorative (unrefreshing), prolonged main sleep episode of 9 hours or more per day (0.7%); and/or confusional arousals (sleep drunkenness) (4.4%).

Adding in the "excessive sleep" definition – frequency of at least three times per week for at least 3 months, despite normal sleep duration – dropped the hypersomnia disorder prevalence to 4.7% of the sample. Adding in "significant distress or impairment in cognitive, social, occupational, or other important areas of functioning" further dropped the prevalence to 2.6%, and the differential "hypersomnia is not better accounted for or does not occur exclusively during the course of another sleep disorder" gave a final prevalence of 1.5% (Arch. Gen. Psychiatry 2012;69:71-9).

"This is a threshold for significant daytime distress/impairment that warrants diagnosis. This kind of empirical basis is something we’ve pursued throughout DSM-5 in order to make it less dependent on expert opinion and be more data driven," Dr. Reynolds commented.

Insomnia Disorder 307.42

According to the Sleep-Wake Disorders Work Group, the following is the proposed wording of the new criteria:

A. The predominant complaint is a global sleep dissatisfaction with one or more of the following symptoms:

1. Difficulty initiating sleep (in children: without caregiver intervention).

2. Difficulty maintaining sleep (e.g., frequent or prolonged awakenings with difficulty returning to sleep) (in children: without caregiver intervention).

3. Early morning awakening (e.g., premature awakening with inability to return to sleep).

4. Nonrestorative sleep (adults).

5. Resistance to going to bed (children).

B. The sleep complaint is accompanied by significant distress or impairment in social, occupational, or other important areas of functioning as indicated by the presence of at least one of the following:

1. Fatigue or low energy.

2. Daytime sleepiness.

3. Cognitive impairments (e.g., attention, concentration, memory).

4. Mood disturbance (e.g., irritability, dysphoria).

5. Behavioral problems in children (hyperactivity, impulsivity, aggression).

6. Impaired occupational function.

7. Impaired interpersonal/social function.

8. Impaired academic function (children).

9. Negative impact on caregiver or family function (children).

C. The sleep difficulty is present for at least 3 months (empirical basis to address severity of the complaint).

D. The sleep difficulty occurs despite adequate age-appropriate circumstances and opportunity for sleep. Clinically comorbid Conditions, (may warrant individual work-up/attention):

1. Mental/psychiatric disorder (specify).

2. Medical disorder (specify).

3. Another disorder (specify).

E. The sleep difficulty occurs at least 3 nights per week.

Dr. Reynolds disclosed that he has received funding from the National Institute of Mental Health; the National Institute on Aging; the National Center on Minority Health and Health Disparities; the National Heart, Lung, and Blood Institute; the John A. Hartford Foundation; the American Foundation for Suicide Prevention; the Commonwealth of Pennsylvania; and the UPMC Endowment in Geriatric Psychiatry. Forest Laboratories, Pfizer, Lilly, and Bristol-Myers Squibb have provided pharmaceuticals for his National Institutes of Health–sponsored research.

WASHINGTON – Proposed DSM-5 criteria for sleep-wake disorders include dropping the DSM-IV’s "primary insomnia" diagnosis in favor of "insomnia disorder," and decreasing use of the term "not otherwise specified."

The changes reflect a move away from the need to make causal attribution between coexisting disorders and also the overall DSM-5 shift toward more data-driven diagnostic criteria, said Dr. Charles F. Reynolds III, professor of geriatric psychiatry, neurology, and neuroscience at the University of Pittsburgh.

"Sleep-wake disorders" is one of 13 diagnostic categories that are undergoing revision from the DSM-IV to the DSM-5, slated for publication in May 2013. Dr. Reynolds is chair of the seven-member Sleep-Wake Disorders Work Group that devised the proposed diagnostic criteria, which – along with the rest of the DSM-5 proposed criteria – will be open for a third and final round of comments from visitors beginning this spring. As before, comments will be systematically reviewed by each of the work groups for consideration of additional changes.

The proposed criteria are meant to be used by nonpsychiatrists and psychiatrists who are not sleep specialists. "We are trying very much to propose a classification and a set of criteria that are friendly [and] clinically useful for the general mental health clinician and to the general medical clinician, because very few users will have specific expertise in sleep disorders medicine," said Dr. Reynolds, also professor of behavioral and community health sciences at the university’s graduate school of public health. "We don’t think such expertise will be necessary. At the same time, our hope is that with these criteria and with the accompanying text, that the general user will feel more confident about when to consult a sleep disorder specialist."

Sleep disorders per se are frequently accompanied by depression, anxiety, and other cognitive mental status changes that must be addressed in treatment planning and management. The differential diagnosis of complaints such as insomnia and daytime sleepiness necessitates consideration of coexisting medical and neurologic conditions, and requires a multidimensional approach. "Coexisting clinical conditions are the rule, not the exception," he noted.

Proposed Terminology Changes

The proposed DSM-5 criteria replace terminology that causally attributes coexisting conditions with a simple listing of the comorbidities. This was done to underscore that the patient has a sleep disorder warranting independent clinical attention in addition to the psychiatric and medical disorders also present. In addition to the switch from "primary insomnia" to "insomnia disorder," the diagnoses of "sleep disorder related to another mental disorder" and "sleep disorder related to a general medical condition" also are proposed to be dropped in favor of "insomnia disorder" or "hypersomnia disorder," along with specification of clinically comorbid medical and psychiatric conditions.

This approach acknowledges bidirectional or interactive effects between sleep disorders and coexisting psychiatric conditions such as depression. It also has implications for treatment. For example, a patient who has persistent insomnia even after adequate treatment for depression might be at increased risk for relapse of the depression, or for worsening of cognitive impairment, and might therefore require independent evaluation of the sleep problem, Dr. Reynolds noted.

In an effort to improve diagnostic precision, use of "insomnia not otherwise specified" is proposed to be reduced by elevating both "REM sleep behavior disorder" and "restless leg syndrome" to full-fledged diagnoses. This recommendation is based on a large amount of epidemiologic, pathophysiologic, genetic, and controlled clinical trial data, he said.

Another proposal is to further subtype circadian rhythm sleep disorders into delayed sleep phase type; advanced sleep phase type; and irregular sleep–wake type, –free-running type, –jet lag type, and –shift work type. Yet another proposal would subtype breathing-related sleep disorder into obstructive vs. central in order to inform treatment planning.

Other Proposed Modifications

Other major proposed changes include distinguishing narcolepsy/hypocretin deficiency from other forms of hypersomnia disorder, which illustrates the increased emphasis on using biomarkers in the DSM-5 where doing so would be scientifically appropriate and clinically practical, he noted.

An example of the effort to move away from expert opinion to evidence-based diagnostic criteria is the proposed "primary hypersomnia/narcolepsy without cataplexy" category. In the DSM-IV, the criteria are "unexplained hypersomnia (excessive sleep) or/and hypersomnolence (sleepiness in spite of sufficient nocturnal sleep), for at least 3 months, occurring 3 or more times per week," with "hypersomnia" defined by a prolonged nocturnal sleep episode or daily sleep amounts (more than 9 hours/day).

In the proposed DSM-5 revision, the definition of hypersomnia includes thresholds: Excessive sleepiness that occurs three or more times per week, for 3 or more months, despite a main sleep lasting 7 hours or longer. Evidence supporting this comes from a recent cross-sectional telephone survey of 15,929 individuals who were representative of the adult general population of 15 U.S. states. A total of 27.8% reported "excessive sleepiness," and 15.6% had recurrent periods of irrepressible need to sleep or to nap within the same day (13.2%); recurrent naps within the same day (1.9%); a nonrestorative (unrefreshing), prolonged main sleep episode of 9 hours or more per day (0.7%); and/or confusional arousals (sleep drunkenness) (4.4%).

Adding in the "excessive sleep" definition – frequency of at least three times per week for at least 3 months, despite normal sleep duration – dropped the hypersomnia disorder prevalence to 4.7% of the sample. Adding in "significant distress or impairment in cognitive, social, occupational, or other important areas of functioning" further dropped the prevalence to 2.6%, and the differential "hypersomnia is not better accounted for or does not occur exclusively during the course of another sleep disorder" gave a final prevalence of 1.5% (Arch. Gen. Psychiatry 2012;69:71-9).

"This is a threshold for significant daytime distress/impairment that warrants diagnosis. This kind of empirical basis is something we’ve pursued throughout DSM-5 in order to make it less dependent on expert opinion and be more data driven," Dr. Reynolds commented.

Insomnia Disorder 307.42

According to the Sleep-Wake Disorders Work Group, the following is the proposed wording of the new criteria:

A. The predominant complaint is a global sleep dissatisfaction with one or more of the following symptoms:

1. Difficulty initiating sleep (in children: without caregiver intervention).

2. Difficulty maintaining sleep (e.g., frequent or prolonged awakenings with difficulty returning to sleep) (in children: without caregiver intervention).

3. Early morning awakening (e.g., premature awakening with inability to return to sleep).

4. Nonrestorative sleep (adults).

5. Resistance to going to bed (children).

B. The sleep complaint is accompanied by significant distress or impairment in social, occupational, or other important areas of functioning as indicated by the presence of at least one of the following:

1. Fatigue or low energy.

2. Daytime sleepiness.

3. Cognitive impairments (e.g., attention, concentration, memory).

4. Mood disturbance (e.g., irritability, dysphoria).

5. Behavioral problems in children (hyperactivity, impulsivity, aggression).

6. Impaired occupational function.

7. Impaired interpersonal/social function.

8. Impaired academic function (children).

9. Negative impact on caregiver or family function (children).

C. The sleep difficulty is present for at least 3 months (empirical basis to address severity of the complaint).

D. The sleep difficulty occurs despite adequate age-appropriate circumstances and opportunity for sleep. Clinically comorbid Conditions, (may warrant individual work-up/attention):

1. Mental/psychiatric disorder (specify).

2. Medical disorder (specify).

3. Another disorder (specify).

E. The sleep difficulty occurs at least 3 nights per week.

Dr. Reynolds disclosed that he has received funding from the National Institute of Mental Health; the National Institute on Aging; the National Center on Minority Health and Health Disparities; the National Heart, Lung, and Blood Institute; the John A. Hartford Foundation; the American Foundation for Suicide Prevention; the Commonwealth of Pennsylvania; and the UPMC Endowment in Geriatric Psychiatry. Forest Laboratories, Pfizer, Lilly, and Bristol-Myers Squibb have provided pharmaceuticals for his National Institutes of Health–sponsored research.

WASHINGTON – Proposed DSM-5 criteria for sleep-wake disorders include dropping the DSM-IV’s "primary insomnia" diagnosis in favor of "insomnia disorder," and decreasing use of the term "not otherwise specified."

The changes reflect a move away from the need to make causal attribution between coexisting disorders and also the overall DSM-5 shift toward more data-driven diagnostic criteria, said Dr. Charles F. Reynolds III, professor of geriatric psychiatry, neurology, and neuroscience at the University of Pittsburgh.

"Sleep-wake disorders" is one of 13 diagnostic categories that are undergoing revision from the DSM-IV to the DSM-5, slated for publication in May 2013. Dr. Reynolds is chair of the seven-member Sleep-Wake Disorders Work Group that devised the proposed diagnostic criteria, which – along with the rest of the DSM-5 proposed criteria – will be open for a third and final round of comments from visitors beginning this spring. As before, comments will be systematically reviewed by each of the work groups for consideration of additional changes.

The proposed criteria are meant to be used by nonpsychiatrists and psychiatrists who are not sleep specialists. "We are trying very much to propose a classification and a set of criteria that are friendly [and] clinically useful for the general mental health clinician and to the general medical clinician, because very few users will have specific expertise in sleep disorders medicine," said Dr. Reynolds, also professor of behavioral and community health sciences at the university’s graduate school of public health. "We don’t think such expertise will be necessary. At the same time, our hope is that with these criteria and with the accompanying text, that the general user will feel more confident about when to consult a sleep disorder specialist."

Sleep disorders per se are frequently accompanied by depression, anxiety, and other cognitive mental status changes that must be addressed in treatment planning and management. The differential diagnosis of complaints such as insomnia and daytime sleepiness necessitates consideration of coexisting medical and neurologic conditions, and requires a multidimensional approach. "Coexisting clinical conditions are the rule, not the exception," he noted.

Proposed Terminology Changes

The proposed DSM-5 criteria replace terminology that causally attributes coexisting conditions with a simple listing of the comorbidities. This was done to underscore that the patient has a sleep disorder warranting independent clinical attention in addition to the psychiatric and medical disorders also present. In addition to the switch from "primary insomnia" to "insomnia disorder," the diagnoses of "sleep disorder related to another mental disorder" and "sleep disorder related to a general medical condition" also are proposed to be dropped in favor of "insomnia disorder" or "hypersomnia disorder," along with specification of clinically comorbid medical and psychiatric conditions.

This approach acknowledges bidirectional or interactive effects between sleep disorders and coexisting psychiatric conditions such as depression. It also has implications for treatment. For example, a patient who has persistent insomnia even after adequate treatment for depression might be at increased risk for relapse of the depression, or for worsening of cognitive impairment, and might therefore require independent evaluation of the sleep problem, Dr. Reynolds noted.

In an effort to improve diagnostic precision, use of "insomnia not otherwise specified" is proposed to be reduced by elevating both "REM sleep behavior disorder" and "restless leg syndrome" to full-fledged diagnoses. This recommendation is based on a large amount of epidemiologic, pathophysiologic, genetic, and controlled clinical trial data, he said.

Another proposal is to further subtype circadian rhythm sleep disorders into delayed sleep phase type; advanced sleep phase type; and irregular sleep–wake type, –free-running type, –jet lag type, and –shift work type. Yet another proposal would subtype breathing-related sleep disorder into obstructive vs. central in order to inform treatment planning.

Other Proposed Modifications

Other major proposed changes include distinguishing narcolepsy/hypocretin deficiency from other forms of hypersomnia disorder, which illustrates the increased emphasis on using biomarkers in the DSM-5 where doing so would be scientifically appropriate and clinically practical, he noted.

An example of the effort to move away from expert opinion to evidence-based diagnostic criteria is the proposed "primary hypersomnia/narcolepsy without cataplexy" category. In the DSM-IV, the criteria are "unexplained hypersomnia (excessive sleep) or/and hypersomnolence (sleepiness in spite of sufficient nocturnal sleep), for at least 3 months, occurring 3 or more times per week," with "hypersomnia" defined by a prolonged nocturnal sleep episode or daily sleep amounts (more than 9 hours/day).

In the proposed DSM-5 revision, the definition of hypersomnia includes thresholds: Excessive sleepiness that occurs three or more times per week, for 3 or more months, despite a main sleep lasting 7 hours or longer. Evidence supporting this comes from a recent cross-sectional telephone survey of 15,929 individuals who were representative of the adult general population of 15 U.S. states. A total of 27.8% reported "excessive sleepiness," and 15.6% had recurrent periods of irrepressible need to sleep or to nap within the same day (13.2%); recurrent naps within the same day (1.9%); a nonrestorative (unrefreshing), prolonged main sleep episode of 9 hours or more per day (0.7%); and/or confusional arousals (sleep drunkenness) (4.4%).

Adding in the "excessive sleep" definition – frequency of at least three times per week for at least 3 months, despite normal sleep duration – dropped the hypersomnia disorder prevalence to 4.7% of the sample. Adding in "significant distress or impairment in cognitive, social, occupational, or other important areas of functioning" further dropped the prevalence to 2.6%, and the differential "hypersomnia is not better accounted for or does not occur exclusively during the course of another sleep disorder" gave a final prevalence of 1.5% (Arch. Gen. Psychiatry 2012;69:71-9).

"This is a threshold for significant daytime distress/impairment that warrants diagnosis. This kind of empirical basis is something we’ve pursued throughout DSM-5 in order to make it less dependent on expert opinion and be more data driven," Dr. Reynolds commented.

Insomnia Disorder 307.42

According to the Sleep-Wake Disorders Work Group, the following is the proposed wording of the new criteria:

A. The predominant complaint is a global sleep dissatisfaction with one or more of the following symptoms:

1. Difficulty initiating sleep (in children: without caregiver intervention).

2. Difficulty maintaining sleep (e.g., frequent or prolonged awakenings with difficulty returning to sleep) (in children: without caregiver intervention).

3. Early morning awakening (e.g., premature awakening with inability to return to sleep).

4. Nonrestorative sleep (adults).

5. Resistance to going to bed (children).

B. The sleep complaint is accompanied by significant distress or impairment in social, occupational, or other important areas of functioning as indicated by the presence of at least one of the following:

1. Fatigue or low energy.

2. Daytime sleepiness.

3. Cognitive impairments (e.g., attention, concentration, memory).

4. Mood disturbance (e.g., irritability, dysphoria).

5. Behavioral problems in children (hyperactivity, impulsivity, aggression).

6. Impaired occupational function.

7. Impaired interpersonal/social function.

8. Impaired academic function (children).

9. Negative impact on caregiver or family function (children).

C. The sleep difficulty is present for at least 3 months (empirical basis to address severity of the complaint).

D. The sleep difficulty occurs despite adequate age-appropriate circumstances and opportunity for sleep. Clinically comorbid Conditions, (may warrant individual work-up/attention):

1. Mental/psychiatric disorder (specify).

2. Medical disorder (specify).

3. Another disorder (specify).

E. The sleep difficulty occurs at least 3 nights per week.

Dr. Reynolds disclosed that he has received funding from the National Institute of Mental Health; the National Institute on Aging; the National Center on Minority Health and Health Disparities; the National Heart, Lung, and Blood Institute; the John A. Hartford Foundation; the American Foundation for Suicide Prevention; the Commonwealth of Pennsylvania; and the UPMC Endowment in Geriatric Psychiatry. Forest Laboratories, Pfizer, Lilly, and Bristol-Myers Squibb have provided pharmaceuticals for his National Institutes of Health–sponsored research.

WASHINGTON – Patients admitted to a freestanding psychiatric hospital with a primary diagnosis of dementia with behavioral disturbance were more likely than those without dementia to experience medical deterioration during their stay, according to a chart review study of 1,000 consecutively admitted adults.

Azotemia or anemia on admission predicted an increased risk for such decompensation among the 71 who had dementia with behavioral disturbance. "Patients with such baseline findings should receive enhanced medical evaluation, monitoring, and management to decrease preventable interruptions in care," Dr. Eugene Grudnikoff and his associates reported in a poster at the annual meeting of the American Association for Geriatric Psychiatry.

Compared with the 929 nondemented patients who were admitted to the 208-bed psychiatric hospital between August and December 2010, the 71 with dementia were significantly older (78 vs. 43 years) and less likely to be male (40% vs. 54%). They were also more likely to have been transferred from another hospital (13% vs. 5%), be taking first-generation antipsychotics (27% vs. 15%), have a longer length of stay (23 vs. 19 days), and be transferred to the emergency department (42% vs. 12%).

Emergency transfer to the adjacent 480-bed medical center was used as a proxy measure for significant medical deterioration, said Dr. Grudnikoff and his associates at Zucker Hillside Hospital, Glen Oaks, N.Y., part of the North Shore–Long Island Jewish Health System.

The psychiatric patients with dementia had a significantly greater number of somatic disorders than did those without dementia, 3.8 vs. 2.8 overall. Specifically, they were more likely to have arterial hypertension (63% vs. 26%), dyslipidemia (32% vs. 19%), coronary artery disease (18% vs. 4%), heart failure (7% vs. 1%), cerebral vascular disease (13% vs. 0.5%), and hypothyroidism (17% vs. 5%). However, those without dementia were more likely to be obese (34% vs. 7% with a body mass index above 30 kg/m²).

The dementia and nondementia groups differed significantly with regard to admission laboratory data. The dementia patients had higher venous blood levels of potassium, chloride, blood urea nitrogen, and creatinine and significantly lower levels of calcium, protein, hemoglobin, and platelets. They also had higher rates of azotemia (26.5% vs. 4%), anemia (40% vs. 16%), and hypoalbuminemia (17% vs. 3%).

During their hospital stays, 30 of the dementia patients (42%) and 114 of the nondemented patients (12%) had a significant medical deterioration that required emergency transfer. Among the 30 with dementia, reasons for transfer included fever in eight patients (27%); falls in another eight (27%); hypoxia in three (10%); hypotension, chest pain, and deep vein thrombosis in two patients each (7%); and stroke, delirium, vomiting, rectal bleeding, and edema in one patient each (3%).

Within the dementia group, the positive predictive values for emergency transfer were 61% for azotemia and 61.5% for anemia, but just 30% for hypoalbuminemia. After evaluation and treatment during a stay in the emergency department of up to 23 hours, patients with dementia were more likely to be admitted to a medical unit of the general hospital (17% vs. 6.5%), Dr. Grudnikoff and his associates reported.

Dr. Grudnikoff stated that he has nothing to disclose. Two of the six study coauthors declared financial relationships with several pharmaceutical companies.

WASHINGTON – Patients admitted to a freestanding psychiatric hospital with a primary diagnosis of dementia with behavioral disturbance were more likely than those without dementia to experience medical deterioration during their stay, according to a chart review study of 1,000 consecutively admitted adults.

Azotemia or anemia on admission predicted an increased risk for such decompensation among the 71 who had dementia with behavioral disturbance. "Patients with such baseline findings should receive enhanced medical evaluation, monitoring, and management to decrease preventable interruptions in care," Dr. Eugene Grudnikoff and his associates reported in a poster at the annual meeting of the American Association for Geriatric Psychiatry.

Compared with the 929 nondemented patients who were admitted to the 208-bed psychiatric hospital between August and December 2010, the 71 with dementia were significantly older (78 vs. 43 years) and less likely to be male (40% vs. 54%). They were also more likely to have been transferred from another hospital (13% vs. 5%), be taking first-generation antipsychotics (27% vs. 15%), have a longer length of stay (23 vs. 19 days), and be transferred to the emergency department (42% vs. 12%).

Emergency transfer to the adjacent 480-bed medical center was used as a proxy measure for significant medical deterioration, said Dr. Grudnikoff and his associates at Zucker Hillside Hospital, Glen Oaks, N.Y., part of the North Shore–Long Island Jewish Health System.

The psychiatric patients with dementia had a significantly greater number of somatic disorders than did those without dementia, 3.8 vs. 2.8 overall. Specifically, they were more likely to have arterial hypertension (63% vs. 26%), dyslipidemia (32% vs. 19%), coronary artery disease (18% vs. 4%), heart failure (7% vs. 1%), cerebral vascular disease (13% vs. 0.5%), and hypothyroidism (17% vs. 5%). However, those without dementia were more likely to be obese (34% vs. 7% with a body mass index above 30 kg/m²).

The dementia and nondementia groups differed significantly with regard to admission laboratory data. The dementia patients had higher venous blood levels of potassium, chloride, blood urea nitrogen, and creatinine and significantly lower levels of calcium, protein, hemoglobin, and platelets. They also had higher rates of azotemia (26.5% vs. 4%), anemia (40% vs. 16%), and hypoalbuminemia (17% vs. 3%).

During their hospital stays, 30 of the dementia patients (42%) and 114 of the nondemented patients (12%) had a significant medical deterioration that required emergency transfer. Among the 30 with dementia, reasons for transfer included fever in eight patients (27%); falls in another eight (27%); hypoxia in three (10%); hypotension, chest pain, and deep vein thrombosis in two patients each (7%); and stroke, delirium, vomiting, rectal bleeding, and edema in one patient each (3%).

Within the dementia group, the positive predictive values for emergency transfer were 61% for azotemia and 61.5% for anemia, but just 30% for hypoalbuminemia. After evaluation and treatment during a stay in the emergency department of up to 23 hours, patients with dementia were more likely to be admitted to a medical unit of the general hospital (17% vs. 6.5%), Dr. Grudnikoff and his associates reported.

Dr. Grudnikoff stated that he has nothing to disclose. Two of the six study coauthors declared financial relationships with several pharmaceutical companies.

WASHINGTON – Patients admitted to a freestanding psychiatric hospital with a primary diagnosis of dementia with behavioral disturbance were more likely than those without dementia to experience medical deterioration during their stay, according to a chart review study of 1,000 consecutively admitted adults.

Azotemia or anemia on admission predicted an increased risk for such decompensation among the 71 who had dementia with behavioral disturbance. "Patients with such baseline findings should receive enhanced medical evaluation, monitoring, and management to decrease preventable interruptions in care," Dr. Eugene Grudnikoff and his associates reported in a poster at the annual meeting of the American Association for Geriatric Psychiatry.

Compared with the 929 nondemented patients who were admitted to the 208-bed psychiatric hospital between August and December 2010, the 71 with dementia were significantly older (78 vs. 43 years) and less likely to be male (40% vs. 54%). They were also more likely to have been transferred from another hospital (13% vs. 5%), be taking first-generation antipsychotics (27% vs. 15%), have a longer length of stay (23 vs. 19 days), and be transferred to the emergency department (42% vs. 12%).

Emergency transfer to the adjacent 480-bed medical center was used as a proxy measure for significant medical deterioration, said Dr. Grudnikoff and his associates at Zucker Hillside Hospital, Glen Oaks, N.Y., part of the North Shore–Long Island Jewish Health System.

The psychiatric patients with dementia had a significantly greater number of somatic disorders than did those without dementia, 3.8 vs. 2.8 overall. Specifically, they were more likely to have arterial hypertension (63% vs. 26%), dyslipidemia (32% vs. 19%), coronary artery disease (18% vs. 4%), heart failure (7% vs. 1%), cerebral vascular disease (13% vs. 0.5%), and hypothyroidism (17% vs. 5%). However, those without dementia were more likely to be obese (34% vs. 7% with a body mass index above 30 kg/m²).

The dementia and nondementia groups differed significantly with regard to admission laboratory data. The dementia patients had higher venous blood levels of potassium, chloride, blood urea nitrogen, and creatinine and significantly lower levels of calcium, protein, hemoglobin, and platelets. They also had higher rates of azotemia (26.5% vs. 4%), anemia (40% vs. 16%), and hypoalbuminemia (17% vs. 3%).

During their hospital stays, 30 of the dementia patients (42%) and 114 of the nondemented patients (12%) had a significant medical deterioration that required emergency transfer. Among the 30 with dementia, reasons for transfer included fever in eight patients (27%); falls in another eight (27%); hypoxia in three (10%); hypotension, chest pain, and deep vein thrombosis in two patients each (7%); and stroke, delirium, vomiting, rectal bleeding, and edema in one patient each (3%).

Within the dementia group, the positive predictive values for emergency transfer were 61% for azotemia and 61.5% for anemia, but just 30% for hypoalbuminemia. After evaluation and treatment during a stay in the emergency department of up to 23 hours, patients with dementia were more likely to be admitted to a medical unit of the general hospital (17% vs. 6.5%), Dr. Grudnikoff and his associates reported.

Dr. Grudnikoff stated that he has nothing to disclose. Two of the six study coauthors declared financial relationships with several pharmaceutical companies.

WASHINGTON – Delirium due to underlying medical conditions was misdiagnosed as a psychiatric disorder in a significant proportion of patients who were admitted to an inpatient geriatric psychiatric unit, a retrospective chart review found.

The analysis of charts from 112 consecutive patients admitted to Central Regional Hospital, Butler, N.C., with a diagnosis of a psychiatric disorder, showed that 27 (24%) were subsequently found to have delirium due to an underlying medical condition. All 27 also had prior psychiatric diagnoses. The results were reported at the annual meeting of the American Association for Geriatric Psychiatry.

"If a patient has a previous psychiatric history, physicians are not as scrupulous or as careful to screen them for underlying medical issues. They are more likely to send them to a psych unit, thinking all of their behavior manifestations are actually psychiatric. ... The message is be more careful and consider any behavioral manifestation as delirium until proven otherwise," Dr. Meera Balasubramaniam said in an interview.

Upon evaluation in the psychiatric unit, most of the patients were diagnosed with hyperactive delirium (23), with the other 4 having mixed delirium. Urinary tract infection was the most common medical etiology for the delirium (11), followed by medications (6), poor glycemic control (3), electrolyte disturbance (1), acute central nervous system events (1), and dehydration (1). The rest did not have a cause documented in the discharge summary, said Dr. Balasubramaniam, a psychiatry resident at Duke University, Durham, N.C.

Nearly half of the patients (12) had been referred from the emergency department, while another 11 had been sent from an inpatient medical unit. An additional 4 were referred from an inpatient psychiatry unit. Among the patients with delirium, the most common referral diagnosis was cognitive disorder (16), followed by psychotic disorder (7), and mood disorder (4).

The delirium group was significantly more likely than those without delirium to be transferred to medical units (41% vs. 4%), and was also more likely to be subsequently discharged to a higher level of care, such as assisted living or skilled nursing, although this was not statistically significant (33% vs. 28%). "The overall outcome was poorer than if the delirium had been recognized in the first place ... There’s a lot of expense involved," she commented.

Visual and hearing impairment were significantly more likely to be present in the patients with delirium, compared to those without, but no differences were found with regard to age, past psychiatric history, number or type of psychotropic medications, or Charlson comorbidity index, she and her associates reported in a poster.

The bottom line, she said: "Even if it’s a patient who has a previous psych history, be careful about making sure they don’t have any underlying medical causes. Rule that out before sending them to a psych unit."

Dr. Balasubramaniam stated that she has no disclosures.

WASHINGTON – Delirium due to underlying medical conditions was misdiagnosed as a psychiatric disorder in a significant proportion of patients who were admitted to an inpatient geriatric psychiatric unit, a retrospective chart review found.

The analysis of charts from 112 consecutive patients admitted to Central Regional Hospital, Butler, N.C., with a diagnosis of a psychiatric disorder, showed that 27 (24%) were subsequently found to have delirium due to an underlying medical condition. All 27 also had prior psychiatric diagnoses. The results were reported at the annual meeting of the American Association for Geriatric Psychiatry.

"If a patient has a previous psychiatric history, physicians are not as scrupulous or as careful to screen them for underlying medical issues. They are more likely to send them to a psych unit, thinking all of their behavior manifestations are actually psychiatric. ... The message is be more careful and consider any behavioral manifestation as delirium until proven otherwise," Dr. Meera Balasubramaniam said in an interview.

Upon evaluation in the psychiatric unit, most of the patients were diagnosed with hyperactive delirium (23), with the other 4 having mixed delirium. Urinary tract infection was the most common medical etiology for the delirium (11), followed by medications (6), poor glycemic control (3), electrolyte disturbance (1), acute central nervous system events (1), and dehydration (1). The rest did not have a cause documented in the discharge summary, said Dr. Balasubramaniam, a psychiatry resident at Duke University, Durham, N.C.

Nearly half of the patients (12) had been referred from the emergency department, while another 11 had been sent from an inpatient medical unit. An additional 4 were referred from an inpatient psychiatry unit. Among the patients with delirium, the most common referral diagnosis was cognitive disorder (16), followed by psychotic disorder (7), and mood disorder (4).

The delirium group was significantly more likely than those without delirium to be transferred to medical units (41% vs. 4%), and was also more likely to be subsequently discharged to a higher level of care, such as assisted living or skilled nursing, although this was not statistically significant (33% vs. 28%). "The overall outcome was poorer than if the delirium had been recognized in the first place ... There’s a lot of expense involved," she commented.

Visual and hearing impairment were significantly more likely to be present in the patients with delirium, compared to those without, but no differences were found with regard to age, past psychiatric history, number or type of psychotropic medications, or Charlson comorbidity index, she and her associates reported in a poster.

The bottom line, she said: "Even if it’s a patient who has a previous psych history, be careful about making sure they don’t have any underlying medical causes. Rule that out before sending them to a psych unit."

Dr. Balasubramaniam stated that she has no disclosures.

WASHINGTON – Delirium due to underlying medical conditions was misdiagnosed as a psychiatric disorder in a significant proportion of patients who were admitted to an inpatient geriatric psychiatric unit, a retrospective chart review found.

The analysis of charts from 112 consecutive patients admitted to Central Regional Hospital, Butler, N.C., with a diagnosis of a psychiatric disorder, showed that 27 (24%) were subsequently found to have delirium due to an underlying medical condition. All 27 also had prior psychiatric diagnoses. The results were reported at the annual meeting of the American Association for Geriatric Psychiatry.

"If a patient has a previous psychiatric history, physicians are not as scrupulous or as careful to screen them for underlying medical issues. They are more likely to send them to a psych unit, thinking all of their behavior manifestations are actually psychiatric. ... The message is be more careful and consider any behavioral manifestation as delirium until proven otherwise," Dr. Meera Balasubramaniam said in an interview.

Upon evaluation in the psychiatric unit, most of the patients were diagnosed with hyperactive delirium (23), with the other 4 having mixed delirium. Urinary tract infection was the most common medical etiology for the delirium (11), followed by medications (6), poor glycemic control (3), electrolyte disturbance (1), acute central nervous system events (1), and dehydration (1). The rest did not have a cause documented in the discharge summary, said Dr. Balasubramaniam, a psychiatry resident at Duke University, Durham, N.C.

Nearly half of the patients (12) had been referred from the emergency department, while another 11 had been sent from an inpatient medical unit. An additional 4 were referred from an inpatient psychiatry unit. Among the patients with delirium, the most common referral diagnosis was cognitive disorder (16), followed by psychotic disorder (7), and mood disorder (4).

The delirium group was significantly more likely than those without delirium to be transferred to medical units (41% vs. 4%), and was also more likely to be subsequently discharged to a higher level of care, such as assisted living or skilled nursing, although this was not statistically significant (33% vs. 28%). "The overall outcome was poorer than if the delirium had been recognized in the first place ... There’s a lot of expense involved," she commented.

Visual and hearing impairment were significantly more likely to be present in the patients with delirium, compared to those without, but no differences were found with regard to age, past psychiatric history, number or type of psychotropic medications, or Charlson comorbidity index, she and her associates reported in a poster.

The bottom line, she said: "Even if it’s a patient who has a previous psych history, be careful about making sure they don’t have any underlying medical causes. Rule that out before sending them to a psych unit."

Dr. Balasubramaniam stated that she has no disclosures.

WASHINGTON – Monitoring for metabolic side effects proved to be infrequent for outpatients with dementia or delirium who had been prescribed antipsychotic medications at 32 Veterans Affairs medical centers.

Antipsychotic medications are approved by the Food and Drug Administration for use in patients with psychotic disorders, not for those with dementia and delirium. However, they are widely used off label to control behavior disturbances among dementia/delirium patients, despite the lack of long-term data. In 2004, the American Psychiatric Association (APA), the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists, and the North American Association for the Study of Obesity issued consensus recommendations for monitoring of glycemic control, lipidemia, and weight gain among all patients taking antipsychotics (Diabetes Care 2004;27:596-601).

Subsequently, in 2005 and 2008, the FDA issued black box warnings about the increased risk for mortality in dementia patients with the use of typical and atypical antipsychotics. Other risks include cerebrovascular events, parkinsonism, pulmonary infections, and metabolic dysfunction

"To my way of thinking, these patients are getting a medication that is not FDA approved for this indication and it has significant risks, so if I’m a prudent clinician, if I prescribe something off label, I have to be more careful," Dr. Dinesh Mittal said in an interview.

But his findings in a large, retrospective cohort analysis suggest that this is not happening. Of patients identified as having received a new antipsychotic prescription and used it for at least 60 days, 916 had dementia or delirium but no psychosis, whereas 3,446 had psychosis but no dementia/delirium. The dementia patients were a mean age of 69 years, nearly all were male (95%), and most were married (56%). Two-thirds of the dementia/delirium group (64%) were aged 65 and older, compared with just 9% of the psychosis patients, said Dr. Mittal, a research scientist at the VA’s Center for Mental Health Outcomes Research and staff psychiatrist at Central Arkansas Veterans Healthcare System, Little Rock.

At baseline (defined as within 30 days of the index prescription), monitoring of either glucose or hemoglobin A_1c had been done for only 45% of those with dementia/delirium who were without psychosis. The proportion was not significantly different (47.5%) for the patients with psychosis but no dementia/delirium. Measurement of LDL cholesterol was even less common in both groups and was significantly lower for the dementia/delirium patients (27% vs. 34% of those with psychosis). Also, significantly more dementia patients than psychosis patients had their weight checked at baseline (71% vs. 66%).

The difference in weight measurement might simply relate to the fact that dementia patients were being seen more often for office visits and were having weight measured routinely, rather than being monitored specifically for metabolic side effects of antipsychotics, noted Dr. Mittal, who is also with the University of Arkansas, Little Rock.

The proportions being monitored for all side effects had dropped by 90 days, with glucose/HbA_1c measurements in just 27% of both the dementia/delirium group and the psychosis group; LDL cholesterol in 12% and 17%, respectively; and weight in 48% and 50%. Of those, the only significant difference between groups was the lower LDL measurement for the dementia/delirium patients, Dr. Mittal and his associates reported in a poster at the annual meeting of the American Association for Geriatric Psychiatry.

In the interview, Dr. Mittal commented that these results are particularly concerning given the absence of data to support the use of antipsychotics beyond a few days in dementia/delirium patients. The study sample was selected based on these patients’ having been prescribed antipsychotics for at least 60 days, which places them under the metabolic monitoring guidelines of the ADA and APA. "There are studies, but the only data [are] for short-term use for agitation of only a few days. That’s why we wanted to select a sample [of] prescribed antipsychotics long enough to get away from the data showing benefit," he explained.

The dilemma, he said, is that stopping an antipsychotic in a patient with dementia for whom they helped curb the agitation requires clinical judgment and is far more difficult in the outpatient setting, which was the focus of this study.

Although neither the psychotic nor the delirium/dementia patients were being adequately monitored for metabolic adverse effects, the delirium patients are older and might be at greater risk for morbidity and mortality while taking antipsychotics, Dr. Mittal said.

"Despite the risks of prescribing antipsychotics for patients with dementia, adherence to recommendations for monitoring metabolic side effects remains low. ... They’re being monitored as frequently as those with psychosis, but it’s not enough in either group."

Such monitoring must be accomplished via collaboration between primary care/endocrinology and mental health, he advised.

The study was funded by a health services grant from the VA’s Health Services Research & Development Service. Dr. Mittal stated that he had no other disclosures.

WASHINGTON – Monitoring for metabolic side effects proved to be infrequent for outpatients with dementia or delirium who had been prescribed antipsychotic medications at 32 Veterans Affairs medical centers.

Antipsychotic medications are approved by the Food and Drug Administration for use in patients with psychotic disorders, not for those with dementia and delirium. However, they are widely used off label to control behavior disturbances among dementia/delirium patients, despite the lack of long-term data. In 2004, the American Psychiatric Association (APA), the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists, and the North American Association for the Study of Obesity issued consensus recommendations for monitoring of glycemic control, lipidemia, and weight gain among all patients taking antipsychotics (Diabetes Care 2004;27:596-601).

Subsequently, in 2005 and 2008, the FDA issued black box warnings about the increased risk for mortality in dementia patients with the use of typical and atypical antipsychotics. Other risks include cerebrovascular events, parkinsonism, pulmonary infections, and metabolic dysfunction

"To my way of thinking, these patients are getting a medication that is not FDA approved for this indication and it has significant risks, so if I’m a prudent clinician, if I prescribe something off label, I have to be more careful," Dr. Dinesh Mittal said in an interview.

But his findings in a large, retrospective cohort analysis suggest that this is not happening. Of patients identified as having received a new antipsychotic prescription and used it for at least 60 days, 916 had dementia or delirium but no psychosis, whereas 3,446 had psychosis but no dementia/delirium. The dementia patients were a mean age of 69 years, nearly all were male (95%), and most were married (56%). Two-thirds of the dementia/delirium group (64%) were aged 65 and older, compared with just 9% of the psychosis patients, said Dr. Mittal, a research scientist at the VA’s Center for Mental Health Outcomes Research and staff psychiatrist at Central Arkansas Veterans Healthcare System, Little Rock.

At baseline (defined as within 30 days of the index prescription), monitoring of either glucose or hemoglobin A_1c had been done for only 45% of those with dementia/delirium who were without psychosis. The proportion was not significantly different (47.5%) for the patients with psychosis but no dementia/delirium. Measurement of LDL cholesterol was even less common in both groups and was significantly lower for the dementia/delirium patients (27% vs. 34% of those with psychosis). Also, significantly more dementia patients than psychosis patients had their weight checked at baseline (71% vs. 66%).

The difference in weight measurement might simply relate to the fact that dementia patients were being seen more often for office visits and were having weight measured routinely, rather than being monitored specifically for metabolic side effects of antipsychotics, noted Dr. Mittal, who is also with the University of Arkansas, Little Rock.

The proportions being monitored for all side effects had dropped by 90 days, with glucose/HbA_1c measurements in just 27% of both the dementia/delirium group and the psychosis group; LDL cholesterol in 12% and 17%, respectively; and weight in 48% and 50%. Of those, the only significant difference between groups was the lower LDL measurement for the dementia/delirium patients, Dr. Mittal and his associates reported in a poster at the annual meeting of the American Association for Geriatric Psychiatry.

In the interview, Dr. Mittal commented that these results are particularly concerning given the absence of data to support the use of antipsychotics beyond a few days in dementia/delirium patients. The study sample was selected based on these patients’ having been prescribed antipsychotics for at least 60 days, which places them under the metabolic monitoring guidelines of the ADA and APA. "There are studies, but the only data [are] for short-term use for agitation of only a few days. That’s why we wanted to select a sample [of] prescribed antipsychotics long enough to get away from the data showing benefit," he explained.

The dilemma, he said, is that stopping an antipsychotic in a patient with dementia for whom they helped curb the agitation requires clinical judgment and is far more difficult in the outpatient setting, which was the focus of this study.

Although neither the psychotic nor the delirium/dementia patients were being adequately monitored for metabolic adverse effects, the delirium patients are older and might be at greater risk for morbidity and mortality while taking antipsychotics, Dr. Mittal said.

"Despite the risks of prescribing antipsychotics for patients with dementia, adherence to recommendations for monitoring metabolic side effects remains low. ... They’re being monitored as frequently as those with psychosis, but it’s not enough in either group."

Such monitoring must be accomplished via collaboration between primary care/endocrinology and mental health, he advised.

The study was funded by a health services grant from the VA’s Health Services Research & Development Service. Dr. Mittal stated that he had no other disclosures.

WASHINGTON – Monitoring for metabolic side effects proved to be infrequent for outpatients with dementia or delirium who had been prescribed antipsychotic medications at 32 Veterans Affairs medical centers.

Antipsychotic medications are approved by the Food and Drug Administration for use in patients with psychotic disorders, not for those with dementia and delirium. However, they are widely used off label to control behavior disturbances among dementia/delirium patients, despite the lack of long-term data. In 2004, the American Psychiatric Association (APA), the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists, and the North American Association for the Study of Obesity issued consensus recommendations for monitoring of glycemic control, lipidemia, and weight gain among all patients taking antipsychotics (Diabetes Care 2004;27:596-601).

Subsequently, in 2005 and 2008, the FDA issued black box warnings about the increased risk for mortality in dementia patients with the use of typical and atypical antipsychotics. Other risks include cerebrovascular events, parkinsonism, pulmonary infections, and metabolic dysfunction

"To my way of thinking, these patients are getting a medication that is not FDA approved for this indication and it has significant risks, so if I’m a prudent clinician, if I prescribe something off label, I have to be more careful," Dr. Dinesh Mittal said in an interview.

But his findings in a large, retrospective cohort analysis suggest that this is not happening. Of patients identified as having received a new antipsychotic prescription and used it for at least 60 days, 916 had dementia or delirium but no psychosis, whereas 3,446 had psychosis but no dementia/delirium. The dementia patients were a mean age of 69 years, nearly all were male (95%), and most were married (56%). Two-thirds of the dementia/delirium group (64%) were aged 65 and older, compared with just 9% of the psychosis patients, said Dr. Mittal, a research scientist at the VA’s Center for Mental Health Outcomes Research and staff psychiatrist at Central Arkansas Veterans Healthcare System, Little Rock.

At baseline (defined as within 30 days of the index prescription), monitoring of either glucose or hemoglobin A_1c had been done for only 45% of those with dementia/delirium who were without psychosis. The proportion was not significantly different (47.5%) for the patients with psychosis but no dementia/delirium. Measurement of LDL cholesterol was even less common in both groups and was significantly lower for the dementia/delirium patients (27% vs. 34% of those with psychosis). Also, significantly more dementia patients than psychosis patients had their weight checked at baseline (71% vs. 66%).

The difference in weight measurement might simply relate to the fact that dementia patients were being seen more often for office visits and were having weight measured routinely, rather than being monitored specifically for metabolic side effects of antipsychotics, noted Dr. Mittal, who is also with the University of Arkansas, Little Rock.

The proportions being monitored for all side effects had dropped by 90 days, with glucose/HbA_1c measurements in just 27% of both the dementia/delirium group and the psychosis group; LDL cholesterol in 12% and 17%, respectively; and weight in 48% and 50%. Of those, the only significant difference between groups was the lower LDL measurement for the dementia/delirium patients, Dr. Mittal and his associates reported in a poster at the annual meeting of the American Association for Geriatric Psychiatry.

In the interview, Dr. Mittal commented that these results are particularly concerning given the absence of data to support the use of antipsychotics beyond a few days in dementia/delirium patients. The study sample was selected based on these patients’ having been prescribed antipsychotics for at least 60 days, which places them under the metabolic monitoring guidelines of the ADA and APA. "There are studies, but the only data [are] for short-term use for agitation of only a few days. That’s why we wanted to select a sample [of] prescribed antipsychotics long enough to get away from the data showing benefit," he explained.

The dilemma, he said, is that stopping an antipsychotic in a patient with dementia for whom they helped curb the agitation requires clinical judgment and is far more difficult in the outpatient setting, which was the focus of this study.

Although neither the psychotic nor the delirium/dementia patients were being adequately monitored for metabolic adverse effects, the delirium patients are older and might be at greater risk for morbidity and mortality while taking antipsychotics, Dr. Mittal said.

"Despite the risks of prescribing antipsychotics for patients with dementia, adherence to recommendations for monitoring metabolic side effects remains low. ... They’re being monitored as frequently as those with psychosis, but it’s not enough in either group."

Such monitoring must be accomplished via collaboration between primary care/endocrinology and mental health, he advised.

The study was funded by a health services grant from the VA’s Health Services Research & Development Service. Dr. Mittal stated that he had no other disclosures.