PHOENIX – Patients who are stable following a myocardial infarction and need isolated coronary artery bypass surgery (CABG) don’t need to wait 5 or so days for their surgery, a delay that many surgeons and cardiologists often impose.

The operation can safely occur after just a 1- or 2-day gap following either an ST-elevation MI or a non–ST-elevation MI, based on real-world outcomes seen in more than 3,000 patients treated at any of seven U.S. medical centers.

“Waiting an arbitrary 5 days is not important,” Elizabeth L. Nichols said during a video interview and during her report at the annual meeting of the Society of Thoracic Surgeons.

Ms. Nichols and her associates analyzed the in-hospital mortality rates among 3,060 patients who underwent isolated CABG during 2008-2014 at any of the seven medical centers that participate in the Northern New England Cardiovascular Disease Study Group and offer CABG. They included patients who had their surgery within 21 days of their MI, and excluded patients who had their CABG within 6 hours of their MI, had emergency surgery, or those with shock or incomplete data. The study group included 529 patients who had a ST-elevation MI and 2,531 patients with a non-ST-elevation MI.

The analysis divided patients into four groups based on timing of their CABG: 99 patients (3%) had surgery within the first 24 hours, 369 patients (12%) had their surgery 1-2 days after their MI, 1,966 (64%) had their operation 3-7 days following their MI, and 626 (21%) had their surgery 8-21 days after the MI.

The unadjusted mortality rates for these four subgroups were 5.1%, 1.6%, 1.6%, and 2.7%, respectively, reported Ms. Nichols, a health services researcher at the Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, N.H.

After researchers adjusted for several demographic and clinical variables, the mortality rates remained identical for patients who underwent CABG 1 or 2 days following their MI, compared with patients whose surgery was deferred until 3-7 days after the MI. Patients with surgery 8-21 days following the MI had a small but not statistically significant higher rate of in-hospital death.

Patients who had their surgery 7-23 hours following an MI had a statistically significant increased hospital mortality following surgery that ran more than threefold greater than patients who underwent CABG 3-7 days after their MI.

The main message from the analysis is that for the typical, stable MI patient who requires CABG to treat multivessel coronary disease, no need exists to wait several days following an MI to do the surgery, Ms. Nichols explained. A delay of just 1 or 2 days is safe and sufficient, as long as it provides adequate time for any acutely administered antiplatelet or antithrombotic drugs to clear.

The findings “provide a degree of comfort for not waiting the 3-5 days that had previously been thought necessary,” said Dr. Jock N. McCullough, chief of cardiac surgery at Dartmouth-Hitchcock Medical Center in Lebanon and a collaborator on the study.

The findings are not meant to supersede clinical judgment, both Dr. McCullough and Ms. Nichols emphasized. Individual patients might have good reasons to either undergo faster surgery or to wait at least 8 days following their MI.

“The patients who waited 8-21 days had a lot of comorbidities and were sicker patients, and their delay is often warranted” to make sure the patient is stable enough for surgery, Ms. Nichols explained. Other patients might be worsening following their MI and need to undergo their surgery within 24 hours of their MI.

“Clinical judgment is always the trump card,” Ms. Nichols said.

Ms. Nichols and Dr. McCullough had no disclosures.

[email protected]

On Twitter @mitchelzoler

PHOENIX – Patients who are stable following a myocardial infarction and need isolated coronary artery bypass surgery (CABG) don’t need to wait 5 or so days for their surgery, a delay that many surgeons and cardiologists often impose.

The operation can safely occur after just a 1- or 2-day gap following either an ST-elevation MI or a non–ST-elevation MI, based on real-world outcomes seen in more than 3,000 patients treated at any of seven U.S. medical centers.

“Waiting an arbitrary 5 days is not important,” Elizabeth L. Nichols said during a video interview and during her report at the annual meeting of the Society of Thoracic Surgeons.

Ms. Nichols and her associates analyzed the in-hospital mortality rates among 3,060 patients who underwent isolated CABG during 2008-2014 at any of the seven medical centers that participate in the Northern New England Cardiovascular Disease Study Group and offer CABG. They included patients who had their surgery within 21 days of their MI, and excluded patients who had their CABG within 6 hours of their MI, had emergency surgery, or those with shock or incomplete data. The study group included 529 patients who had a ST-elevation MI and 2,531 patients with a non-ST-elevation MI.

The analysis divided patients into four groups based on timing of their CABG: 99 patients (3%) had surgery within the first 24 hours, 369 patients (12%) had their surgery 1-2 days after their MI, 1,966 (64%) had their operation 3-7 days following their MI, and 626 (21%) had their surgery 8-21 days after the MI.

The unadjusted mortality rates for these four subgroups were 5.1%, 1.6%, 1.6%, and 2.7%, respectively, reported Ms. Nichols, a health services researcher at the Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, N.H.

After researchers adjusted for several demographic and clinical variables, the mortality rates remained identical for patients who underwent CABG 1 or 2 days following their MI, compared with patients whose surgery was deferred until 3-7 days after the MI. Patients with surgery 8-21 days following the MI had a small but not statistically significant higher rate of in-hospital death.

Patients who had their surgery 7-23 hours following an MI had a statistically significant increased hospital mortality following surgery that ran more than threefold greater than patients who underwent CABG 3-7 days after their MI.

The main message from the analysis is that for the typical, stable MI patient who requires CABG to treat multivessel coronary disease, no need exists to wait several days following an MI to do the surgery, Ms. Nichols explained. A delay of just 1 or 2 days is safe and sufficient, as long as it provides adequate time for any acutely administered antiplatelet or antithrombotic drugs to clear.

The findings “provide a degree of comfort for not waiting the 3-5 days that had previously been thought necessary,” said Dr. Jock N. McCullough, chief of cardiac surgery at Dartmouth-Hitchcock Medical Center in Lebanon and a collaborator on the study.

The findings are not meant to supersede clinical judgment, both Dr. McCullough and Ms. Nichols emphasized. Individual patients might have good reasons to either undergo faster surgery or to wait at least 8 days following their MI.

“The patients who waited 8-21 days had a lot of comorbidities and were sicker patients, and their delay is often warranted” to make sure the patient is stable enough for surgery, Ms. Nichols explained. Other patients might be worsening following their MI and need to undergo their surgery within 24 hours of their MI.

“Clinical judgment is always the trump card,” Ms. Nichols said.

Ms. Nichols and Dr. McCullough had no disclosures.

[email protected]

On Twitter @mitchelzoler

PHOENIX – Patients who are stable following a myocardial infarction and need isolated coronary artery bypass surgery (CABG) don’t need to wait 5 or so days for their surgery, a delay that many surgeons and cardiologists often impose.

The operation can safely occur after just a 1- or 2-day gap following either an ST-elevation MI or a non–ST-elevation MI, based on real-world outcomes seen in more than 3,000 patients treated at any of seven U.S. medical centers.

“Waiting an arbitrary 5 days is not important,” Elizabeth L. Nichols said during a video interview and during her report at the annual meeting of the Society of Thoracic Surgeons.

Ms. Nichols and her associates analyzed the in-hospital mortality rates among 3,060 patients who underwent isolated CABG during 2008-2014 at any of the seven medical centers that participate in the Northern New England Cardiovascular Disease Study Group and offer CABG. They included patients who had their surgery within 21 days of their MI, and excluded patients who had their CABG within 6 hours of their MI, had emergency surgery, or those with shock or incomplete data. The study group included 529 patients who had a ST-elevation MI and 2,531 patients with a non-ST-elevation MI.

The analysis divided patients into four groups based on timing of their CABG: 99 patients (3%) had surgery within the first 24 hours, 369 patients (12%) had their surgery 1-2 days after their MI, 1,966 (64%) had their operation 3-7 days following their MI, and 626 (21%) had their surgery 8-21 days after the MI.

The unadjusted mortality rates for these four subgroups were 5.1%, 1.6%, 1.6%, and 2.7%, respectively, reported Ms. Nichols, a health services researcher at the Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, N.H.

After researchers adjusted for several demographic and clinical variables, the mortality rates remained identical for patients who underwent CABG 1 or 2 days following their MI, compared with patients whose surgery was deferred until 3-7 days after the MI. Patients with surgery 8-21 days following the MI had a small but not statistically significant higher rate of in-hospital death.

Patients who had their surgery 7-23 hours following an MI had a statistically significant increased hospital mortality following surgery that ran more than threefold greater than patients who underwent CABG 3-7 days after their MI.

The main message from the analysis is that for the typical, stable MI patient who requires CABG to treat multivessel coronary disease, no need exists to wait several days following an MI to do the surgery, Ms. Nichols explained. A delay of just 1 or 2 days is safe and sufficient, as long as it provides adequate time for any acutely administered antiplatelet or antithrombotic drugs to clear.

The findings “provide a degree of comfort for not waiting the 3-5 days that had previously been thought necessary,” said Dr. Jock N. McCullough, chief of cardiac surgery at Dartmouth-Hitchcock Medical Center in Lebanon and a collaborator on the study.

The findings are not meant to supersede clinical judgment, both Dr. McCullough and Ms. Nichols emphasized. Individual patients might have good reasons to either undergo faster surgery or to wait at least 8 days following their MI.

“The patients who waited 8-21 days had a lot of comorbidities and were sicker patients, and their delay is often warranted” to make sure the patient is stable enough for surgery, Ms. Nichols explained. Other patients might be worsening following their MI and need to undergo their surgery within 24 hours of their MI.

“Clinical judgment is always the trump card,” Ms. Nichols said.

Ms. Nichols and Dr. McCullough had no disclosures.

[email protected]

On Twitter @mitchelzoler

The patient, a 10-year-old girl, was exhibiting defiant and angry behavior at home. Her pediatrician in rural Vermont was not able to support the family optimally, so he referred her to Dr. David C. Rettew.

Dr. Rettew soon learned that the girl blamed herself for her father’s absence, and she interpreted efforts by her mother to set limits as evidence that her mom didn’t love her.

Courtesy David C. Rettew, MD

“During the course of the interview, it became clear that the girl had some specific thoughts that were likely fueling her anger,” said Dr. Rettew, director of the Pediatric Psychiatry Clinic at the University of Vermont, Burlington. “She also met criteria clearly for ADHD, which had never been diagnosed. The consultation recommendations not only included some possible medications to try, but also some specific areas that could be addressed for psychotherapy that could really help the relationship between this child and her mother.”

The successful intervention took place via a secure, two-way videoconference. It is one example of how physicians at the University of Vermont are using telemental health to treat children in underserved areas. As part of a state-funded training program, child psychiatry fellows at the university consult with primary care doctors at federally qualified health centers across the state. The primary care physicians discuss patient cases with fellows via phone or email and can refer patients for in-person or telemental health assessments.

The program has been running for about 5 years and so far has yielded countless benefits, said Dr. Rettew, who directs the university’s Child and Adolescent Psychiatry Fellowship Program. “It helps keep the care housed and centered within the primary care home. That can help coordination of services so that care isn’t fragmented around multiple centers. It also allows evaluations to happen that wouldn’t happen otherwise because it’s too much of a hardship for families to travel long distances and come for regular follow-up appointments.”

University of Vermont physicians also use telemedicine to consult with other mental health clinicians across the state. Child psychiatrist Allison Y. Hall provides in-person training to clinicians and then counsels and supervises their efforts through a telemedicine unit.

“For this purpose, it’s great,” said Dr. Hall, who practices at the Vermont Center for Children, Youth, and Families, which is housed within the university’s psychiatry department. “There’s more confidentiality than Skype, for instance. It’s wonderful to be able to reach clinicians at a great distance.”

On a broader scale, telemental health is a promising tool to address the shortage of mental health providers in the United States, said Dr. Robert C. Gunther, a pediatrician at the University of Virginia Health System in Fishersville. Recent research found that one in three children receiving outpatient care for mental health conditions saw only their primary care doctor for care (Pediatrics. 2015 Nov;136;e1178-85).

“There is a tremendous need for pediatric mental health care,” Dr. Gunther said in an interview. “There is a great shortage of child psychiatrists and other child mental health specialists. Telemental health can help in areas where geography or financial barriers exist to accessing care.”

Data from the Children’s ADHD Telemental Health Treatment Study (CATTS) illustrates the impact that telemental health can have on children facing such barriers to care. Researchers randomized 223 children referred by 88 primary care providers in seven underserved communities into two study groups. Children in the first group were seen by child psychiatrists via videoconference six times over 22 weeks; treatment included pharmacotherapy. Their caregivers received behavior training provided in person by community therapists who were supervised remotely. Children in the second group were treated by their primary care physicians and received one telepsychiatry consult.

Children in both groups improved; however, those randomized to the telemental health model improved “significantly more than patients in the augmented primary care arm” (J Am Acad Child Adolesc Psychiatry. 2015 Apr;54[4]:263-74).

Courtesy David C. Rettew, MD

“The CATTS trial demonstrated the effectiveness of a telehealth service model to treat ADHD in communities with limited access to specialty mental health services,” investigators concluded.

But Dr. Joshua J. Alexander, chair of the American Academy of Pediatrics Section on Telehealth Care, notes that some mental health conditions fit more smoothly within the telemental health model than others. ADHD is the most common condition treated by telemental health, he said. The model also has shown success in the treatment of childhood adjustment disorders, anxiety, oppositional defiant disorder, mood disorders, anxiety, and depression.

“I think you have to be careful in determining where telemental health would be beneficial to use and in which cases it might not be an appropriate method to deliver care,” Dr. Alexander said in an interview.

Developing trust and rapport with patients through videoconferencing also can be a challenge, added Dr. Alexander, who is director of the TelAbility telehealth program at the University of North Carolina at Chapel Hill. He recommends that specialists use the technology to continue an existing doctor-patient relationship or to provide care in a consultative model in which the child’s primary care doctor is present along with the patient and patient’s family.

The AAP advocates for the use of telemedicine so long as it is conducted within the context of the medical home. Fragmented telemedicine services that could disrupt continuity of care should be avoided, according to a 2015 AAP policy statement (Pediatrics. 2015 Jun. doi: 10.1542/peds.2015-1253). The academy also calls for the expansion of pediatric telemedicine to increase access to care for underserved communities and improve quality of care for children.

More partnerships between mental health specialists and primary care providers are a key step in delivering high quality pediatric telemental care, Dr. Alexander said.

“Some larger pediatric practices already do this by hiring and colocating individuals at their practice site, but other, smaller practices might not have the room, finances, sufficient patient population, or enough local providers to make this happen,” he said. “A telemedicine program, located within the practice, could enable this specialized service to be provided in a convenient, coordinated setting.”

[email protected]

On Twitter @legal_med

The patient, a 10-year-old girl, was exhibiting defiant and angry behavior at home. Her pediatrician in rural Vermont was not able to support the family optimally, so he referred her to Dr. David C. Rettew.

Dr. Rettew soon learned that the girl blamed herself for her father’s absence, and she interpreted efforts by her mother to set limits as evidence that her mom didn’t love her.

Courtesy David C. Rettew, MD

“During the course of the interview, it became clear that the girl had some specific thoughts that were likely fueling her anger,” said Dr. Rettew, director of the Pediatric Psychiatry Clinic at the University of Vermont, Burlington. “She also met criteria clearly for ADHD, which had never been diagnosed. The consultation recommendations not only included some possible medications to try, but also some specific areas that could be addressed for psychotherapy that could really help the relationship between this child and her mother.”

The successful intervention took place via a secure, two-way videoconference. It is one example of how physicians at the University of Vermont are using telemental health to treat children in underserved areas. As part of a state-funded training program, child psychiatry fellows at the university consult with primary care doctors at federally qualified health centers across the state. The primary care physicians discuss patient cases with fellows via phone or email and can refer patients for in-person or telemental health assessments.

The program has been running for about 5 years and so far has yielded countless benefits, said Dr. Rettew, who directs the university’s Child and Adolescent Psychiatry Fellowship Program. “It helps keep the care housed and centered within the primary care home. That can help coordination of services so that care isn’t fragmented around multiple centers. It also allows evaluations to happen that wouldn’t happen otherwise because it’s too much of a hardship for families to travel long distances and come for regular follow-up appointments.”

University of Vermont physicians also use telemedicine to consult with other mental health clinicians across the state. Child psychiatrist Allison Y. Hall provides in-person training to clinicians and then counsels and supervises their efforts through a telemedicine unit.

“For this purpose, it’s great,” said Dr. Hall, who practices at the Vermont Center for Children, Youth, and Families, which is housed within the university’s psychiatry department. “There’s more confidentiality than Skype, for instance. It’s wonderful to be able to reach clinicians at a great distance.”

On a broader scale, telemental health is a promising tool to address the shortage of mental health providers in the United States, said Dr. Robert C. Gunther, a pediatrician at the University of Virginia Health System in Fishersville. Recent research found that one in three children receiving outpatient care for mental health conditions saw only their primary care doctor for care (Pediatrics. 2015 Nov;136;e1178-85).

“There is a tremendous need for pediatric mental health care,” Dr. Gunther said in an interview. “There is a great shortage of child psychiatrists and other child mental health specialists. Telemental health can help in areas where geography or financial barriers exist to accessing care.”

Data from the Children’s ADHD Telemental Health Treatment Study (CATTS) illustrates the impact that telemental health can have on children facing such barriers to care. Researchers randomized 223 children referred by 88 primary care providers in seven underserved communities into two study groups. Children in the first group were seen by child psychiatrists via videoconference six times over 22 weeks; treatment included pharmacotherapy. Their caregivers received behavior training provided in person by community therapists who were supervised remotely. Children in the second group were treated by their primary care physicians and received one telepsychiatry consult.

Children in both groups improved; however, those randomized to the telemental health model improved “significantly more than patients in the augmented primary care arm” (J Am Acad Child Adolesc Psychiatry. 2015 Apr;54[4]:263-74).

Courtesy David C. Rettew, MD

“The CATTS trial demonstrated the effectiveness of a telehealth service model to treat ADHD in communities with limited access to specialty mental health services,” investigators concluded.

But Dr. Joshua J. Alexander, chair of the American Academy of Pediatrics Section on Telehealth Care, notes that some mental health conditions fit more smoothly within the telemental health model than others. ADHD is the most common condition treated by telemental health, he said. The model also has shown success in the treatment of childhood adjustment disorders, anxiety, oppositional defiant disorder, mood disorders, anxiety, and depression.

“I think you have to be careful in determining where telemental health would be beneficial to use and in which cases it might not be an appropriate method to deliver care,” Dr. Alexander said in an interview.

Developing trust and rapport with patients through videoconferencing also can be a challenge, added Dr. Alexander, who is director of the TelAbility telehealth program at the University of North Carolina at Chapel Hill. He recommends that specialists use the technology to continue an existing doctor-patient relationship or to provide care in a consultative model in which the child’s primary care doctor is present along with the patient and patient’s family.

The AAP advocates for the use of telemedicine so long as it is conducted within the context of the medical home. Fragmented telemedicine services that could disrupt continuity of care should be avoided, according to a 2015 AAP policy statement (Pediatrics. 2015 Jun. doi: 10.1542/peds.2015-1253). The academy also calls for the expansion of pediatric telemedicine to increase access to care for underserved communities and improve quality of care for children.

More partnerships between mental health specialists and primary care providers are a key step in delivering high quality pediatric telemental care, Dr. Alexander said.

“Some larger pediatric practices already do this by hiring and colocating individuals at their practice site, but other, smaller practices might not have the room, finances, sufficient patient population, or enough local providers to make this happen,” he said. “A telemedicine program, located within the practice, could enable this specialized service to be provided in a convenient, coordinated setting.”

[email protected]

On Twitter @legal_med

The patient, a 10-year-old girl, was exhibiting defiant and angry behavior at home. Her pediatrician in rural Vermont was not able to support the family optimally, so he referred her to Dr. David C. Rettew.

Dr. Rettew soon learned that the girl blamed herself for her father’s absence, and she interpreted efforts by her mother to set limits as evidence that her mom didn’t love her.

Courtesy David C. Rettew, MD

“During the course of the interview, it became clear that the girl had some specific thoughts that were likely fueling her anger,” said Dr. Rettew, director of the Pediatric Psychiatry Clinic at the University of Vermont, Burlington. “She also met criteria clearly for ADHD, which had never been diagnosed. The consultation recommendations not only included some possible medications to try, but also some specific areas that could be addressed for psychotherapy that could really help the relationship between this child and her mother.”

The successful intervention took place via a secure, two-way videoconference. It is one example of how physicians at the University of Vermont are using telemental health to treat children in underserved areas. As part of a state-funded training program, child psychiatry fellows at the university consult with primary care doctors at federally qualified health centers across the state. The primary care physicians discuss patient cases with fellows via phone or email and can refer patients for in-person or telemental health assessments.

The program has been running for about 5 years and so far has yielded countless benefits, said Dr. Rettew, who directs the university’s Child and Adolescent Psychiatry Fellowship Program. “It helps keep the care housed and centered within the primary care home. That can help coordination of services so that care isn’t fragmented around multiple centers. It also allows evaluations to happen that wouldn’t happen otherwise because it’s too much of a hardship for families to travel long distances and come for regular follow-up appointments.”

University of Vermont physicians also use telemedicine to consult with other mental health clinicians across the state. Child psychiatrist Allison Y. Hall provides in-person training to clinicians and then counsels and supervises their efforts through a telemedicine unit.

“For this purpose, it’s great,” said Dr. Hall, who practices at the Vermont Center for Children, Youth, and Families, which is housed within the university’s psychiatry department. “There’s more confidentiality than Skype, for instance. It’s wonderful to be able to reach clinicians at a great distance.”

On a broader scale, telemental health is a promising tool to address the shortage of mental health providers in the United States, said Dr. Robert C. Gunther, a pediatrician at the University of Virginia Health System in Fishersville. Recent research found that one in three children receiving outpatient care for mental health conditions saw only their primary care doctor for care (Pediatrics. 2015 Nov;136;e1178-85).

“There is a tremendous need for pediatric mental health care,” Dr. Gunther said in an interview. “There is a great shortage of child psychiatrists and other child mental health specialists. Telemental health can help in areas where geography or financial barriers exist to accessing care.”

Data from the Children’s ADHD Telemental Health Treatment Study (CATTS) illustrates the impact that telemental health can have on children facing such barriers to care. Researchers randomized 223 children referred by 88 primary care providers in seven underserved communities into two study groups. Children in the first group were seen by child psychiatrists via videoconference six times over 22 weeks; treatment included pharmacotherapy. Their caregivers received behavior training provided in person by community therapists who were supervised remotely. Children in the second group were treated by their primary care physicians and received one telepsychiatry consult.

Children in both groups improved; however, those randomized to the telemental health model improved “significantly more than patients in the augmented primary care arm” (J Am Acad Child Adolesc Psychiatry. 2015 Apr;54[4]:263-74).

Courtesy David C. Rettew, MD

“The CATTS trial demonstrated the effectiveness of a telehealth service model to treat ADHD in communities with limited access to specialty mental health services,” investigators concluded.

But Dr. Joshua J. Alexander, chair of the American Academy of Pediatrics Section on Telehealth Care, notes that some mental health conditions fit more smoothly within the telemental health model than others. ADHD is the most common condition treated by telemental health, he said. The model also has shown success in the treatment of childhood adjustment disorders, anxiety, oppositional defiant disorder, mood disorders, anxiety, and depression.

“I think you have to be careful in determining where telemental health would be beneficial to use and in which cases it might not be an appropriate method to deliver care,” Dr. Alexander said in an interview.

Developing trust and rapport with patients through videoconferencing also can be a challenge, added Dr. Alexander, who is director of the TelAbility telehealth program at the University of North Carolina at Chapel Hill. He recommends that specialists use the technology to continue an existing doctor-patient relationship or to provide care in a consultative model in which the child’s primary care doctor is present along with the patient and patient’s family.

The AAP advocates for the use of telemedicine so long as it is conducted within the context of the medical home. Fragmented telemedicine services that could disrupt continuity of care should be avoided, according to a 2015 AAP policy statement (Pediatrics. 2015 Jun. doi: 10.1542/peds.2015-1253). The academy also calls for the expansion of pediatric telemedicine to increase access to care for underserved communities and improve quality of care for children.

More partnerships between mental health specialists and primary care providers are a key step in delivering high quality pediatric telemental care, Dr. Alexander said.

“Some larger pediatric practices already do this by hiring and colocating individuals at their practice site, but other, smaller practices might not have the room, finances, sufficient patient population, or enough local providers to make this happen,” he said. “A telemedicine program, located within the practice, could enable this specialized service to be provided in a convenient, coordinated setting.”

[email protected]

On Twitter @legal_med

Recently, my secretary was out on maternity leave for 6 weeks.

I run a small practice, and my medical assistant works from home on the far side of town. So I was on my own at the office. My MA and I split things up, and since I was the only one physically in the building, I took over all the front office stuff and she took the back office.

I ran the front desk for the whole time – checking people in and out, taking copays, copying insurance cards, giving referrals to therapy places, sending logs to the billing company, and doing other everyday stuff.

Plenty of people asked why I didn’t hire a temp, obviously not knowing how close to the edge a modern solo practice runs. If I hire a temp, that’s another salary to pay, meaning one of the other three of us here would have to skip a few paychecks. I’m not going to put my secretary on unpaid leave for that time. She’s awesome, has been with me since 2004, and has stuck with me through good and bad years. If I don’t pay her that time, she can’t pay her rent, and I don’t have the heart to do that to her. Maybe a big corporate person wouldn’t lose any sleep about it, but I would. Great people are hard to find, and I want to keep the ones I have.

Besides, if I hired a temp, I’d have to train them from the beginning. I don’t use off-the-shelf medical software, just a system I designed myself. It would take time out of my day to teach them how to use it, where I send patients for tests and referrals, and how to sort documents accurately into the correct e-charts. So, for 6 weeks it just seemed easier to do it myself. I know how I like it done.

It wasn’t easy for my MA as well. She had to take over scheduling appointments, handling billing questions, making reminder calls, and doing other miscellaneous stuff. Even after work was over, I’d be at home catching up on all the dictations I hadn’t had time to do, and we’d be going back and forth by phone and email to settle different issues until 8:00 at night or so. By the end of the 6 weeks, we were both pretty burned out and exhausted.

I’m sure the patients weren’t thrilled, either. During that time, they could only reach a voice mail box telling them to leave a message and we’d get back to them as quickly as possible.

I assumed my practice was the only one dinky (or poor, by medical standards) enough to have to resort to this – until I had a chance conversation with a local family practice doctor, when he mentioned he’d had to do something similar when his secretary retired and he didn’t find a replacement for several weeks. A cardiologist mentioned doing the same thing while we were chatting at the hospital. Like me, they were both in solo practice.

This is, apparently, the nature of a modern small practice. The revenue and expense streams are too tight to allow for an extra salary, so even the doctor pitches in to cover. I’m sure my colleagues in large groups will laugh at the thought, but I don’t care. I have to do what’s right for my practice and to survive in the modern medical climate. And if working the front desk for a few weeks is what’s needed to stay independent, so be it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently, my secretary was out on maternity leave for 6 weeks.

I run a small practice, and my medical assistant works from home on the far side of town. So I was on my own at the office. My MA and I split things up, and since I was the only one physically in the building, I took over all the front office stuff and she took the back office.

I ran the front desk for the whole time – checking people in and out, taking copays, copying insurance cards, giving referrals to therapy places, sending logs to the billing company, and doing other everyday stuff.

Plenty of people asked why I didn’t hire a temp, obviously not knowing how close to the edge a modern solo practice runs. If I hire a temp, that’s another salary to pay, meaning one of the other three of us here would have to skip a few paychecks. I’m not going to put my secretary on unpaid leave for that time. She’s awesome, has been with me since 2004, and has stuck with me through good and bad years. If I don’t pay her that time, she can’t pay her rent, and I don’t have the heart to do that to her. Maybe a big corporate person wouldn’t lose any sleep about it, but I would. Great people are hard to find, and I want to keep the ones I have.

Besides, if I hired a temp, I’d have to train them from the beginning. I don’t use off-the-shelf medical software, just a system I designed myself. It would take time out of my day to teach them how to use it, where I send patients for tests and referrals, and how to sort documents accurately into the correct e-charts. So, for 6 weeks it just seemed easier to do it myself. I know how I like it done.

It wasn’t easy for my MA as well. She had to take over scheduling appointments, handling billing questions, making reminder calls, and doing other miscellaneous stuff. Even after work was over, I’d be at home catching up on all the dictations I hadn’t had time to do, and we’d be going back and forth by phone and email to settle different issues until 8:00 at night or so. By the end of the 6 weeks, we were both pretty burned out and exhausted.

I’m sure the patients weren’t thrilled, either. During that time, they could only reach a voice mail box telling them to leave a message and we’d get back to them as quickly as possible.

I assumed my practice was the only one dinky (or poor, by medical standards) enough to have to resort to this – until I had a chance conversation with a local family practice doctor, when he mentioned he’d had to do something similar when his secretary retired and he didn’t find a replacement for several weeks. A cardiologist mentioned doing the same thing while we were chatting at the hospital. Like me, they were both in solo practice.

This is, apparently, the nature of a modern small practice. The revenue and expense streams are too tight to allow for an extra salary, so even the doctor pitches in to cover. I’m sure my colleagues in large groups will laugh at the thought, but I don’t care. I have to do what’s right for my practice and to survive in the modern medical climate. And if working the front desk for a few weeks is what’s needed to stay independent, so be it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently, my secretary was out on maternity leave for 6 weeks.

I run a small practice, and my medical assistant works from home on the far side of town. So I was on my own at the office. My MA and I split things up, and since I was the only one physically in the building, I took over all the front office stuff and she took the back office.

I ran the front desk for the whole time – checking people in and out, taking copays, copying insurance cards, giving referrals to therapy places, sending logs to the billing company, and doing other everyday stuff.

Plenty of people asked why I didn’t hire a temp, obviously not knowing how close to the edge a modern solo practice runs. If I hire a temp, that’s another salary to pay, meaning one of the other three of us here would have to skip a few paychecks. I’m not going to put my secretary on unpaid leave for that time. She’s awesome, has been with me since 2004, and has stuck with me through good and bad years. If I don’t pay her that time, she can’t pay her rent, and I don’t have the heart to do that to her. Maybe a big corporate person wouldn’t lose any sleep about it, but I would. Great people are hard to find, and I want to keep the ones I have.

Besides, if I hired a temp, I’d have to train them from the beginning. I don’t use off-the-shelf medical software, just a system I designed myself. It would take time out of my day to teach them how to use it, where I send patients for tests and referrals, and how to sort documents accurately into the correct e-charts. So, for 6 weeks it just seemed easier to do it myself. I know how I like it done.

It wasn’t easy for my MA as well. She had to take over scheduling appointments, handling billing questions, making reminder calls, and doing other miscellaneous stuff. Even after work was over, I’d be at home catching up on all the dictations I hadn’t had time to do, and we’d be going back and forth by phone and email to settle different issues until 8:00 at night or so. By the end of the 6 weeks, we were both pretty burned out and exhausted.

I’m sure the patients weren’t thrilled, either. During that time, they could only reach a voice mail box telling them to leave a message and we’d get back to them as quickly as possible.

I assumed my practice was the only one dinky (or poor, by medical standards) enough to have to resort to this – until I had a chance conversation with a local family practice doctor, when he mentioned he’d had to do something similar when his secretary retired and he didn’t find a replacement for several weeks. A cardiologist mentioned doing the same thing while we were chatting at the hospital. Like me, they were both in solo practice.

This is, apparently, the nature of a modern small practice. The revenue and expense streams are too tight to allow for an extra salary, so even the doctor pitches in to cover. I’m sure my colleagues in large groups will laugh at the thought, but I don’t care. I have to do what’s right for my practice and to survive in the modern medical climate. And if working the front desk for a few weeks is what’s needed to stay independent, so be it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Medicare will cover allogeneic hematopoietic stem cell transplantation (HSCT) for beneficiaries with multiple myeloma, myelofibrosis, or sickle cell disease in the context of approved, prospective clinical trials, the Centers for Medicare & Medicaid Services announced in a final decision memo Jan. 27.

Approvable studies must examine whether Medicare beneficiaries who receive allogeneic HSCT have improved outcomes, compared with patients who do not receive allogeneic HSCT as measured by graft vs. host disease, other transplant-related adverse events, overall survival, and, optionally, quality of life measures.

In multiple myeloma, allogeneic HSCT will be covered only for Medicare beneficiaries who have Durie-Salmon Stage II or III multiple myeloma, or International Staging System (ISS) Stage II or Stage III multiple myeloma, and are participating in an approved prospective clinical study. Such studies must control for selection bias and potential confounding by age, duration of diagnosis, disease classification, International Myeloma Working Group (IMWG) classification, ISS staging, Durie-Salmon staging, comorbid conditions, type of preparative/conditioning regimen, graft vs. host disease (GVHD) prophylaxis, donor type, and cell source, the CMS said in its memo.

In myelofibrosis, allogeneic HSCT will be covered by Medicare in an approved prospective study only for beneficiaries with Dynamic International Prognostic Scoring System (DIPSS plus) intermediate-2 or high primary or secondary myelofibrosis. Studies must be controlled for selection bias and potential confounding by age, duration of diagnosis, disease classification, DIPSS plus score, comorbid conditions, type of preparative/conditioning regimen, GVHD prophylaxis, donor type, and cell source.

In sickle cell disease, allogeneic HSCT will be covered by Medicare only for beneficiaries who have severe, symptomatic disease. Approvable studies must control for selection bias and potential confounding by age, duration of diagnosis, comorbid conditions, type of preparative/conditioning regimen, GVHD prophylaxis, donor type, and cell source.

[email protected]

On Twitter @maryjodales

Medicare will cover allogeneic hematopoietic stem cell transplantation (HSCT) for beneficiaries with multiple myeloma, myelofibrosis, or sickle cell disease in the context of approved, prospective clinical trials, the Centers for Medicare & Medicaid Services announced in a final decision memo Jan. 27.

Approvable studies must examine whether Medicare beneficiaries who receive allogeneic HSCT have improved outcomes, compared with patients who do not receive allogeneic HSCT as measured by graft vs. host disease, other transplant-related adverse events, overall survival, and, optionally, quality of life measures.

In multiple myeloma, allogeneic HSCT will be covered only for Medicare beneficiaries who have Durie-Salmon Stage II or III multiple myeloma, or International Staging System (ISS) Stage II or Stage III multiple myeloma, and are participating in an approved prospective clinical study. Such studies must control for selection bias and potential confounding by age, duration of diagnosis, disease classification, International Myeloma Working Group (IMWG) classification, ISS staging, Durie-Salmon staging, comorbid conditions, type of preparative/conditioning regimen, graft vs. host disease (GVHD) prophylaxis, donor type, and cell source, the CMS said in its memo.

In myelofibrosis, allogeneic HSCT will be covered by Medicare in an approved prospective study only for beneficiaries with Dynamic International Prognostic Scoring System (DIPSS plus) intermediate-2 or high primary or secondary myelofibrosis. Studies must be controlled for selection bias and potential confounding by age, duration of diagnosis, disease classification, DIPSS plus score, comorbid conditions, type of preparative/conditioning regimen, GVHD prophylaxis, donor type, and cell source.

In sickle cell disease, allogeneic HSCT will be covered by Medicare only for beneficiaries who have severe, symptomatic disease. Approvable studies must control for selection bias and potential confounding by age, duration of diagnosis, comorbid conditions, type of preparative/conditioning regimen, GVHD prophylaxis, donor type, and cell source.

[email protected]

On Twitter @maryjodales

Medicare will cover allogeneic hematopoietic stem cell transplantation (HSCT) for beneficiaries with multiple myeloma, myelofibrosis, or sickle cell disease in the context of approved, prospective clinical trials, the Centers for Medicare & Medicaid Services announced in a final decision memo Jan. 27.

Approvable studies must examine whether Medicare beneficiaries who receive allogeneic HSCT have improved outcomes, compared with patients who do not receive allogeneic HSCT as measured by graft vs. host disease, other transplant-related adverse events, overall survival, and, optionally, quality of life measures.

In multiple myeloma, allogeneic HSCT will be covered only for Medicare beneficiaries who have Durie-Salmon Stage II or III multiple myeloma, or International Staging System (ISS) Stage II or Stage III multiple myeloma, and are participating in an approved prospective clinical study. Such studies must control for selection bias and potential confounding by age, duration of diagnosis, disease classification, International Myeloma Working Group (IMWG) classification, ISS staging, Durie-Salmon staging, comorbid conditions, type of preparative/conditioning regimen, graft vs. host disease (GVHD) prophylaxis, donor type, and cell source, the CMS said in its memo.

In myelofibrosis, allogeneic HSCT will be covered by Medicare in an approved prospective study only for beneficiaries with Dynamic International Prognostic Scoring System (DIPSS plus) intermediate-2 or high primary or secondary myelofibrosis. Studies must be controlled for selection bias and potential confounding by age, duration of diagnosis, disease classification, DIPSS plus score, comorbid conditions, type of preparative/conditioning regimen, GVHD prophylaxis, donor type, and cell source.

In sickle cell disease, allogeneic HSCT will be covered by Medicare only for beneficiaries who have severe, symptomatic disease. Approvable studies must control for selection bias and potential confounding by age, duration of diagnosis, comorbid conditions, type of preparative/conditioning regimen, GVHD prophylaxis, donor type, and cell source.

[email protected]

On Twitter @maryjodales

Incidence of newly acquired hepatitis C virus has increased recently in patients undergoing hemodialysis, according to a health advisory from the Centers for Disease Control and Prevention.

In 2014 and 2015, 36 cases of HCV infection were reported to the CDC from 19 clinics in eight states. While investigation is ongoing, HCV transmission between patients has been confirmed in at least nine facilities, and in several facilities, lapses in infection control were also identified. Better screening and awareness of HCV infection potential may also play a role in the increased disease incidence.

The CDC recommends that dialysis facilities assess current infection control practices, environmental cleaning, and disinfection practices to evaluate adherence to standards, address any gaps, screen patients for HCV, and to report all HCV infections to the CDC promptly.

“Dialysis facilities should actively assess and continuously improve their infection control, environmental cleaning and disinfection, and HCV screening practices, whether or not they are aware of infections in their clinic. Any case of new HCV infection in a patient undergoing hemodialysis is likely to be a health care–associated infection and should be reported to public health authorities in a timely manner,” the CDC said

Find the full health advisory on the CDC website.

[email protected]

Incidence of newly acquired hepatitis C virus has increased recently in patients undergoing hemodialysis, according to a health advisory from the Centers for Disease Control and Prevention.

In 2014 and 2015, 36 cases of HCV infection were reported to the CDC from 19 clinics in eight states. While investigation is ongoing, HCV transmission between patients has been confirmed in at least nine facilities, and in several facilities, lapses in infection control were also identified. Better screening and awareness of HCV infection potential may also play a role in the increased disease incidence.

The CDC recommends that dialysis facilities assess current infection control practices, environmental cleaning, and disinfection practices to evaluate adherence to standards, address any gaps, screen patients for HCV, and to report all HCV infections to the CDC promptly.

“Dialysis facilities should actively assess and continuously improve their infection control, environmental cleaning and disinfection, and HCV screening practices, whether or not they are aware of infections in their clinic. Any case of new HCV infection in a patient undergoing hemodialysis is likely to be a health care–associated infection and should be reported to public health authorities in a timely manner,” the CDC said

Find the full health advisory on the CDC website.

[email protected]

Incidence of newly acquired hepatitis C virus has increased recently in patients undergoing hemodialysis, according to a health advisory from the Centers for Disease Control and Prevention.

In 2014 and 2015, 36 cases of HCV infection were reported to the CDC from 19 clinics in eight states. While investigation is ongoing, HCV transmission between patients has been confirmed in at least nine facilities, and in several facilities, lapses in infection control were also identified. Better screening and awareness of HCV infection potential may also play a role in the increased disease incidence.

The CDC recommends that dialysis facilities assess current infection control practices, environmental cleaning, and disinfection practices to evaluate adherence to standards, address any gaps, screen patients for HCV, and to report all HCV infections to the CDC promptly.

“Dialysis facilities should actively assess and continuously improve their infection control, environmental cleaning and disinfection, and HCV screening practices, whether or not they are aware of infections in their clinic. Any case of new HCV infection in a patient undergoing hemodialysis is likely to be a health care–associated infection and should be reported to public health authorities in a timely manner,” the CDC said

Find the full health advisory on the CDC website.

[email protected]

Post-surgical pain scores may be an overlooked quality indicator among hospitals, according to new research linking patient-reported pain scores with institutional pain management practices and also surgical outcomes.

A retrospective cohort study of patient-reported pain scores after colorectal resections at 52 Michigan hospitals, published in Annals of Surgery (2016 Jan 7; epub ahead of print; doi: 10.1097/SLA.0000000000001541), found that patients treated at the best-performing hospitals for postoperative pain scores were more likely to have received patient-controlled analgesia, compared with those in the worst-performing ones (56.5% vs. 22.8%; P less than .001).

For their research, Dr. Scott E. Regenbogen of the University of Michigan, Ann Arbor, and his colleagues looked at patient-reported pain scores on the first morning post-surgery for 7,221 colorectal operations between 2012 and 2014. The participating hospitals were part of a statewide collaborative that collects data on surgery patients with the aim of improving quality.

Dr. Regenbogen and his colleagues found that patients in the quartile of hospitals with the best pain scores stayed fewer days (6.5 vs. 7.9, P less than .007) and had fewer post-surgical complications (20.3% vs. 26.4%; P less than .001), compared with those in the worst-performing quartile of hospitals.

In addition, Dr. Regenbogen and his colleagues found postoperative emergency department visits, readmissions, and pulmonary complications to be significantly lower in the quartile of hospitals with the best pain scores. The fewer pulmonary complications seen linked with better pain control “could be an indicator of better pulmonary toilet or lesser respiratory depression,” they noted.

DiverDave/Wikicommons Creative Commons License

The correlation between surgical outcomes and pain scores, the investigators wrote, suggests “consistency in the overall quality performance across both clinical and patient-reported outcomes for colectomy.”

Mean self-rated pain scores, in which patients characterize the intensity of their pain on a scale of 0 to 10, ranged from 4 to 6 across the hospitals in the study, with 5.1 (standard deviation 2.44) reported for the cohort as a whole. The type of surgery also affected pain scores, with minimally invasive procedures associated with lower scores, compared with open or converted procedures. The type of anesthesia used (local or epidural) also significantly affected scores.

Hospitals with better pain scores tended to be somewhat larger than those with poor scores, and performed more colorectal resections per year, the investigators found.

The researchers noted that while a previous meta-analysis showed that patient-controlled analgesia post-surgery provided superior pain control, compared with intermittent treatment (Cochrane Database Syst Rev. 2006 Oct 18;18:CD003348), the hospitals in this study varied widely in their approaches, with 89% of the poorly performing quartile of hospitals using intermittent parenteral narcotics, compared with 66% in the best-performing quartile.

Dr. Regenbogen and his colleagues noted in their analysis that it was possible that the association between pain control and clinical outcomes such as readmissions and complications was driven by case or patient complexity differences among institutions. The 52 hospitals in the study varied in size and type, with community and academic hospitals as well as rural and urban institutions represented.

However, they wrote, it is more likely that “both pain scores and clinical outcomes reflect … global features of the quality of care in hospitals’ surgical performance. Thus, hospitals with the most streamlined, high-quality perioperative care pathways experience the best pain scores, as well as improved clinical outcomes.”

The findings, they concluded, “reveal systematic clinical care variation that could be reduced to improve patients’ experience of pain after colorectal resections.”

The researchers noted as a limitation of the study its reliance on patient-reported pain measures, and that it did not include data on patients’ pain history, opioid use prior to admission, or the administration of pre-emptive analgesia before surgery. The study was funded by the Michigan Surgical Quality Collaborative, which receives support from Blue Cross Blue Shield. None of the study authors declared conflicts of interest.

Post-surgical pain scores may be an overlooked quality indicator among hospitals, according to new research linking patient-reported pain scores with institutional pain management practices and also surgical outcomes.

A retrospective cohort study of patient-reported pain scores after colorectal resections at 52 Michigan hospitals, published in Annals of Surgery (2016 Jan 7; epub ahead of print; doi: 10.1097/SLA.0000000000001541), found that patients treated at the best-performing hospitals for postoperative pain scores were more likely to have received patient-controlled analgesia, compared with those in the worst-performing ones (56.5% vs. 22.8%; P less than .001).

For their research, Dr. Scott E. Regenbogen of the University of Michigan, Ann Arbor, and his colleagues looked at patient-reported pain scores on the first morning post-surgery for 7,221 colorectal operations between 2012 and 2014. The participating hospitals were part of a statewide collaborative that collects data on surgery patients with the aim of improving quality.

Dr. Regenbogen and his colleagues found that patients in the quartile of hospitals with the best pain scores stayed fewer days (6.5 vs. 7.9, P less than .007) and had fewer post-surgical complications (20.3% vs. 26.4%; P less than .001), compared with those in the worst-performing quartile of hospitals.

In addition, Dr. Regenbogen and his colleagues found postoperative emergency department visits, readmissions, and pulmonary complications to be significantly lower in the quartile of hospitals with the best pain scores. The fewer pulmonary complications seen linked with better pain control “could be an indicator of better pulmonary toilet or lesser respiratory depression,” they noted.

DiverDave/Wikicommons Creative Commons License

The correlation between surgical outcomes and pain scores, the investigators wrote, suggests “consistency in the overall quality performance across both clinical and patient-reported outcomes for colectomy.”

Mean self-rated pain scores, in which patients characterize the intensity of their pain on a scale of 0 to 10, ranged from 4 to 6 across the hospitals in the study, with 5.1 (standard deviation 2.44) reported for the cohort as a whole. The type of surgery also affected pain scores, with minimally invasive procedures associated with lower scores, compared with open or converted procedures. The type of anesthesia used (local or epidural) also significantly affected scores.

Hospitals with better pain scores tended to be somewhat larger than those with poor scores, and performed more colorectal resections per year, the investigators found.

The researchers noted that while a previous meta-analysis showed that patient-controlled analgesia post-surgery provided superior pain control, compared with intermittent treatment (Cochrane Database Syst Rev. 2006 Oct 18;18:CD003348), the hospitals in this study varied widely in their approaches, with 89% of the poorly performing quartile of hospitals using intermittent parenteral narcotics, compared with 66% in the best-performing quartile.

Dr. Regenbogen and his colleagues noted in their analysis that it was possible that the association between pain control and clinical outcomes such as readmissions and complications was driven by case or patient complexity differences among institutions. The 52 hospitals in the study varied in size and type, with community and academic hospitals as well as rural and urban institutions represented.

However, they wrote, it is more likely that “both pain scores and clinical outcomes reflect … global features of the quality of care in hospitals’ surgical performance. Thus, hospitals with the most streamlined, high-quality perioperative care pathways experience the best pain scores, as well as improved clinical outcomes.”

The findings, they concluded, “reveal systematic clinical care variation that could be reduced to improve patients’ experience of pain after colorectal resections.”

The researchers noted as a limitation of the study its reliance on patient-reported pain measures, and that it did not include data on patients’ pain history, opioid use prior to admission, or the administration of pre-emptive analgesia before surgery. The study was funded by the Michigan Surgical Quality Collaborative, which receives support from Blue Cross Blue Shield. None of the study authors declared conflicts of interest.

Post-surgical pain scores may be an overlooked quality indicator among hospitals, according to new research linking patient-reported pain scores with institutional pain management practices and also surgical outcomes.

A retrospective cohort study of patient-reported pain scores after colorectal resections at 52 Michigan hospitals, published in Annals of Surgery (2016 Jan 7; epub ahead of print; doi: 10.1097/SLA.0000000000001541), found that patients treated at the best-performing hospitals for postoperative pain scores were more likely to have received patient-controlled analgesia, compared with those in the worst-performing ones (56.5% vs. 22.8%; P less than .001).

For their research, Dr. Scott E. Regenbogen of the University of Michigan, Ann Arbor, and his colleagues looked at patient-reported pain scores on the first morning post-surgery for 7,221 colorectal operations between 2012 and 2014. The participating hospitals were part of a statewide collaborative that collects data on surgery patients with the aim of improving quality.

Dr. Regenbogen and his colleagues found that patients in the quartile of hospitals with the best pain scores stayed fewer days (6.5 vs. 7.9, P less than .007) and had fewer post-surgical complications (20.3% vs. 26.4%; P less than .001), compared with those in the worst-performing quartile of hospitals.

In addition, Dr. Regenbogen and his colleagues found postoperative emergency department visits, readmissions, and pulmonary complications to be significantly lower in the quartile of hospitals with the best pain scores. The fewer pulmonary complications seen linked with better pain control “could be an indicator of better pulmonary toilet or lesser respiratory depression,” they noted.

DiverDave/Wikicommons Creative Commons License

The correlation between surgical outcomes and pain scores, the investigators wrote, suggests “consistency in the overall quality performance across both clinical and patient-reported outcomes for colectomy.”

Mean self-rated pain scores, in which patients characterize the intensity of their pain on a scale of 0 to 10, ranged from 4 to 6 across the hospitals in the study, with 5.1 (standard deviation 2.44) reported for the cohort as a whole. The type of surgery also affected pain scores, with minimally invasive procedures associated with lower scores, compared with open or converted procedures. The type of anesthesia used (local or epidural) also significantly affected scores.

Hospitals with better pain scores tended to be somewhat larger than those with poor scores, and performed more colorectal resections per year, the investigators found.

The researchers noted that while a previous meta-analysis showed that patient-controlled analgesia post-surgery provided superior pain control, compared with intermittent treatment (Cochrane Database Syst Rev. 2006 Oct 18;18:CD003348), the hospitals in this study varied widely in their approaches, with 89% of the poorly performing quartile of hospitals using intermittent parenteral narcotics, compared with 66% in the best-performing quartile.

Dr. Regenbogen and his colleagues noted in their analysis that it was possible that the association between pain control and clinical outcomes such as readmissions and complications was driven by case or patient complexity differences among institutions. The 52 hospitals in the study varied in size and type, with community and academic hospitals as well as rural and urban institutions represented.

However, they wrote, it is more likely that “both pain scores and clinical outcomes reflect … global features of the quality of care in hospitals’ surgical performance. Thus, hospitals with the most streamlined, high-quality perioperative care pathways experience the best pain scores, as well as improved clinical outcomes.”

The findings, they concluded, “reveal systematic clinical care variation that could be reduced to improve patients’ experience of pain after colorectal resections.”

The researchers noted as a limitation of the study its reliance on patient-reported pain measures, and that it did not include data on patients’ pain history, opioid use prior to admission, or the administration of pre-emptive analgesia before surgery. The study was funded by the Michigan Surgical Quality Collaborative, which receives support from Blue Cross Blue Shield. None of the study authors declared conflicts of interest.

A mood disorder is a chronic illness, associated with episodic recurrence over time^1,2; when a patient experiences a new mood episode, explore possible underlying causes of that recurrence. The mnemonic RELAPSE can help you take an informed approach to treatment, instead of making reflexive medication changes (Table).

Rhythm disturbances. Seasonal changes, shift work, jet lag, and sleep irregularity can induce a mood episode in a vulnerable patient. Failure of a patient’s circadian clock to resynchronize itself after such disruption in the dark–light cycle can trigger mood symptoms.

Ending treatment. Intentional or unintentional non-adherence to a prescribed medication or psychotherapy can trigger a mood episode. Likewise, switching from a brand-name medication to a generic equivalent can induce a new episode because the generic drug might be as much as 20% less bioavailable than the brand formulation.³

Life change. Some life events, such as divorce or job loss, can be sufficiently overwhelming—despite medical therapy and psychotherapy—to induce a new episode in a vulnerable patient.

Additional drugs. Opiates, interferon, steroids, reserpine, and other drugs can be depressogenic; on the other hand, steroids, anticholinergic agents, and antidepressants can induce mania. If another physician, or the patient, adds a medication or supplement that causes an interaction with the patient’s current psychotropic prescription, the result might be increased metabolism or clearance of the psychotropic—thus decreasing its efficacy and leading to a new mood episode.

Physical health changes. Neurologic conditions (epilepsy, multiple sclerosis, stroke), autoimmune illnesses (eg, lupus), primary sleep disorders (eg, obstructive sleep apnea), and hormone changes (eg, testosterone, estrogen, and thyroid) that can occur over the lifespan of a patient with a mood disorder can trigger a new episode.

Substance use and withdrawal. Chronic use of alcohol and opiates and withdrawal from cocaine and stimulants in a patient with a mood disorder can induce a depressive episode; use of cocaine, stimulants, and caffeine can induce a manic state.

End of drug response. Some patients experience a loss of drug response over time (tachyphylaxis) or a depressive recurrence while taking an antidepressant.⁴ These phenomena might be caused by brain changes over time. These are a diagnosis of exclusion after other possibilities have been ruled out.

A mood disorder is a chronic illness, associated with episodic recurrence over time^1,2; when a patient experiences a new mood episode, explore possible underlying causes of that recurrence. The mnemonic RELAPSE can help you take an informed approach to treatment, instead of making reflexive medication changes (Table).

Rhythm disturbances. Seasonal changes, shift work, jet lag, and sleep irregularity can induce a mood episode in a vulnerable patient. Failure of a patient’s circadian clock to resynchronize itself after such disruption in the dark–light cycle can trigger mood symptoms.

Ending treatment. Intentional or unintentional non-adherence to a prescribed medication or psychotherapy can trigger a mood episode. Likewise, switching from a brand-name medication to a generic equivalent can induce a new episode because the generic drug might be as much as 20% less bioavailable than the brand formulation.³

Life change. Some life events, such as divorce or job loss, can be sufficiently overwhelming—despite medical therapy and psychotherapy—to induce a new episode in a vulnerable patient.

Additional drugs. Opiates, interferon, steroids, reserpine, and other drugs can be depressogenic; on the other hand, steroids, anticholinergic agents, and antidepressants can induce mania. If another physician, or the patient, adds a medication or supplement that causes an interaction with the patient’s current psychotropic prescription, the result might be increased metabolism or clearance of the psychotropic—thus decreasing its efficacy and leading to a new mood episode.

Physical health changes. Neurologic conditions (epilepsy, multiple sclerosis, stroke), autoimmune illnesses (eg, lupus), primary sleep disorders (eg, obstructive sleep apnea), and hormone changes (eg, testosterone, estrogen, and thyroid) that can occur over the lifespan of a patient with a mood disorder can trigger a new episode.

Substance use and withdrawal. Chronic use of alcohol and opiates and withdrawal from cocaine and stimulants in a patient with a mood disorder can induce a depressive episode; use of cocaine, stimulants, and caffeine can induce a manic state.

End of drug response. Some patients experience a loss of drug response over time (tachyphylaxis) or a depressive recurrence while taking an antidepressant.⁴ These phenomena might be caused by brain changes over time. These are a diagnosis of exclusion after other possibilities have been ruled out.

A mood disorder is a chronic illness, associated with episodic recurrence over time^1,2; when a patient experiences a new mood episode, explore possible underlying causes of that recurrence. The mnemonic RELAPSE can help you take an informed approach to treatment, instead of making reflexive medication changes (Table).

Rhythm disturbances. Seasonal changes, shift work, jet lag, and sleep irregularity can induce a mood episode in a vulnerable patient. Failure of a patient’s circadian clock to resynchronize itself after such disruption in the dark–light cycle can trigger mood symptoms.

Ending treatment. Intentional or unintentional non-adherence to a prescribed medication or psychotherapy can trigger a mood episode. Likewise, switching from a brand-name medication to a generic equivalent can induce a new episode because the generic drug might be as much as 20% less bioavailable than the brand formulation.³

Life change. Some life events, such as divorce or job loss, can be sufficiently overwhelming—despite medical therapy and psychotherapy—to induce a new episode in a vulnerable patient.

Additional drugs. Opiates, interferon, steroids, reserpine, and other drugs can be depressogenic; on the other hand, steroids, anticholinergic agents, and antidepressants can induce mania. If another physician, or the patient, adds a medication or supplement that causes an interaction with the patient’s current psychotropic prescription, the result might be increased metabolism or clearance of the psychotropic—thus decreasing its efficacy and leading to a new mood episode.

Physical health changes. Neurologic conditions (epilepsy, multiple sclerosis, stroke), autoimmune illnesses (eg, lupus), primary sleep disorders (eg, obstructive sleep apnea), and hormone changes (eg, testosterone, estrogen, and thyroid) that can occur over the lifespan of a patient with a mood disorder can trigger a new episode.

Substance use and withdrawal. Chronic use of alcohol and opiates and withdrawal from cocaine and stimulants in a patient with a mood disorder can induce a depressive episode; use of cocaine, stimulants, and caffeine can induce a manic state.

End of drug response. Some patients experience a loss of drug response over time (tachyphylaxis) or a depressive recurrence while taking an antidepressant.⁴ These phenomena might be caused by brain changes over time. These are a diagnosis of exclusion after other possibilities have been ruled out.

A crescendo of paranoid fear sharply increases the likelihood that a person will kill his (her) misperceived persecutor. Persecutory delusions are more likely to lead to homicide than any other psychiatric symptom.1 If people define a delusional situation as real, the situation is real in its consequences.

Based on my experience performing more than 100 insanity evaluations of paranoid persons charged with murder, I have identified 4 paranoid motives for homicide.

Self-defense. The most common paranoid motive for murder is the misperceived need to defend one’s self.

A steel worker believed that there was a conspiracy to kill him. His wife insisted that he go to a hospital emergency room for an evaluation. He then concluded that his wife was in on the conspiracy and stabbed her to death.

Defense of one’s manhood. Homosexual panic occurs in men who think of themselves as heterosexual.

A man with paranoid schizophrenia developed a delusion that his former high school football coach was having the entire team rape him at night. He shot the coach 6 times in front of 22 witnesses.

Defense of one’s children. A parent may kill to save her (his) children’s souls.

A deeply religious woman developed persecutory delusions that her 9-year-old son and 3-year-old daughter were going to be kidnapped and forced to make child pornography. To save her children’s souls, she stabbed her children more than 100 times.

Defense of the world. Homicide may be seen as a way to protect all humankind.

A woman developed a delusion that her father was Satan and would kill her. She believed that if she could kill her father (Satan) and his family she would save herself and bring about world peace. After killing her father, she thrust the sharp end of a tire iron into her grandmother’s umbilicus and vagina because those body parts were involved in “birthing Satan.”

Questioning to determine risk
I have found that, when evaluating a paranoid, delusional person for potential violence, it is better to present that person with a hypothetical question about encountering his perceived persecutor than with a generic question about homicidality.² For example, a delusional person who reports that he was afraid of being killed by the Mafia could be asked, “If you were walking down an alley and encountered a man dressed like a Mafia hit man with a bulge in his jacket, what would you do?” One interviewee might reply, “The Mafia has so much power there is nothing I could do.” Another might answer, “As soon as I got close enough I would blow his head off with my .357 Magnum.” Although both people would be reporting honestly that they have no homicidal ideas, the latter has a much lower threshold for killing in misperceived self-defense.

Summing up
Persecutory delusions are more likely than any other psychiatric symptom to lead a psychotic person to commit homicide. The killing might be motivated by misperceived self-defense, defense of one’s manhood, defense of one’s children, or defense of the world.

A crescendo of paranoid fear sharply increases the likelihood that a person will kill his (her) misperceived persecutor. Persecutory delusions are more likely to lead to homicide than any other psychiatric symptom.1 If people define a delusional situation as real, the situation is real in its consequences.

Based on my experience performing more than 100 insanity evaluations of paranoid persons charged with murder, I have identified 4 paranoid motives for homicide.

Self-defense. The most common paranoid motive for murder is the misperceived need to defend one’s self.

A steel worker believed that there was a conspiracy to kill him. His wife insisted that he go to a hospital emergency room for an evaluation. He then concluded that his wife was in on the conspiracy and stabbed her to death.

Defense of one’s manhood. Homosexual panic occurs in men who think of themselves as heterosexual.

A man with paranoid schizophrenia developed a delusion that his former high school football coach was having the entire team rape him at night. He shot the coach 6 times in front of 22 witnesses.

Defense of one’s children. A parent may kill to save her (his) children’s souls.

A deeply religious woman developed persecutory delusions that her 9-year-old son and 3-year-old daughter were going to be kidnapped and forced to make child pornography. To save her children’s souls, she stabbed her children more than 100 times.

Defense of the world. Homicide may be seen as a way to protect all humankind.

A woman developed a delusion that her father was Satan and would kill her. She believed that if she could kill her father (Satan) and his family she would save herself and bring about world peace. After killing her father, she thrust the sharp end of a tire iron into her grandmother’s umbilicus and vagina because those body parts were involved in “birthing Satan.”

Questioning to determine risk
I have found that, when evaluating a paranoid, delusional person for potential violence, it is better to present that person with a hypothetical question about encountering his perceived persecutor than with a generic question about homicidality.² For example, a delusional person who reports that he was afraid of being killed by the Mafia could be asked, “If you were walking down an alley and encountered a man dressed like a Mafia hit man with a bulge in his jacket, what would you do?” One interviewee might reply, “The Mafia has so much power there is nothing I could do.” Another might answer, “As soon as I got close enough I would blow his head off with my .357 Magnum.” Although both people would be reporting honestly that they have no homicidal ideas, the latter has a much lower threshold for killing in misperceived self-defense.

Summing up
Persecutory delusions are more likely than any other psychiatric symptom to lead a psychotic person to commit homicide. The killing might be motivated by misperceived self-defense, defense of one’s manhood, defense of one’s children, or defense of the world.

A crescendo of paranoid fear sharply increases the likelihood that a person will kill his (her) misperceived persecutor. Persecutory delusions are more likely to lead to homicide than any other psychiatric symptom.1 If people define a delusional situation as real, the situation is real in its consequences.

Based on my experience performing more than 100 insanity evaluations of paranoid persons charged with murder, I have identified 4 paranoid motives for homicide.

Self-defense. The most common paranoid motive for murder is the misperceived need to defend one’s self.

A steel worker believed that there was a conspiracy to kill him. His wife insisted that he go to a hospital emergency room for an evaluation. He then concluded that his wife was in on the conspiracy and stabbed her to death.

Defense of one’s manhood. Homosexual panic occurs in men who think of themselves as heterosexual.

A man with paranoid schizophrenia developed a delusion that his former high school football coach was having the entire team rape him at night. He shot the coach 6 times in front of 22 witnesses.

Defense of one’s children. A parent may kill to save her (his) children’s souls.

A deeply religious woman developed persecutory delusions that her 9-year-old son and 3-year-old daughter were going to be kidnapped and forced to make child pornography. To save her children’s souls, she stabbed her children more than 100 times.

Defense of the world. Homicide may be seen as a way to protect all humankind.

A woman developed a delusion that her father was Satan and would kill her. She believed that if she could kill her father (Satan) and his family she would save herself and bring about world peace. After killing her father, she thrust the sharp end of a tire iron into her grandmother’s umbilicus and vagina because those body parts were involved in “birthing Satan.”

Questioning to determine risk
I have found that, when evaluating a paranoid, delusional person for potential violence, it is better to present that person with a hypothetical question about encountering his perceived persecutor than with a generic question about homicidality.² For example, a delusional person who reports that he was afraid of being killed by the Mafia could be asked, “If you were walking down an alley and encountered a man dressed like a Mafia hit man with a bulge in his jacket, what would you do?” One interviewee might reply, “The Mafia has so much power there is nothing I could do.” Another might answer, “As soon as I got close enough I would blow his head off with my .357 Magnum.” Although both people would be reporting honestly that they have no homicidal ideas, the latter has a much lower threshold for killing in misperceived self-defense.

Summing up
Persecutory delusions are more likely than any other psychiatric symptom to lead a psychotic person to commit homicide. The killing might be motivated by misperceived self-defense, defense of one’s manhood, defense of one’s children, or defense of the world.

CASE Inconsistent stories
Ms. P, age 56, is an Asian American woman who was brought in by police after being found standing by her car in the middle of a busy road displaying bizarre behavior. She provides an inconsistent story about why she was brought to the hospital, saying that the police did so because she wasn’t driving fast enough and because her English is weak. At another point, she says that she had stopped her car to pick up a penny from the road and the police brought her to the hospital “to experience life, to rest, to meet people.”

Upon further questioning, Ms. P reveals that she is experiencing racing thoughts, feels full of energy, has pressured speech, and does not need much sleep. She also is sexually preoccupied, talks about having extra-marital affairs, and expresses her infatuation with TV news anchors. She says she is sexually active but is unable to offer any further details, and—while giggling—asks the treatment team not to reveal this information to her husband. Ms. P also reports hearing angels singing from the sky.

Chart review reveals that Ms. P had been admitted to same hospital 5 years earlier, at which time she was given diagnoses of late-onset schizophrenia (LOS) and mild cognitive impairment. Ms. P also had 3 psychiatric inpatient admissions in the past 2 years at a different hospital, but her records are inaccessible because she refuses to allow her chart to be released.

Ms. P has not taken the psychiatric medications prescribed for her for several months; she says, “I don’t need medication. I am self-healing.” She denies using illicit substances, including marijuana, smoking, and current alcohol use, but reports occasional social drinking in the past. Her urine drug screen is negative.

The most striking revelation in Ms. P’s social history is her high premorbid functional status. She has 2 master’s degrees and had been working as a senior accountant at a major hospital system until 7 years ago. In contrast, when interviewed at the hospital, Ms. P reports that she is working at a child care center.

On mental status exam, Ms. P is half-draped in a hospital gown, casual, overly friendly, smiling, and twirling her hair. Her mood is elevated with inappropriate affect. Her thought process is bizarre and illogical. She is alert, fully oriented, and her sensorium is clear. She has persistent ambivalence and contradictory thoughts regarding suicidal ideation. Recent and remote memory are largely intact. She does not express homicidal ideation.

What could be causing Ms. P’s psychosis and functional decline?
   a) major neurocognitive disorder
   b) schizophrenia
   c) schizoaffective disorder
   d) bipolar disorder, current manic episode

HISTORY Fired from her job
According to Ms. P’s chart from her admission 5 years earlier, police brought her to the hospital because she was causing a disturbance at a restaurant. When interviewed, Ms. P reported a false story that she fought with her husband, kicked him, and spat on his face. She said that her husband then punched her in the face, she ran out of the house, and a bystander called the police. At the time, her husband was contacted and denied the incident. He said that Ms. P had gone to the store and not returned, and he did not know what happened to her.

Her husband reported a steady and progressive decline in function and behavior dating back to 8 years ago with no known prior behavioral disturbances. In the chart from 5 years ago, her husband reported that Ms. P had been a high-functioning senior executive accountant at a major hospital system 7 years before the current admission, at which time she was fired from her job. He said that, just before being fired, Ms. P had been reading the mystery novel The Da Vinci Code and believed that events in the book specifically applied to her. Ms. P would stay up all night making clothes; when she would go to work, she was caught sleeping on the job and performing poorly, including submitting reports with incorrect information. She yelled at co-workers and was unable to take direction from her supervisors.

Ms. P’s husband also reported that she believed people were trying to “look like her,” by having plastic surgery. He reported unusual behavior at home, including eating food off the countertop that had been out for hours and was not fit for consumption.

Ms. P’s husband could not be contacted during this admission because he was out of country and they were separated. Collateral information is obtained from Ms. P’s mother, who lives apart from her but in the same city and speaks no English. She confirms Ms. P’s high premorbid functioning, and reports that her daughter’s change in behavior went back as far as 10 years. She reports that Ms. P had problems controlling anger and had frequent altercations with her husband and mother, including threatening her with a knife. Self-care and hygiene then declined strikingly. She began to have odd religious beliefs (eg, she was the daughter of Jesus Christ) and insisted on dressing in peculiar ways.

No family history of psychiatric disorders, such as schizophrenia, bipolar disorder, or dementia, was reported (Table 1).

The authors’ observations
The existence of LOS as a distinct subtype of schizophrenia has been the subject of discussion and controversy as far back as Manfred Bleuler in 1943 who coined the term “late-onset schizophrenia.”¹ In 2000, a consensus statement by the International Late-Onset Schizophrenia Group standardized the nomenclature, defining LOS as onset between age 40 and 60, and very-late-onset schizophrenia-like psychosis (VLOS) as onset after age 60.² Although there is no diagnostic subcategory for LOS in DSM, DSM-5 notes that (1) women are overrepresented in late-onset cases and (2) the course generally is characterized by a predominance of psychotic symptoms with preservation of affect and social functioning.³ DSM authors comment that it is not yet clear whether LOS is the same condition as schizophrenia diagnosed earlier in life. Approximately 23% of schizophrenia cases have onset after age 40.⁴

Cognitive symptoms in LOS
The presence of cognitive deficits in schizophrenia is common and well-recognized. The intellectual impairment is generalized and global, and there also is specific impairment in a range of cognitive functions, such as executive functions, memory, psycho­motor speed, attention, and social cognition.⁵ Typically these cognitive impairments are present before onset of psychotic symptoms. Although cognitive symptoms are not part of the formal diagnostic criteria, DSM-5 acknowledges their presence.³ In a systematic review on nature and course of cognitive function in LOS, Rajji and Mulsant⁶ report that global deficits and specific deficits in executive functions, visuospatial constructional abilities, verbal fluency, and psychomotor speech have been found consistently in studies of LOS, although the presence of deficits in memory, attention, and working memory has been less consistent.

The presence of cognitive symptoms in LOS is less well-studied and understood (Table 2). The International Consensus Statement reported that no difference in type of cognitive deficit has been found in early–onset cases (onset before age 40) compared with late-onset cases, although LOS is associated with relatively milder cognitive deficits. Additionally, premorbid educational, occupational, and psychosocial functioning are less impaired in LOS than they are in early-onset schizophrenia.²

Rajji et al⁷ performed a meta-analysis comparison of patients with youth-onset schizophrenia, adults with first-episode schizophrenia, and those with LOS on their cognitive profiles. They reported that patients with youth-onset schizophrenia have globally severe cognitive deficits, whereas those with LOS demonstrate minimal deficits on arithmetic, digit symbol coding, and vocabulary but larger deficits on attention, fluency, global cognition, IQ, and visuospatial construction.⁷

There are conflicting views in the literature with regards to the course of cognitive deficits in schizophrenia. One group of researchers believes that there is progressive deterioration in cognitive functioning over time, while another maintains that cognitive impairment in schizophrenia is largely “a static encephalopathy” with no significant progression of symptoms.⁸ A number of studies referenced by Rajji and Mulsant⁶ in their systematic review report that cognitive deficits seen in patients with LOS largely are stable on follow-up with an average duration of up to 3 years. However, 2 studies with longer follow-up report evidence of cognitive decline.^9,10

Relevant findings from the literature. Brodaty et al⁹ followed 27 patients with LOS without dementia and 34 otherwise healthy participants at baseline, 1 year, and 5 years. They reported that 9 patients with LOS and none of the control group were found to have dementia (5 Alzheimer type, 1 vascular, and 3 dementia of unknown type) at 5-year follow-up. Some patients had no clinical signs of dementia at baseline or at 1-year follow-up, but were found to have dementia at 5-year follow-up. The authors speculated that LOS might be a prodrome of Alzheimer-type dementia.

Kørner et al¹⁰ studied 12,600 patients with LOS and 7,700 with VLOS, selected from the Danish nationwide registry; follow-up was 3 to 4.58 years. They concluded that patients with LOS and VLOS were at 2 to 3 times greater risk of developing dementia than patients with osteoarthritis or the general population. The most common diagnosis among patients with schizophrenia was unspecified dementia, with Alzheimer’s dementia (AD) being the most common diagnosis in control groups. The findings suggest that dementia in LOS and VLOS has a different basis than AD.

Zakzanis et al¹¹ investigated which neuropsychological tests best differentiate patients with LOS and those with AD or frontotemporal dementia. They reported that Wechsler Adult Intelligence Scale-Revised (WAIS-R) Similarities subtest and the California Verbal Learning Test (both short- and long-delay free recall) can differentiate LOS from AD, and a test battery comprising the WAIS-R Vocabulary, Information, Digit Span, and Comprehension subtests, and the Hooper Visual Organization test can differentiate LOS and frontotemporal dementia.¹²

EVALUATION Significant impairment
CT head and MRI brain scans without contrast suggest mild generalized atrophy that is more prominent in frontal and parietal areas, but the scans are otherwise unremarkable overall. A PET scan is significant for hypoactivity in the temporal and parietal lobes but, again, the images are interpreted as unremarkable overall.

Ms. P scores 21 on the Montreal Cognitive Assessment (MoCA), indicative of significant cognitive impairment (normal score, ≥26). This is a 3-point decline on a MoCA performed during her admission 5 years earlier.

Ms. P scores 8 on the Middlesex Elderly Assessment of Mental State, the lowest score in the borderline range of cognitive function for geriatric patients. She scores 13 on the Kohlman Evaluation of Living Skills, indicating that she needs maximal supervision, structure, and support to live in the community. Particularly notable is that Ms. P failed 5 out of 6 subtests in money management—a marked decline for someone who had worked as a senior accountant.

Given Ms. P’s significant cognitive decline from premorbid functioning, verified by collateral information, and current cognitive deficits established on standardized tests, we determine that, in addition to a diagnosis of schizoaffective disorder, she might meet DSM-5 criteria for unspecified major neurocognitive disorder if her functioning does not improve with treatment.

The authors’ observations
There is scant literature on late-onset schizoaffective disorder. Webster and Grossberg¹³ conducted a retrospective chart review of 1,730 patients age >65 who were admitted to a geriatric psychiatry unit from 1988 to 1995. Of these patients, 166 (approximately 10%) were found to have late life-onset psychosis. The psychosis was attributed to various causes, such as dementia, depression, bipolar disorder, medical causes, delirium, medication toxicity. Two patients were diagnosed with schizophrenia and 2 were diagnosed with schizoaffective disorder (the authors did not provide additional information about the patients with schizoaffective disorder). Brenner et al¹⁴ reports a case of late-onset schizoaffective disorder in a 70-year-old female patient. Evans et al¹⁵ compared outpatients age 45 to 77 with a diagnosis of schizoaffective disorder (n = 29), schizophrenia (n = 154), or nonpsychotic mood disorder (n = 27) and concluded that late-onset schizoaffective disorder might represent a variant of LOS in clinical symptom profiles and cognitive impairment but with additional mood symptoms.¹⁶

How would you begin treating Ms. P?
   a) start a mood stabilizer
   b) start an atypical antipsychotic
   c) obtain more history and collateral information
   d) recommend outpatient treatment

The authors’ observations
Given Ms. P’s manic symptoms, thought disorder, and history of psychotic symptoms with diagnosis of LOS, we assigned her a presumptive diagnosis of schizoaffective disorder, bipolar type. From the patient report, collateral information from her mother, earlier documented collateral from her husband, and chart review, it was apparent to us that Ms. P’s psychiatric history went back only 10 years—therefore meeting temporal criteria for LOS.

Clinical assessment (Figure) and standardized tests revealed the presence of neurocognitive deficits sufficient to meet criteria for major neurocognitive disorder (Table 3³). The pattern of neurocognitive deficits is consistent with an AD-like amnestic picture, although no clear-cut diagnosis was present, and the neurocognitive disorder was better classified as unspecified rather than of a particular type. It remains uncertain whether cognitive deficits of severity that meet criteria for major neurocognitive disorder are sufficiently accounted for by the diagnosis of LOS alone. Unless diagnostic criteria for schizophrenia are expanded to include cognitive deficits, a separate diagnosis of major neurocognitive disorder is warranted at present.

TREATMENT Pharmacotherapy
On the unit, Ms. P is observed by nursing staff wandering, with some pressured speech but no behavioral agitation. Her clothing had been bizarre, with multiple layers, and, at one point, she walks with her gown open and without undergarments. She also reports to the nurses that she has a lot of sexual thoughts. When the interview team enters her room, they find her masturbating.

Ms. P is started on aripiprazole, 10 mg/d, titrated to 20 mg/d, and divalproex sodium, 500 mg/d. The decision to initiate a cognitive enhancer, such as an acetylcholinesterase inhibitor or memantine, is deferred to outpatient care to allow for the possibility that her cognitive features will improve after the psychosis is treated.

By the end of first week, Ms. P’s manic features are no longer prominent but her thought process continues to be bizarre, with poor insight and judgment. She demonstrates severe ambivalence in all matters, consistently gives inconsistent accounts of the past, and makes dramatic false statements.

For example, when asked about her children, Ms. P tells us that she has 6 children—the youngest 3 months old, at home by himself and “probably dead by now.” In reality, she has only a 20-year-old son who is studying abroad. Talking about her marriage, Ms. P says she and her husband are not divorced on paper but that, because they haven’t had sex for 8 years, the law has provided them with an automatic divorce.

OUTCOME Significant improvement
Ms. P shows significant response to aripiprazole and divalproex, which are well tolerated without significant adverse effects. Her limitations in executive functioning and rational thought process lead the treatment team to consider nursing home placement under guardianship. Days before discharge, however, reexamination of her neuropsychiatric state suggests significant improvement in thought process, with improvement in cognitive features. Ms. P also becomes cooperative with treatment planning.

The treatment team has meetings with Ms. P’s mother to discuss monitoring and plans for discharge. Ms. P is discharged with follow-up arranged at community mental health services.

Bottom Line
Global as well as specific cognitive deficits are associated with late-onset schizophrenia. Studies have reported increased risk of dementia in these patients over the course of 3 to 5 years, usually unspecified or Alzheimer’s type. It is imperative to assess patients with schizophrenia, especially those age ≥40, for presence of neurocognitive disorder by means of neurocognitive testing.

Related Resources

• Goff DC, Hill M, Barch D. The treatment of cognitive impairment in schizophrenia. Pharmacol Biochem Behav. 2011;99(2):245-253.
• Radhakrishnan R, Butler R, Head L. Dementia in schizophrenia. Adv Psychiatr Treat. 2012;18(2):144-153.
  
  

Drug Brand Names
Aripiprazole • Abilify
Divalproex sodium • Depakote
Mematine • Namenda

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturer of competing products.

CASE Inconsistent stories
Ms. P, age 56, is an Asian American woman who was brought in by police after being found standing by her car in the middle of a busy road displaying bizarre behavior. She provides an inconsistent story about why she was brought to the hospital, saying that the police did so because she wasn’t driving fast enough and because her English is weak. At another point, she says that she had stopped her car to pick up a penny from the road and the police brought her to the hospital “to experience life, to rest, to meet people.”

Upon further questioning, Ms. P reveals that she is experiencing racing thoughts, feels full of energy, has pressured speech, and does not need much sleep. She also is sexually preoccupied, talks about having extra-marital affairs, and expresses her infatuation with TV news anchors. She says she is sexually active but is unable to offer any further details, and—while giggling—asks the treatment team not to reveal this information to her husband. Ms. P also reports hearing angels singing from the sky.

Chart review reveals that Ms. P had been admitted to same hospital 5 years earlier, at which time she was given diagnoses of late-onset schizophrenia (LOS) and mild cognitive impairment. Ms. P also had 3 psychiatric inpatient admissions in the past 2 years at a different hospital, but her records are inaccessible because she refuses to allow her chart to be released.

Ms. P has not taken the psychiatric medications prescribed for her for several months; she says, “I don’t need medication. I am self-healing.” She denies using illicit substances, including marijuana, smoking, and current alcohol use, but reports occasional social drinking in the past. Her urine drug screen is negative.

The most striking revelation in Ms. P’s social history is her high premorbid functional status. She has 2 master’s degrees and had been working as a senior accountant at a major hospital system until 7 years ago. In contrast, when interviewed at the hospital, Ms. P reports that she is working at a child care center.

On mental status exam, Ms. P is half-draped in a hospital gown, casual, overly friendly, smiling, and twirling her hair. Her mood is elevated with inappropriate affect. Her thought process is bizarre and illogical. She is alert, fully oriented, and her sensorium is clear. She has persistent ambivalence and contradictory thoughts regarding suicidal ideation. Recent and remote memory are largely intact. She does not express homicidal ideation.

What could be causing Ms. P’s psychosis and functional decline?
   a) major neurocognitive disorder
   b) schizophrenia
   c) schizoaffective disorder
   d) bipolar disorder, current manic episode

HISTORY Fired from her job
According to Ms. P’s chart from her admission 5 years earlier, police brought her to the hospital because she was causing a disturbance at a restaurant. When interviewed, Ms. P reported a false story that she fought with her husband, kicked him, and spat on his face. She said that her husband then punched her in the face, she ran out of the house, and a bystander called the police. At the time, her husband was contacted and denied the incident. He said that Ms. P had gone to the store and not returned, and he did not know what happened to her.

Her husband reported a steady and progressive decline in function and behavior dating back to 8 years ago with no known prior behavioral disturbances. In the chart from 5 years ago, her husband reported that Ms. P had been a high-functioning senior executive accountant at a major hospital system 7 years before the current admission, at which time she was fired from her job. He said that, just before being fired, Ms. P had been reading the mystery novel The Da Vinci Code and believed that events in the book specifically applied to her. Ms. P would stay up all night making clothes; when she would go to work, she was caught sleeping on the job and performing poorly, including submitting reports with incorrect information. She yelled at co-workers and was unable to take direction from her supervisors.

Ms. P’s husband also reported that she believed people were trying to “look like her,” by having plastic surgery. He reported unusual behavior at home, including eating food off the countertop that had been out for hours and was not fit for consumption.

Ms. P’s husband could not be contacted during this admission because he was out of country and they were separated. Collateral information is obtained from Ms. P’s mother, who lives apart from her but in the same city and speaks no English. She confirms Ms. P’s high premorbid functioning, and reports that her daughter’s change in behavior went back as far as 10 years. She reports that Ms. P had problems controlling anger and had frequent altercations with her husband and mother, including threatening her with a knife. Self-care and hygiene then declined strikingly. She began to have odd religious beliefs (eg, she was the daughter of Jesus Christ) and insisted on dressing in peculiar ways.

No family history of psychiatric disorders, such as schizophrenia, bipolar disorder, or dementia, was reported (Table 1).

The authors’ observations
The existence of LOS as a distinct subtype of schizophrenia has been the subject of discussion and controversy as far back as Manfred Bleuler in 1943 who coined the term “late-onset schizophrenia.”¹ In 2000, a consensus statement by the International Late-Onset Schizophrenia Group standardized the nomenclature, defining LOS as onset between age 40 and 60, and very-late-onset schizophrenia-like psychosis (VLOS) as onset after age 60.² Although there is no diagnostic subcategory for LOS in DSM, DSM-5 notes that (1) women are overrepresented in late-onset cases and (2) the course generally is characterized by a predominance of psychotic symptoms with preservation of affect and social functioning.³ DSM authors comment that it is not yet clear whether LOS is the same condition as schizophrenia diagnosed earlier in life. Approximately 23% of schizophrenia cases have onset after age 40.⁴

Cognitive symptoms in LOS
The presence of cognitive deficits in schizophrenia is common and well-recognized. The intellectual impairment is generalized and global, and there also is specific impairment in a range of cognitive functions, such as executive functions, memory, psycho­motor speed, attention, and social cognition.⁵ Typically these cognitive impairments are present before onset of psychotic symptoms. Although cognitive symptoms are not part of the formal diagnostic criteria, DSM-5 acknowledges their presence.³ In a systematic review on nature and course of cognitive function in LOS, Rajji and Mulsant⁶ report that global deficits and specific deficits in executive functions, visuospatial constructional abilities, verbal fluency, and psychomotor speech have been found consistently in studies of LOS, although the presence of deficits in memory, attention, and working memory has been less consistent.

The presence of cognitive symptoms in LOS is less well-studied and understood (Table 2). The International Consensus Statement reported that no difference in type of cognitive deficit has been found in early–onset cases (onset before age 40) compared with late-onset cases, although LOS is associated with relatively milder cognitive deficits. Additionally, premorbid educational, occupational, and psychosocial functioning are less impaired in LOS than they are in early-onset schizophrenia.²

Rajji et al⁷ performed a meta-analysis comparison of patients with youth-onset schizophrenia, adults with first-episode schizophrenia, and those with LOS on their cognitive profiles. They reported that patients with youth-onset schizophrenia have globally severe cognitive deficits, whereas those with LOS demonstrate minimal deficits on arithmetic, digit symbol coding, and vocabulary but larger deficits on attention, fluency, global cognition, IQ, and visuospatial construction.⁷

There are conflicting views in the literature with regards to the course of cognitive deficits in schizophrenia. One group of researchers believes that there is progressive deterioration in cognitive functioning over time, while another maintains that cognitive impairment in schizophrenia is largely “a static encephalopathy” with no significant progression of symptoms.⁸ A number of studies referenced by Rajji and Mulsant⁶ in their systematic review report that cognitive deficits seen in patients with LOS largely are stable on follow-up with an average duration of up to 3 years. However, 2 studies with longer follow-up report evidence of cognitive decline.^9,10

Relevant findings from the literature. Brodaty et al⁹ followed 27 patients with LOS without dementia and 34 otherwise healthy participants at baseline, 1 year, and 5 years. They reported that 9 patients with LOS and none of the control group were found to have dementia (5 Alzheimer type, 1 vascular, and 3 dementia of unknown type) at 5-year follow-up. Some patients had no clinical signs of dementia at baseline or at 1-year follow-up, but were found to have dementia at 5-year follow-up. The authors speculated that LOS might be a prodrome of Alzheimer-type dementia.

Kørner et al¹⁰ studied 12,600 patients with LOS and 7,700 with VLOS, selected from the Danish nationwide registry; follow-up was 3 to 4.58 years. They concluded that patients with LOS and VLOS were at 2 to 3 times greater risk of developing dementia than patients with osteoarthritis or the general population. The most common diagnosis among patients with schizophrenia was unspecified dementia, with Alzheimer’s dementia (AD) being the most common diagnosis in control groups. The findings suggest that dementia in LOS and VLOS has a different basis than AD.

Zakzanis et al¹¹ investigated which neuropsychological tests best differentiate patients with LOS and those with AD or frontotemporal dementia. They reported that Wechsler Adult Intelligence Scale-Revised (WAIS-R) Similarities subtest and the California Verbal Learning Test (both short- and long-delay free recall) can differentiate LOS from AD, and a test battery comprising the WAIS-R Vocabulary, Information, Digit Span, and Comprehension subtests, and the Hooper Visual Organization test can differentiate LOS and frontotemporal dementia.¹²

EVALUATION Significant impairment
CT head and MRI brain scans without contrast suggest mild generalized atrophy that is more prominent in frontal and parietal areas, but the scans are otherwise unremarkable overall. A PET scan is significant for hypoactivity in the temporal and parietal lobes but, again, the images are interpreted as unremarkable overall.

Ms. P scores 21 on the Montreal Cognitive Assessment (MoCA), indicative of significant cognitive impairment (normal score, ≥26). This is a 3-point decline on a MoCA performed during her admission 5 years earlier.

Ms. P scores 8 on the Middlesex Elderly Assessment of Mental State, the lowest score in the borderline range of cognitive function for geriatric patients. She scores 13 on the Kohlman Evaluation of Living Skills, indicating that she needs maximal supervision, structure, and support to live in the community. Particularly notable is that Ms. P failed 5 out of 6 subtests in money management—a marked decline for someone who had worked as a senior accountant.

Given Ms. P’s significant cognitive decline from premorbid functioning, verified by collateral information, and current cognitive deficits established on standardized tests, we determine that, in addition to a diagnosis of schizoaffective disorder, she might meet DSM-5 criteria for unspecified major neurocognitive disorder if her functioning does not improve with treatment.

The authors’ observations
There is scant literature on late-onset schizoaffective disorder. Webster and Grossberg¹³ conducted a retrospective chart review of 1,730 patients age >65 who were admitted to a geriatric psychiatry unit from 1988 to 1995. Of these patients, 166 (approximately 10%) were found to have late life-onset psychosis. The psychosis was attributed to various causes, such as dementia, depression, bipolar disorder, medical causes, delirium, medication toxicity. Two patients were diagnosed with schizophrenia and 2 were diagnosed with schizoaffective disorder (the authors did not provide additional information about the patients with schizoaffective disorder). Brenner et al¹⁴ reports a case of late-onset schizoaffective disorder in a 70-year-old female patient. Evans et al¹⁵ compared outpatients age 45 to 77 with a diagnosis of schizoaffective disorder (n = 29), schizophrenia (n = 154), or nonpsychotic mood disorder (n = 27) and concluded that late-onset schizoaffective disorder might represent a variant of LOS in clinical symptom profiles and cognitive impairment but with additional mood symptoms.¹⁶

How would you begin treating Ms. P?
   a) start a mood stabilizer
   b) start an atypical antipsychotic
   c) obtain more history and collateral information
   d) recommend outpatient treatment

The authors’ observations
Given Ms. P’s manic symptoms, thought disorder, and history of psychotic symptoms with diagnosis of LOS, we assigned her a presumptive diagnosis of schizoaffective disorder, bipolar type. From the patient report, collateral information from her mother, earlier documented collateral from her husband, and chart review, it was apparent to us that Ms. P’s psychiatric history went back only 10 years—therefore meeting temporal criteria for LOS.

Clinical assessment (Figure) and standardized tests revealed the presence of neurocognitive deficits sufficient to meet criteria for major neurocognitive disorder (Table 3³). The pattern of neurocognitive deficits is consistent with an AD-like amnestic picture, although no clear-cut diagnosis was present, and the neurocognitive disorder was better classified as unspecified rather than of a particular type. It remains uncertain whether cognitive deficits of severity that meet criteria for major neurocognitive disorder are sufficiently accounted for by the diagnosis of LOS alone. Unless diagnostic criteria for schizophrenia are expanded to include cognitive deficits, a separate diagnosis of major neurocognitive disorder is warranted at present.

TREATMENT Pharmacotherapy
On the unit, Ms. P is observed by nursing staff wandering, with some pressured speech but no behavioral agitation. Her clothing had been bizarre, with multiple layers, and, at one point, she walks with her gown open and without undergarments. She also reports to the nurses that she has a lot of sexual thoughts. When the interview team enters her room, they find her masturbating.

Ms. P is started on aripiprazole, 10 mg/d, titrated to 20 mg/d, and divalproex sodium, 500 mg/d. The decision to initiate a cognitive enhancer, such as an acetylcholinesterase inhibitor or memantine, is deferred to outpatient care to allow for the possibility that her cognitive features will improve after the psychosis is treated.

By the end of first week, Ms. P’s manic features are no longer prominent but her thought process continues to be bizarre, with poor insight and judgment. She demonstrates severe ambivalence in all matters, consistently gives inconsistent accounts of the past, and makes dramatic false statements.

For example, when asked about her children, Ms. P tells us that she has 6 children—the youngest 3 months old, at home by himself and “probably dead by now.” In reality, she has only a 20-year-old son who is studying abroad. Talking about her marriage, Ms. P says she and her husband are not divorced on paper but that, because they haven’t had sex for 8 years, the law has provided them with an automatic divorce.

OUTCOME Significant improvement
Ms. P shows significant response to aripiprazole and divalproex, which are well tolerated without significant adverse effects. Her limitations in executive functioning and rational thought process lead the treatment team to consider nursing home placement under guardianship. Days before discharge, however, reexamination of her neuropsychiatric state suggests significant improvement in thought process, with improvement in cognitive features. Ms. P also becomes cooperative with treatment planning.

The treatment team has meetings with Ms. P’s mother to discuss monitoring and plans for discharge. Ms. P is discharged with follow-up arranged at community mental health services.

Bottom Line
Global as well as specific cognitive deficits are associated with late-onset schizophrenia. Studies have reported increased risk of dementia in these patients over the course of 3 to 5 years, usually unspecified or Alzheimer’s type. It is imperative to assess patients with schizophrenia, especially those age ≥40, for presence of neurocognitive disorder by means of neurocognitive testing.

Related Resources

• Goff DC, Hill M, Barch D. The treatment of cognitive impairment in schizophrenia. Pharmacol Biochem Behav. 2011;99(2):245-253.
• Radhakrishnan R, Butler R, Head L. Dementia in schizophrenia. Adv Psychiatr Treat. 2012;18(2):144-153.
  
  

Drug Brand Names
Aripiprazole • Abilify
Divalproex sodium • Depakote
Mematine • Namenda

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturer of competing products.

CASE Inconsistent stories
Ms. P, age 56, is an Asian American woman who was brought in by police after being found standing by her car in the middle of a busy road displaying bizarre behavior. She provides an inconsistent story about why she was brought to the hospital, saying that the police did so because she wasn’t driving fast enough and because her English is weak. At another point, she says that she had stopped her car to pick up a penny from the road and the police brought her to the hospital “to experience life, to rest, to meet people.”

Upon further questioning, Ms. P reveals that she is experiencing racing thoughts, feels full of energy, has pressured speech, and does not need much sleep. She also is sexually preoccupied, talks about having extra-marital affairs, and expresses her infatuation with TV news anchors. She says she is sexually active but is unable to offer any further details, and—while giggling—asks the treatment team not to reveal this information to her husband. Ms. P also reports hearing angels singing from the sky.

Chart review reveals that Ms. P had been admitted to same hospital 5 years earlier, at which time she was given diagnoses of late-onset schizophrenia (LOS) and mild cognitive impairment. Ms. P also had 3 psychiatric inpatient admissions in the past 2 years at a different hospital, but her records are inaccessible because she refuses to allow her chart to be released.

Ms. P has not taken the psychiatric medications prescribed for her for several months; she says, “I don’t need medication. I am self-healing.” She denies using illicit substances, including marijuana, smoking, and current alcohol use, but reports occasional social drinking in the past. Her urine drug screen is negative.

The most striking revelation in Ms. P’s social history is her high premorbid functional status. She has 2 master’s degrees and had been working as a senior accountant at a major hospital system until 7 years ago. In contrast, when interviewed at the hospital, Ms. P reports that she is working at a child care center.

On mental status exam, Ms. P is half-draped in a hospital gown, casual, overly friendly, smiling, and twirling her hair. Her mood is elevated with inappropriate affect. Her thought process is bizarre and illogical. She is alert, fully oriented, and her sensorium is clear. She has persistent ambivalence and contradictory thoughts regarding suicidal ideation. Recent and remote memory are largely intact. She does not express homicidal ideation.

What could be causing Ms. P’s psychosis and functional decline?
   a) major neurocognitive disorder
   b) schizophrenia
   c) schizoaffective disorder
   d) bipolar disorder, current manic episode

HISTORY Fired from her job
According to Ms. P’s chart from her admission 5 years earlier, police brought her to the hospital because she was causing a disturbance at a restaurant. When interviewed, Ms. P reported a false story that she fought with her husband, kicked him, and spat on his face. She said that her husband then punched her in the face, she ran out of the house, and a bystander called the police. At the time, her husband was contacted and denied the incident. He said that Ms. P had gone to the store and not returned, and he did not know what happened to her.

Her husband reported a steady and progressive decline in function and behavior dating back to 8 years ago with no known prior behavioral disturbances. In the chart from 5 years ago, her husband reported that Ms. P had been a high-functioning senior executive accountant at a major hospital system 7 years before the current admission, at which time she was fired from her job. He said that, just before being fired, Ms. P had been reading the mystery novel The Da Vinci Code and believed that events in the book specifically applied to her. Ms. P would stay up all night making clothes; when she would go to work, she was caught sleeping on the job and performing poorly, including submitting reports with incorrect information. She yelled at co-workers and was unable to take direction from her supervisors.

Ms. P’s husband also reported that she believed people were trying to “look like her,” by having plastic surgery. He reported unusual behavior at home, including eating food off the countertop that had been out for hours and was not fit for consumption.

Ms. P’s husband could not be contacted during this admission because he was out of country and they were separated. Collateral information is obtained from Ms. P’s mother, who lives apart from her but in the same city and speaks no English. She confirms Ms. P’s high premorbid functioning, and reports that her daughter’s change in behavior went back as far as 10 years. She reports that Ms. P had problems controlling anger and had frequent altercations with her husband and mother, including threatening her with a knife. Self-care and hygiene then declined strikingly. She began to have odd religious beliefs (eg, she was the daughter of Jesus Christ) and insisted on dressing in peculiar ways.

No family history of psychiatric disorders, such as schizophrenia, bipolar disorder, or dementia, was reported (Table 1).

The authors’ observations
The existence of LOS as a distinct subtype of schizophrenia has been the subject of discussion and controversy as far back as Manfred Bleuler in 1943 who coined the term “late-onset schizophrenia.”¹ In 2000, a consensus statement by the International Late-Onset Schizophrenia Group standardized the nomenclature, defining LOS as onset between age 40 and 60, and very-late-onset schizophrenia-like psychosis (VLOS) as onset after age 60.² Although there is no diagnostic subcategory for LOS in DSM, DSM-5 notes that (1) women are overrepresented in late-onset cases and (2) the course generally is characterized by a predominance of psychotic symptoms with preservation of affect and social functioning.³ DSM authors comment that it is not yet clear whether LOS is the same condition as schizophrenia diagnosed earlier in life. Approximately 23% of schizophrenia cases have onset after age 40.⁴

Cognitive symptoms in LOS
The presence of cognitive deficits in schizophrenia is common and well-recognized. The intellectual impairment is generalized and global, and there also is specific impairment in a range of cognitive functions, such as executive functions, memory, psycho­motor speed, attention, and social cognition.⁵ Typically these cognitive impairments are present before onset of psychotic symptoms. Although cognitive symptoms are not part of the formal diagnostic criteria, DSM-5 acknowledges their presence.³ In a systematic review on nature and course of cognitive function in LOS, Rajji and Mulsant⁶ report that global deficits and specific deficits in executive functions, visuospatial constructional abilities, verbal fluency, and psychomotor speech have been found consistently in studies of LOS, although the presence of deficits in memory, attention, and working memory has been less consistent.

The presence of cognitive symptoms in LOS is less well-studied and understood (Table 2). The International Consensus Statement reported that no difference in type of cognitive deficit has been found in early–onset cases (onset before age 40) compared with late-onset cases, although LOS is associated with relatively milder cognitive deficits. Additionally, premorbid educational, occupational, and psychosocial functioning are less impaired in LOS than they are in early-onset schizophrenia.²

Rajji et al⁷ performed a meta-analysis comparison of patients with youth-onset schizophrenia, adults with first-episode schizophrenia, and those with LOS on their cognitive profiles. They reported that patients with youth-onset schizophrenia have globally severe cognitive deficits, whereas those with LOS demonstrate minimal deficits on arithmetic, digit symbol coding, and vocabulary but larger deficits on attention, fluency, global cognition, IQ, and visuospatial construction.⁷

There are conflicting views in the literature with regards to the course of cognitive deficits in schizophrenia. One group of researchers believes that there is progressive deterioration in cognitive functioning over time, while another maintains that cognitive impairment in schizophrenia is largely “a static encephalopathy” with no significant progression of symptoms.⁸ A number of studies referenced by Rajji and Mulsant⁶ in their systematic review report that cognitive deficits seen in patients with LOS largely are stable on follow-up with an average duration of up to 3 years. However, 2 studies with longer follow-up report evidence of cognitive decline.^9,10

Relevant findings from the literature. Brodaty et al⁹ followed 27 patients with LOS without dementia and 34 otherwise healthy participants at baseline, 1 year, and 5 years. They reported that 9 patients with LOS and none of the control group were found to have dementia (5 Alzheimer type, 1 vascular, and 3 dementia of unknown type) at 5-year follow-up. Some patients had no clinical signs of dementia at baseline or at 1-year follow-up, but were found to have dementia at 5-year follow-up. The authors speculated that LOS might be a prodrome of Alzheimer-type dementia.

Kørner et al¹⁰ studied 12,600 patients with LOS and 7,700 with VLOS, selected from the Danish nationwide registry; follow-up was 3 to 4.58 years. They concluded that patients with LOS and VLOS were at 2 to 3 times greater risk of developing dementia than patients with osteoarthritis or the general population. The most common diagnosis among patients with schizophrenia was unspecified dementia, with Alzheimer’s dementia (AD) being the most common diagnosis in control groups. The findings suggest that dementia in LOS and VLOS has a different basis than AD.

Zakzanis et al¹¹ investigated which neuropsychological tests best differentiate patients with LOS and those with AD or frontotemporal dementia. They reported that Wechsler Adult Intelligence Scale-Revised (WAIS-R) Similarities subtest and the California Verbal Learning Test (both short- and long-delay free recall) can differentiate LOS from AD, and a test battery comprising the WAIS-R Vocabulary, Information, Digit Span, and Comprehension subtests, and the Hooper Visual Organization test can differentiate LOS and frontotemporal dementia.¹²

EVALUATION Significant impairment
CT head and MRI brain scans without contrast suggest mild generalized atrophy that is more prominent in frontal and parietal areas, but the scans are otherwise unremarkable overall. A PET scan is significant for hypoactivity in the temporal and parietal lobes but, again, the images are interpreted as unremarkable overall.

Ms. P scores 21 on the Montreal Cognitive Assessment (MoCA), indicative of significant cognitive impairment (normal score, ≥26). This is a 3-point decline on a MoCA performed during her admission 5 years earlier.

Ms. P scores 8 on the Middlesex Elderly Assessment of Mental State, the lowest score in the borderline range of cognitive function for geriatric patients. She scores 13 on the Kohlman Evaluation of Living Skills, indicating that she needs maximal supervision, structure, and support to live in the community. Particularly notable is that Ms. P failed 5 out of 6 subtests in money management—a marked decline for someone who had worked as a senior accountant.

Given Ms. P’s significant cognitive decline from premorbid functioning, verified by collateral information, and current cognitive deficits established on standardized tests, we determine that, in addition to a diagnosis of schizoaffective disorder, she might meet DSM-5 criteria for unspecified major neurocognitive disorder if her functioning does not improve with treatment.

The authors’ observations
There is scant literature on late-onset schizoaffective disorder. Webster and Grossberg¹³ conducted a retrospective chart review of 1,730 patients age >65 who were admitted to a geriatric psychiatry unit from 1988 to 1995. Of these patients, 166 (approximately 10%) were found to have late life-onset psychosis. The psychosis was attributed to various causes, such as dementia, depression, bipolar disorder, medical causes, delirium, medication toxicity. Two patients were diagnosed with schizophrenia and 2 were diagnosed with schizoaffective disorder (the authors did not provide additional information about the patients with schizoaffective disorder). Brenner et al¹⁴ reports a case of late-onset schizoaffective disorder in a 70-year-old female patient. Evans et al¹⁵ compared outpatients age 45 to 77 with a diagnosis of schizoaffective disorder (n = 29), schizophrenia (n = 154), or nonpsychotic mood disorder (n = 27) and concluded that late-onset schizoaffective disorder might represent a variant of LOS in clinical symptom profiles and cognitive impairment but with additional mood symptoms.¹⁶

How would you begin treating Ms. P?
   a) start a mood stabilizer
   b) start an atypical antipsychotic
   c) obtain more history and collateral information
   d) recommend outpatient treatment

The authors’ observations
Given Ms. P’s manic symptoms, thought disorder, and history of psychotic symptoms with diagnosis of LOS, we assigned her a presumptive diagnosis of schizoaffective disorder, bipolar type. From the patient report, collateral information from her mother, earlier documented collateral from her husband, and chart review, it was apparent to us that Ms. P’s psychiatric history went back only 10 years—therefore meeting temporal criteria for LOS.

Clinical assessment (Figure) and standardized tests revealed the presence of neurocognitive deficits sufficient to meet criteria for major neurocognitive disorder (Table 3³). The pattern of neurocognitive deficits is consistent with an AD-like amnestic picture, although no clear-cut diagnosis was present, and the neurocognitive disorder was better classified as unspecified rather than of a particular type. It remains uncertain whether cognitive deficits of severity that meet criteria for major neurocognitive disorder are sufficiently accounted for by the diagnosis of LOS alone. Unless diagnostic criteria for schizophrenia are expanded to include cognitive deficits, a separate diagnosis of major neurocognitive disorder is warranted at present.

TREATMENT Pharmacotherapy
On the unit, Ms. P is observed by nursing staff wandering, with some pressured speech but no behavioral agitation. Her clothing had been bizarre, with multiple layers, and, at one point, she walks with her gown open and without undergarments. She also reports to the nurses that she has a lot of sexual thoughts. When the interview team enters her room, they find her masturbating.

Ms. P is started on aripiprazole, 10 mg/d, titrated to 20 mg/d, and divalproex sodium, 500 mg/d. The decision to initiate a cognitive enhancer, such as an acetylcholinesterase inhibitor or memantine, is deferred to outpatient care to allow for the possibility that her cognitive features will improve after the psychosis is treated.

By the end of first week, Ms. P’s manic features are no longer prominent but her thought process continues to be bizarre, with poor insight and judgment. She demonstrates severe ambivalence in all matters, consistently gives inconsistent accounts of the past, and makes dramatic false statements.

For example, when asked about her children, Ms. P tells us that she has 6 children—the youngest 3 months old, at home by himself and “probably dead by now.” In reality, she has only a 20-year-old son who is studying abroad. Talking about her marriage, Ms. P says she and her husband are not divorced on paper but that, because they haven’t had sex for 8 years, the law has provided them with an automatic divorce.

OUTCOME Significant improvement
Ms. P shows significant response to aripiprazole and divalproex, which are well tolerated without significant adverse effects. Her limitations in executive functioning and rational thought process lead the treatment team to consider nursing home placement under guardianship. Days before discharge, however, reexamination of her neuropsychiatric state suggests significant improvement in thought process, with improvement in cognitive features. Ms. P also becomes cooperative with treatment planning.

The treatment team has meetings with Ms. P’s mother to discuss monitoring and plans for discharge. Ms. P is discharged with follow-up arranged at community mental health services.

Bottom Line
Global as well as specific cognitive deficits are associated with late-onset schizophrenia. Studies have reported increased risk of dementia in these patients over the course of 3 to 5 years, usually unspecified or Alzheimer’s type. It is imperative to assess patients with schizophrenia, especially those age ≥40, for presence of neurocognitive disorder by means of neurocognitive testing.

Related Resources

• Goff DC, Hill M, Barch D. The treatment of cognitive impairment in schizophrenia. Pharmacol Biochem Behav. 2011;99(2):245-253.
• Radhakrishnan R, Butler R, Head L. Dementia in schizophrenia. Adv Psychiatr Treat. 2012;18(2):144-153.
  
  

Drug Brand Names
Aripiprazole • Abilify
Divalproex sodium • Depakote
Mematine • Namenda

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturer of competing products.