P EER C OUNSELING R EGAINING ATTENTION ,
The Leader
Clinical Psychiatry News
VO L . 3 4 , N O. 6
Bipolar disorder can mimic dementia or depression in the elderly,
leading to ineffective treatment measures, Dr. Josepha Cheong said.
Bipolar Diagnosis
Elusive in Elderly
BY ROBERT FINN
San Francisco Bureau
S A N F R A N C I S C O — A diag-
nosis of bipolar disorder can be
missed in any patient, but this
appears to be a particular prob-
lem in the elderly population, Dr.
Josepha A. Cheong said at the an-
nual meeting of the American
Academy of Clinical Psychiatrists.
According to clinical lore
passed down through genera-
tions of psychiatrists, bipolar dis-
order is rare in the geriatric pop-
ulation, because these patients
all burn out while they’re still
young. Dr. Cheong, of the Uni-
versity of Florida, Gainesville, re-
called being taught that during
her training. But it’s just not true.
Studies show that bipolar dis-
order accounts for 5%-19% of
mood disorder presentations in
the elderly. In one study, about
10% of chronically institutional-
ized elderly patients were diag-
nosed with bipolar disorder, and
in another study, 17% of people
over the age of 60 presenting to
a psychiatric emergency room
were diagnosed with bipolar dis-
order, she noted, defining her
role as a clinician who is report-
ing on others’ research.
The diagnosis can be difficult,
because bipolar disorder shares
some features of Alzheimer’s dis-
ease or other types of dementia,
on the one hand, and of unipolar
PAGE 74
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INSIDE
Naltrexone Favored
Over Acamprosate
In Alcoholism Trial
Therapy did not improve drug treatment.
Visionary Art B Y T I M O T H Y F. K I R N “We feel this is important, as it
Martin Cohen’s artistic Sacramento Bureau may broaden the options for
©R ANDY B ATISTA
constancy has helped him treatment for those not current-
weather mental illness. S A N D I E G O — A study that is ly being treated,” Dr. Raymond
perhaps the most important con- F. Anton said in a presentation of
PAGE 18
ducted on alcohol dependence the study results at the annual
treatment in recent years has conference of the American So-
found that use of the opiate an- ciety of Addiction Medicine,
tagonist naltrexone reduces which coincided with publica-
Kick the Habit drinking, but use of acamprosate tion of the results ( JAMA
FDA-approved varenicline is
specifically designed to treat
nicotine dependence.
does not.
The COMBINE (Effect of
Combined Pharmacotherapies
2006;295:2003-17).
The trial enrolled 1,383 alco-
hol-dependent subjects and ran-
and Behavioral Interventions) domly assigned them to one of
PAGE 8
study also suggests that medical
management of an alcohol-de-
eight groups that could include
one or both of the drugs, or
pendent patient, with a physician placebo, with or without what
depression, on the other (see box). providing a prescription for nal- the investigators termed a “cog-
But it’s critical to make the right trexone and basic information nitive-behavioral intervention.”
diagnosis. If bipolar disorder is and advice, is as effective as cog- One group received the cogni-
misdiagnosed as dementia, the nitive-behavioral therapy. See Alcoholism page 8
misdiagnosis can lead to ineffec-
tive treatment, early nursing
home placement, continued dis-
ability, and an increased risk of sui- Suicide Experts Linking
cide. If bipolar disorder is misdi-
agnosed as agitated depression,
symptoms might worsen and an-
Molestation Mnemonic to Prevention
tidepressant use could precipitate Message BY BRUCE JANCIN following: IS PATH WARM?
rapid cycling or a switch to mania. Billboard and helpline may Denver Bureau This mnemonic phrase is an
Some of the DSM-IV criteria break the cycle of abuse. attempt to introduce a sem-
for mania might present differ- S E A T T L E — An American As- blance of order and coherence
PAGE 51
ently in the elderly. For example, sociation of Suicidology expert into what until now have been
“impaired function” can be hard consensus panel has developed the totally chaotic efforts of a
See Elderly page 40 the first evidence-based list of multitude of organizations try-
warning signs for suicide—and ing to assist the public and oth-
VITAL SIGNS fashioned a mnemonic designed ers who are not mental health
to help get out the message. clinicians to spot those in need
Top 10 Drugs Prescribed by The mnemonic, which AAS of help, M. David Rudd, Ph.D.,
Psychiatrists in 2005 officials hope to disseminate explained at the annual meeting
widely as an easy aid to addiction of the American Association of
Millions specialists, emergency medicine Suicidology.
Lexapro 4,893 specialists, primary care physi- To illustrate the current chaos,
Zoloft 4,671 cians, and the general public in he described his Internet search
Seroquel 4,232 identifying individuals who are at on Google using the key words
Effexor XR 4,032 heightened suicide risk, is the See Suicide page 52
Risperdal 3,493
Wellbutrin XL 3,379
E LSEVIER G LOBAL M EDICAL N EWS
Adderall XR 2,759
Ambien 2,405
Concerta 2,248
Lamictal 2,074
Note: Estimated data based on prescription drugs dispensed by retail
pharmacies throughout the United States.
Source: Verispan
40 Geriatric Psychiatry C L I N I C A L P S YC H I AT RY N E W S • Ju n e 2 0 0 6

Age May Confound Bipolar Dx larly, a low-sodium diet, dehydration, and

Elderly from page 1
to demonstrate, because many elderly pa-
tients don’t have a regular occupational en-
vironment or routine.
Mania might present with less of the
grandiosity often seen in younger patients
and more irritability. “There’s more of a
dysphoric quality to geriatric mania,” Dr.
Cheong said. Additionally, disorientation
and distractibility might be mistaken for
symptoms of dementia instead of mania.
Elderly patients with bipolar disorder
also have some special issues with com-
1.2 mEq/L for acute mania and 0.6-1.0
mEq/L for maintenance, these ranges are
much too high for most geriatric patients.
“With geriatrics, I would definitely rec-
ommend keeping the range somewhere
between 0.3 and 0.6 [mEq/L],” Dr. Cheong
said. “Higher than that in the geriatric pa-
tient [and you can run into] a lot of trou-
ble with things like tremor, metallic taste,
gait ataxia, blurred vision...You really need
to titrate according to the symptoms as
well as the side effects.”
renal disease can increase lithium levels.
teractions and many serious side effects.
Serum carbamazepine levels can be in-
Serum lithium levels can be decreased creased by cimetidine (Tagamet), fluoxe-
by acetazolamide, aminophylline, caffeine, tine, isoniazid, ketoconazole, valproate, ve-
mannitol, and theophylline. rapamil, and macrolides. Carbamazepine
Carbamazepine is a major alternative to can decrease serum levels of alprazolam
lithium, but it has problems of its own. Dr. (Xanax), bupropion, clonazepam (Klono-
Cheong refers to it as a “dirty drug,” be- pin), clozapine (Clozaril), haloperidol
cause it’s subject to a lot of drug-drug in- (Haldol), and olanzapine (Zyprexa). ■
Comparison of Symptom Characteristics
Alzheimer’s Unipolar Bipolar
Disease Depression Disorder
Cognitive impairment Present Possible Possible

E LSEVIER G LOBAL M EDICAL N EWS

mon drug treatments. Lithium in particu- But too low a serum concentration is also Depressive symptoms Possible Likely Possible
lar has a very narrow therapeutic index in risky, because patients with bipolar disorder Sleep disruptions Possible Possible Possible
all patients, but this problem is exacerbat- are more likely to commit suicide in the Inappropriate sexual behavior Possible Less likely Possible
ed in the elderly, who might be taking oth- manic phase than in the depressed phase. Progressive functional and
er medications that can increase or de- Serum lithium levels can be increased by clinical deterioration Present Possible Possible
crease serum lithium levels. a host of medications, including ACE in-
While therapeutic plasma concentra- hibitors, cyclooxygenase-2 inhibitors, Source: Dr. Cheong
tions of lithium are generally quoted as 0.8- NSAIDs, furosemide, and thiazides. Simi-

Skip Meds First in Treating Agitation Episodic Nature Key to Dx Of

BY ROBERT FINN
San Francisco Bureau
S A N F R A N C I S C O — At least
80% of patients with dementia
will experience agitation, Dr.
Josepha A. Cheong said at the
annual meeting of the American
Academy of Clinical Psychia-
trists. The temptation, especial-
ly at in-patient facilities, is to go
immediately to medical man-
agement for that agitation.
Before reaching for the pre-
scription pad, however, one
should rule out any medical
causes for that agitation, and
then try nonmedical manage-
ment, which can be highly effec-
tive, said Dr. Cheong of the Uni-
versity of Florida, Gainesville.
In dealing with patients with
dementia, Dr. Cheong asks her-
self how she would deal with
this patient if he or she were a
3- to 5-year-old child. “Has there
ever been a time when you were
raising [toddlers] that you want-
ed to just pull out that syringe of
Haldol?” Dr. Cheong asked. “It
would be nice, but that’s not
what we do. One, it’s not so-
cially acceptable. And two, it’s
not appropriate.
“I really feel much the same
way in treating agitation in de-
mentia. A lot of times, there’s a
tendency to go straight to the
meds. And there’s nothing
wrong with that if what’s least
restrictive has failed.”
Urinary tract infections are one
of the most common medical
causes of agitation. This has in-
spired a joke: What’s the first-line
medication for agitation in an in-
patient medical unit? Septra.
Dehydration is another com-
mon cause of agitation. “Even if
they don’t have a urinary tract in-
fection, it’s amazing how people
will perk up if you just hydrate
them a little,” Dr. Cheong said.
Anticholinergics and over-the-
counter medications can also re-
sult in agitation. Ditropan,
which is used for urinary incon-
tinence, is one of the biggest of-
fenders, in Dr. Cheong’s view. “I
always tell patients and their
families: ‘Look, it’s better to be
in Depends than to be dement-
ed because of Ditropan.’ This
can make the difference between
keeping someone at home and
having them in a nursing home
in restraints or in an inpatient
unit,” Dr. Cheong said.
Drug interactions can also
cause agitation. The combina-
tion of an NSAID and lithium is
a frequent culprit. A patient tak-
ing lithium might turn to a
seemingly innocuous dose of
ibuprofen after an especially vig-
orous golf game, and the next
thing you know he’s in the
emergency room suffering from
lithium toxicity.
Once medical causes have
been excluded, consider
whether the patient has experi-
enced a recent change in envi-
ronment, which can often result
in agitation. Has a beloved pet
died recently? Has the care fa-
cility’s routine changed? Is there
a new nurse on the ward?
Consider also whether the pa-
tient’s agitation comes at a cer-
tain time of the day, or with
certain activities. Shower time
often precipitates agitation. One
solution is simply not to insist
that patients shower daily. El-
derly patients often do fine
showering or bathing just twice
a week, and this has the extra
benefit of preventing their skin
from drying out.
Another tip is to enter the re-
ality of the patient. People who
work in geriatric units are used to
seeing patients waiting every
morning by the front door for the
bus to take them to work. The
patient is likely to become upset
if told he or she has been retired
for 20 years. Instead, it might be
better to say, “Why don’t you
come sit down and have some
breakfast while you’re waiting?”
Overstimulation and under-
stimulation should both be
avoided. The change-of-shift
chaos in many in-patient units
can be highly disturbing to pa-
tients. This might be a good
time to have patients away from
the chaos in a quiet day room
with soothing music. On the
other hand, lack of activities and
boredom can lead to restless be-
havior and attempts to escape.
Studies show that simply adding
a recreational therapist to a
nursing-home setting can de-
crease the amount of agitation
that patients experience.
Keep the patients’ choices sim-
ple. Three choices of salad dress-
ing and four choices of entrées
at meals may be confusing to the
patient; it’s better to provide a
single offering. And, just like tod-
dlers, patients with dementia do
best with finger foods.
Everyone needs attention, in-
timacy, and affection. The lack
of that human connection can
lead to agitation and impulsive
sexual behavior. Soothing rituals
such as massage or even hair
brushing can go a long way to
calming the agitated patient.
Psychiatrists may have diffi-
culty getting paid for nonmed-
ical treatment of agitated pa-
tients, because Medicare may
regard it as psychotherapy, and
psychotherapy is not indicated
for patients with dementia. Dr.
Cheong’s tip is to code the
treatment as being for behav-
ioral and psychotic symptoms of
dementia. ■ syncope, transient ischemic at-
Seizures in Older Adults
BY KERRI WACHTER
Senior Writer
S A N J U A N , P. R . — Seizures
in older adults have a different
presentation than they do in
younger patients, with these
events resembling many other
conditions and making diagnosis
difficult, but there are a few keys
that can help make the right di-
agnosis, said one expert speaking
at the annual meeting of the
American Association for Geri-
atric Psychiatry.
Seizures in older adults often
are a byproduct of stroke and/or
hemorrhage, said Dr. Joseph I.
Sirven, of the department of
neurology at the Mayo Clinic in
Phoenix, who spoke from anec-
dotal experience. In addition,
neurodegenerative conditions,
such as dementia, also cause
problems that lead to seizures.
In general, partial seizures are
most commonly seen in older
adults because there is a specific
area of injury or damage involved,
said Dr. Sirven. In older adults, the
foci of seizures usually occur in
the frontal or parietal lobes.
“We also know that simple par-
tial seizures, in which there is not
a loss of consciousness, tend to
have more focal and/or sensory
symptoms [such as] tremor or a
sense of numbness,” said Dr. Sir-
ven. Auras—primarily dizzi-
ness—may also be present. Com-
plex partial seizures often present
with altered mental activity, star-
ing, blackouts, and confusion.
Diagnosing seizures in older
adults is difficult because the pre-
sentation can resemble so many
other conditions. “The differen-
tial mirrors almost everything
else,” said Dr. Sirven, including
tack, transient global amnesia,
vertigo, and delirium.
The key to seizure recognition
is episodic frequency of symp-
toms that are stereotypic. In par-
ticular, episodes may present
with loss of consciousness, dizzi-
ness, confusion, or language
change. “If you see transient
episodes of certain behaviors that
are stereotypic, the first test really
is the EEG,” said Dr. Sirven. Oth-
er diagnostic tests to consider in-
clude MRI, laboratory tests, car-
diovascular testing, ambulatory
EKG, and tilt table testing.
Seizure medication should be
considered only if the seizures
are truly impacting the patient’s
quality of life. “Why I’m making
a big deal about it is that the mo-
ment you start someone on
seizure medication ... you’ve
branded that person and no one
down the road is going to stop
that medication,” said Dr. Sirven.
Dr. Sirven listed the following
three main points to consider
when deciding on a seizure med-
ication for an elderly patient:
씰 Efficacy. Try to use monother-
apy whenever possible. Choose a
medication that is appropriate
for the seizure type. If the seizure
type is unspecified, choose a
broad-spectrum agent.
씰 Safety and tolerability. First
minimize drug interactions. In
addition, choose a drug with a fa-
vorable safety profile that mini-
mizes the inhibition of cognitive
function and has a minimal effect
on gait, balance, and orthostatic
blood pressure.
씰 Simplification. Once-daily
dosing helps with patient com-
pliance. Choose a drug with a
quick onset of action. Reduce in-
teracting drugs, especially psy-
choactive ones. ■