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VO L . 3 4 , N O. 6 T he Leading Inde p endent Ne wspaper for the Psychiatrist—Since 1973 JUNE 2006

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

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
ducted on alcohol dependence the study results at the annual
Bipolar disorder can mimic dementia or depression in the elderly, treatment in recent years has conference of the American So-
leading to ineffective treatment measures, Dr. Josepha Cheong said. 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
Bipolar Diagnosis specifically designed to treat
nicotine dependence.
does not.
The COMBINE (Effect of
Combined Pharmacotherapies
The trial enrolled 1,383 alco-
hol-dependent subjects and ran-
and Behavioral Interventions) domly assigned them to one of
Elusive in Elderly 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
BY ROBERT FINN depression, on the other (see box). providing a prescription for nal- the investigators termed a “cog-
San Francisco Bureau 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-
S A N F R A N C I S C O — A diag- misdiagnosed as dementia, the nitive-behavioral therapy. See Alcoholism page 8
nosis of bipolar disorder can be misdiagnosis can lead to ineffec-
missed in any patient, but this tive treatment, early nursing
appears to be a particular prob-
lem in the elderly population, Dr.
home placement, continued dis-
ability, and an increased risk of sui- Suicide Experts Linking
Josepha A. Cheong said at the an- cide. If bipolar disorder is misdi-
nual meeting of the American
Academy of Clinical Psychiatrists.
agnosed as agitated depression,
symptoms might worsen and an-
Molestation Mnemonic to Prevention
According to clinical lore tidepressant use could precipitate Message BY BRUCE JANCIN following: IS PATH WARM?
passed down through genera- rapid cycling or a switch to mania. Billboard and helpline may Denver Bureau This mnemonic phrase is an
tions of psychiatrists, bipolar dis- Some of the DSM-IV criteria break the cycle of abuse. attempt to introduce a sem-
order is rare in the geriatric pop- for mania might present differ- S E A T T L E — An American As- blance of order and coherence
ulation, because these patients ently in the elderly. For example, sociation of Suicidology expert into what until now have been
all burn out while they’re still “impaired function” can be hard consensus panel has developed the totally chaotic efforts of a
young. Dr. Cheong, of the Uni- See Elderly page 40 the first evidence-based list of multitude of organizations try-
versity of Florida, Gainesville, re- warning signs for suicide—and ing to assist the public and oth-
called being taught that during VITAL SIGNS fashioned a mnemonic designed ers who are not mental health
her training. But it’s just not true. to help get out the message. clinicians to spot those in need
Studies show that bipolar dis- Top 10 Drugs Prescribed by The mnemonic, which AAS of help, M. David Rudd, Ph.D.,
order accounts for 5%-19% of Psychiatrists in 2005 officials hope to disseminate explained at the annual meeting
mood disorder presentations in widely as an easy aid to addiction of the American Association of
the elderly. In one study, about Millions specialists, emergency medicine Suicidology.
10% of chronically institutional- Lexapro 4,893 specialists, primary care physi- To illustrate the current chaos,
ized elderly patients were diag- Zoloft 4,671 cians, and the general public in he described his Internet search
nosed with bipolar disorder, and Seroquel 4,232 identifying individuals who are at on Google using the key words
in another study, 17% of people Effexor XR 4,032 heightened suicide risk, is the See Suicide page 52
over the age of 60 presenting to Risperdal 3,493
a psychiatric emergency room Wellbutrin XL 3,379
were diagnosed with bipolar dis-

Adderall XR 2,759
order, she noted, defining her
Ambien 2,405
role as a clinician who is report-
Concerta 2,248
ing on others’ research.
The diagnosis can be difficult, Lamictal 2,074
because bipolar disorder shares
some features of Alzheimer’s dis- Note: Estimated data based on prescription drugs dispensed by retail
pharmacies throughout the United States.
ease or other types of dementia, Source: Verispan
on the one hand, and of unipolar
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

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


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