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Two studies were conducted among patients in a male dual diagnosis (severe mental illness [SMI] with substance use) ward. The research examined the following questions: (1) Do immigrant and non-immigrant dual diagnosis patients exhibit similar or different socio-demographic, clinical and criminological characteristics? (2) What are the implications for treatment of immigrant (and non-immigrant) patients? Study one analyzed computerized hospital records of 413 male patients; Study two examined patient files of a subgroup of 141 (70 immigrant) male patients. Alongside similarities, non-immigrant patients reported higher numbers of repeat and involuntary hospitalizations and more drug use while immigrants showed longer hospitalizations, more suicide attempts, more violent suicide attempts, more violent offenses and more alcohol use. Among non-immigrants significant relationships were found between severity of SMI and crime/violence while among immigrants a significant relationship was found between suicidality and crime/violence. Implications for treatment include need for awareness of suicide risk among immigrant dual-diagnosis patients and an understanding of the differential relationship with crime/violence for the two populations.

OBJECTIVES: To examine quality of life (QOL) in nursing home (NH) residents with advanced dementia and identify correlates of QOL near the end of life. DESIGN: Cross-sectional data derived from NH records, interviews with residents' surrogate decision-makers, QOL ratings by NH caregivers, and assessment of residents' cognitive function. SETTING: Three NHs in Maryland. PARTICIPANTS: A cohort of NH residents with dementia (n=119) who were receiving hospice or palliative care or met hospice criteria for dementia and their surrogates. MEASUREMENTS: QOL based on the proxy-rated Alzheimer' Disease-Related Quality of Life (ADRQL) scale administered to NH staff and validated against a single-item surrogate-rated measure of QOL, the Severe Impairment Rating Scale, to measure cognitive function and dichotomous indicators of neuropsychiatric symptoms (behavior problems, mood disorders, psychosis, delusions). RESULTS: Total ADRQL scores, ranging from 12.4 to 95.1 out of 100, were normally distributed and positively correlated (P

Objective: The role of environmental factors in hospitalization of patients with schizophrenia is incompletely understood. This study attempts to relate the pattern of hospital admissions to environmental variables such as season and to social factors such as nationally celebrated holidays. Methods: Charts of all adults ( n = 4,331) with a discharge diagnosis of schizophrenia admitted to the Abarbanel Mental Health Centre (Bat Yam, Israel) between 1 January 2001 and 31 December 2005 were reviewed. Hospitalizations were classified by gender, first or repeat admission, month and season of admission, and whether or not the admission coincided with a major Jewish holiday period. Results: There was a significant reduction ( p < 0.05) in first admissions for men during April, the month corresponding to Passover, the most widely celebrated holiday in Israel. This pattern was not seen for women or for repeat admissions. There was no significant effect of the season upon admission rates, using two different methods of defining the season. Conclusions: This study demonstrated significant monthly variability in admission rates and a possible protective effect of a widely celebrated public religious holiday. A consistent effect of season upon rates of admission was not found. Future studies need to identify which specific social factors exert a protective or harmful effect and study how knowledge of these effects can be translated into clinical practice.

Objectives: This study examines how surrogate decision makers for dementia patients developed an understanding of patient preferences about end-of-life (EOL) care and patient wishes. Methods: Semistructured interviews were conducted with 34 surrogate decision makers for hospice-eligible nursing home patients with dementia. The data were content analyzed. Results: Most surrogates reported that patients had previously completed an advance directive (59%), discussed preferences for EOL care (56%), or done both (38%). Catalysts for and barriers to completing an advance directive or having EOL care discussions included factors that were both intrinsic and extrinsic to the patient. The most commonly reported wish for EOL care was to not be kept alive by “machines” or “extraordinary measures.” Discussion: Health care providers may be able to assist patients and families by normalizing discussions of dying, encouraging advance care planning, helping them identify goals for EOL care, and providing information to support treatment decisions consistent with patients' wishes.

Neuropsychiatric symptoms (NPS) are common in dementia, although little is known about their prevalence and treatment near the end of life. This study used a retrospective review of the medical records of 123 hospice-eligible nursing home residents with advanced dementia to investigate the prevalence of NPS and NPS-targeted pharmacological and non-pharmacological treatments. The most prevalent NPS were agitation or aggression (50.4%), depression (45.5%), and withdrawal/lethargy (43.1%). Of the 105 (85.4%) residents who exhibited one or more NPS, 90.5% were receiving at least one NPS-targeted treatment, yet 41.9% received no documented nonpharmacological NPS-targeted care. The majority of documented nonpharmacological care focused on safety and explanations or instructions given to residents. Given the high prevalence of comorbidities, associated risks for medication interactions or serious side effects, and potential low-risk benefits of psychobehavioral care, these findings raise concerns about how to best increase the provision and documentation of nonpharmacological care in advanced dementia.

Progress in regenerative medicine seems likely to produce new treatments for neurologic conditions that use human cells as therapeutic agents; at least one trial for such an intervention is already under way. The development of cell-based interventions for neurologic conditions (CBI-NCs) will likely include preclinical studies using animals as models for humans with conditions of interest. This paper explores predictive validity challenges and the proper role for animal models in developing CBI-NCs. In spite of limitations, animal models are and will remain an essential tool for gathering data in advance of first-in-human clinical trials. The goal of this paper is to provide a realistic lens for viewing the role of animal models in the context of CBI-NCs and to provide recommendations for moving forward through this challenging terrain. © 2009 ISCBFM All rights reserved.

Objective To describe medication usage in nursing home residents with advanced dementia, to identify how this usage changed as patients advanced towards death, and to identify correlates of increased medication usage. Methods Prospective cohort study (CareAD) during which data on medication prescription were extracted from medical records at regular intervals using standardized extraction procedures. Results Patients (n = 125) were prescribed a mean of 14.6 medications during the 6 months prior to study enrollment. In a subgroup of patients who died during the study (n = 88), as the time of death approached, the total number of medications prescribed did not vary but the types of medications prescribed did change, with an increase in palliative medications such as opiate analgesics and a decrease in other medication classes such as antibiotics, anti-dementia agents, cardiovascular agents, and psychotropic agents, among others. In linear regression analyses, total medication prescription at study entry was associated with study site, antibiotic treatment, presence of cardiovascular disease, and treatment of gastrointestinal or dermatological conditions. Conclusions Nursing home residents with advanced dementia are prescribed a large number of medications from numerous medication classes and prescribing patterns change over time. Further study is needed to determine the ideal approach to treating chronic medical problems at the end of life in this patient population. Copyright © 2007 John Wiley & Sons, Ltd.

The authors descripe a pragmatic and atheoretical frameword for teaching psychiatry residents how to assess and treat religious patients. The psychiatrist’s goals in assessing the religious history are clarified. These goals differ between the assessment and treatment phases. During assessment, attention is paid to psychiatric phenomenology and careful history-taking utilizing knowledgeable outside informants. A framework is presented for engaging religious patients, fostering therapeutic alliance, avoiding pitfalls, and facilitating treatment within the patient’s religious context. Emphasizing knowledge of phenomenology and information gathering skills may be more effective than emphasizing broad knowledge of many religions, except for clinicians practicing within a particular religious community.

We aimed to identify characteristics and outcomes of involuntary and voluntary admissions of dual-diagnosis patients in a single, large mental health center in Israel.Using a retrospective chart review methodology, 24 patient records were reviewed spanning a period of five years; clinical and demographic variables of voluntary and involuntary admissions were compared.No significant differences were found in sociodemographic characteristics, admission diagnosis and length of hospitalization between the two types of admission. A smaller proportion of patients discharged from involuntary admissions were in remission compared to those discharged from voluntary admission. Nevertheless, involuntary admissions were associated with longer time to next hospitalization.The data were based on a small number of patients in a single ward, thus the generalizability of the results is uncertain.The finding of the current study that involuntary admission leads to longer tenure in the community suggests that there may be clinical advantages to involuntary admissions for certain dual diagnosis patients.

Unique and challenging ethical difficulties arise during mobile psychiatric treatment of elderly patients. This article outlines and analyzes five of these challenges that have been encountered during nearly 20 years of experience with the Psychogeriatric Assessment and Treatment in City Housing Program in Baltimore, Maryland. The ethical challenges reviewed are: establishing the treatment contract versus the right to refuse treatment, protecting confidentiality versus patient protection, protecting autonomy versus asserting beneficence, treatment termination versus open-ended treatment, and cost versus benefit of care. Ethical challenges with homebound elderly patients are unique because of patient characteristics as well as features of the treatment environment.

Hippocampal sclerosis dementia (HSD) is a disease of unknown etiology and pathogenesis. To determine whether HSD cases could be reclassified as variants of frontotemporal dementia (FTD), a heterogeneous group of disorders, 18 brain autopsy cases previously diagnosed as HSD were re-evaluated. In 11 cases, ubiquitinated neuronal inclusions, similar to those of motor neuron disease inclusion dementia (MNDID), were found. Brain levels of soluble and insoluble tau were normal. Most patients with pathologic findings of HSD may actually have the MNDID variant of FTD.

Treatment of sexual disorders within a culturally distinct subpopulation requires familiarity with the beliefs and mores of that community. Differences between subgroups within orthodox Judaism can be substantial, especially regarding attitudes toward sexuality, reproduction, and modesty in behavior, speech, and dress. These factors can influence treatment and need to be understood. Traditional restrictions on intimate contact during portions of the menstrual cycle have the potential to enhance sexual intimacy, but may necessitate modifications of therapy technique to accommodate these guidelines. The rabbi has an important role in the treatment of orthodox patients, often serving as a culture broker, facilitating referrals and treatment. Orthodox patients view sexuality as one component of a complex matrix of values, traditions, and laws that give meaning and spirituality to all aspects of life, a perspective that may differ substantially from the prevailing attitudes of the general culture. This religio...

The relationship between psychiatry and religion is complex, and has been complicated by the heterogeneity of each. This paper proposes a modest framework within which the interaction between the fields can be organized. The aim of this framework is to provide clarity to the interaction to further the care of individuals, as well as to promote research into and teaching of the psychiatry-religion interaction.

Current measures of severity and disability do not stage or track the progression of disability in frontotemporal dementia (FTD) well. We investigated the reliability of the newly developed Dementia Disability Rating (DDR) in the measurement and staging of illness severity in FTD and dementia of the Alzheimer type (DAT).We studied 48 consecutive patients of the Johns Hopkins FTD and Young-Onset Dementias Clinic, with diagnoses of DAT, FTD, vascular dementia and "other" cognitive disorder (CDNOS). Cases were scored on the CDR and DDR by three trained raters, based on neuropsychiatric examinations performed at first visit and other assessments performed within the preceding year. Consensus ratings were assigned in conference.Inter-rater correlations of DDR sum of ranks scores for DAT ranged from 0.88 to 0.91, for FTD 0.89-0.96 and for CDNOS 0.85-0.97. Similar correlations were observed of the CDR sum of rank scores for DAT and FTD. Correlations of DDR summary scores for DAT were 0.67-0.91 and for FTD 0.79-0.91, as compared to CDR data: 0.87-0.92 (p0.0001) and 0.80-0.93 (p0.0001) for DAT and FTD respectively. In DAT patients the correlation between CDR and DDR summary scores was higher than in FTD patients, whereas correlations based on sum of ranks scores were high in both groups.These preliminary data indicate the DDR measures disability in DAT and FTD, with reliability comparable to the CDR. Convergent validity was demonstrated for the DDR.

Objective The authors describe mood abnormalities seen in a case series of patients with frontotemporal dementia (FTD). Method Authors provide a structured review of outpatient and inpatient charts of FTD patients. Results Three distinct depressive syndromes were identified: The first corresponds to DSM–IV major depression. The second is a syndrome of mood lability with prominent responsiveness to the environment. The third is a syndrome of profound apathy, without other evidence of depression. Conclusion A variety of mood disorders are seen in FTD, requiring careful attention to differential diagnosis. FTD should be included in the differential diagnosis during the evaluation of older patients with mood abnormalities.

The prospect of using cell-based interventions (CBIs) to treat neurological conditions raises several important ethical and policy questions. In this target article, we focus on issues related to the unique constellation of traits that characterize CBIs targeted at the central nervous system. In particular, there is at least a theoretical prospect that these cells will alter the recipients' cognition, mood, and behavior-brain functions that are central to our concept of the self. The potential for such changes, although perhaps remote, is cause for concern and careful ethical analysis. Both to enable better informed consent in the future and as an end in itself, we argue that early human trials of CBIs for neurological conditions must monitor subjects for changes in cognition, mood, and behavior; further, we recommend concrete steps for that monitoring. Such steps will help better characterize the potential risks and benefits of CBIs as they are tested and potentially used for treatment. © Taylor & Francis Group, LLC.

Background: Attempts to translate basic stem cell research into treatments for neurologic diseases and injury are well under way. With a clinical trial for one such treatment approved and in progress in the United States, and additional proposals under review, we must begin to address the ethical issues raised by such early forays into human clinical trials for cell-based interventions for neurologic conditions. Methods: An interdisciplinary working group composed of experts in neuroscience, cell biology, bioethics, law, and transplantation, along with leading disease researchers, was convened twice over 2 years to identify and deliberate on the scientific and ethical issues raised by the transition from preclinical to clinical research of cell-based interventions for neurologic conditions. Results: While the relevant ethical issues are in many respects standard challenges of human subjects research, they are heightened in complexity by the novelty of the science, the focus on the CNS, and the political climate in which the science is proceeding. Conclusions: Distinctive challenges confronting US scientists, administrators, institutional review boards, stem cell research oversight committees, and others who will need to make decisions about work involving stem cells and their derivatives and evaluate the ethics of early human trials include evaluating the risks, safety, and benefits of these trials, determining and evaluating cell line provenance, and determining inclusion criteria, informed consent, and the ethics of conducting early human trials in the public spotlight. Further study and deliberation by stakeholders is required to move toward professional and institutional policies and practices governing this research.

This issue provides a clinical overview of dementia, focusing on prevention, diagnosis, treatment, practice improvement, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, https://mksap.acponline.org/, and other resources referenced in each issue of In the Clinic.

Frontotemporal dementia (FTD) is a family of neurodegenerative diseases and syndromes that most commonly involve the frontal and temporal lobes, producing dramatic alterations of personality, behavior, language, and other cognitive abilities (McKhann et al., 2001). Age of onset tends to be younger than in Alzheimer’s disease (AD), with most patients becoming symptomatic in the sixth decade of life. Although population-based epidemiologic studies of FTD have found a prevalence of approximately 5–10 per 100,000 in patients 50 years of age and older, autopsy-based case series have found that approximately 5% to15% of people with dementia have FTD, a discrepancy suggesting that many cases go undiagnosed during life (Rosso et al., 2003). Recent advances in clinicopathologic correlation have revealed that a number of neurologic conditions previously conceived of as independent disease entities such as progressive supranuclear palsy (PSP), corticobasilar degeneration (CBD), and hippocampal sclerosis dementia are in many cases better classified in the FTD family (McKhann et al., 2001; Blass et al., 2004). Many patients with FTD develop other neurologic syndromes as well, including parkinsonism and amyotrophic lateral sclerosis (ALS). FTD is actually a group of clinical syndromes with overlapping neuropathologies. The clinical expression of the disease relates primarily to the anatomic location of disease involvement rather than the neuropathologic subtype; there are many such subtypes. Clinical variants are most distinct early in the disease course, when the degree of anatomic involvement may be limited to discrete regions. As the disease spreads through the brain, many patients have symptoms that become complex and take on char acteristics of other variants. The first clinical FTD variant is one in which behavioral abnormalities and personality changes dominate the clinical presentation. This syndrome is usually associated with disease involvement of the frontal and anterior temporal lobes. In addition, there are two language presentations: primary progressive aphasia and semantic dementia (McKhann et al., 2001). The neurologic syndromes of PSP, CBD, and ALS with dementia are familiar to the neurologist because of their neurologic symptoms; it is noteworthy that patients with any of the previously mentioned syndromes routinely develop the psychiatric symptoms reviewed below.

Objective The purpose of this study was to determine whether specific neuropsychiatric symptom patterns could be identified in a cohort of hospice-eligible nursing home residents with advanced dementia. Methods Surrogate decision makers gave informed consent to enroll 123 residents from 3 nursing homes. All participating residents met criteria for hospice eligibility and were determined by direct examination at the time of study enrollment to have advanced dementia. Retrospective medical record review was used to collect data on residents' demographics, diagnoses, and the presence of any neuropsychiatric symptoms during the 6 months prior to study enrollment. Latent class analysis (LCA) was used to classify residents based on neuropsychiatric symptom patterns. Results Overall, 85% of residents exhibited one or more neuropsychiatric symptoms. LCA revealed that these individuals could be classified into 3 groups: one with low symptom frequencies (36%) considered to be the normative class, one characterized by psychosis and agitation or aggression (23%), and a third characterized by withdrawal or lethargy (41%). Conclusions These results add to the growing understanding of neuropsychiatric symptom patterns in advanced dementia and have implications for more dimensional classification and treatment approaches.

Background: Dementia differs from other terminal illnesses both in its slow progression and the fact that patients and family members often do not perceive it as a cause of death. Furthermore, because decisional incapacity is almost universal in patients with advanced dementia, decisions must be made by surrogates. However, little is known about the factors that influence how surrogates make decisions for persons with late-stage dementia. Methods: The setting was the first wave of a study of patients with advanced dementia in three Maryland nursing homes (The Care of Nursing Home Residents with Advanced Dementia Study). Of 125 consented participants, 123 residents and their surrogates provided adequate information and agreed to interviews and medical record reviews. Bivariate analysis and logistic regression models were used to explore whether variables related to demographics, illness, communication and surrogate background were associated with surrogate decisions to not provide aggressive treatments (i.e. hospitalization or surgery). Results: Treatment decisions regarding aggressive medical care had been made by 81 % of surrogates over the preceding 6 months. In bivariate analysis the following factors were significantly associated with not providing aggressive care: resident and surrogate of white race, older surrogate age, worse resident medical illness, worse surrogate perception of resident quality of life, presence of a 'do not hospitalize' order (DNH), and more contact with nurses. In the multivariate analysis, resident white race and presence of a DNH were significant predictors of surrogate decisions to not provide aggressive treatments. Treatment decisions were not associated with surrogate relationship or religiosity. Conclusions: Treatment decisions for individuals with advanced dementia are mostly strongly associated with the patient's race and presence ofDNH and less so with changeable features of illness or environment.

Medical care of patients with dementia often occurs within a physician—patient relationship whose features differ from relationships with patients without dementia. Many basic assumptions of the physician—patient relationship may not completely hold true, and certain aspects of the patient role may be shared by others besides the patient. For example, the entire premise of consent to the patient role may be inapplicable to patients who lack insight into their illness. In addition, caring for cognitively impaired patients who do not comprehend the purpose of the physician—patient interaction may render physicians vulnerable to losing empathy with their patients and objectifying them. This can lead to viewing patients as collections of symptoms rather than as humans suffering with illnesses and burdens. The fact that certain medical interventions, such as treatment of neuropsychiatric disturbances that do not trouble the patient, may appear to be initiated for the primary purpose of alleviating caregiver emotional stress also affects the physician—patient relationship. The present review examines how this relationship may be altered and presents a framework within which these alterations can be considered.

This study describes the health problems and comorbid illnesses of nursing home (NH) residents with advanced dementia (n = 123) and identifies correlates of staff-identified pain. Study participants were residents of 3 NHs in Maryland, their surrogate decision makers and their physicians. Residents' cognitive function was assessed at study enrollment, and their medical records were reviewed to identify all health problems/illnesses and use of pain medications during the 6 months before their enrollment. The most prevalent health problems were skin problems (95%), nutrition/hydration problems (85%), psychiatric/behavioral problems (85%), gastrointestinal problems (81%), and infections (80%). Sixty-three percent of residents had recognized pain, and 95% of those residents received pain medications. In a multivariate regression analysis, staff-identified pain was associated with aspiration (P = 0.008), peripheral vascular disease (P = 0.021), musculoskeletal disorders (P = 0.032), higher cognitive function (P = 0.013), and use of pain medications, including nonopiates (P = 0.004) and the combination of opiates and nonopiates (P = 0.001). NH residents with advanced dementia experience a complex mixture of multiple chronic and acute comorbidities. These results suggest the need for clinicians in long-term care facilities to be vigilant in assessing and treating pain, particularly as cognitive function declines in those with advanced dementia.

Unique and challenging ethical difficulties arise during mobile psychiatric treatment of elderly patients. This article outlines and analyzes five of these challenges that have been encountered during nearly 20 years of experience with the Psychogeriatric Assessment and Treatment in City Housing Program in Baltimore, Maryland. The ethical challenges reviewed are: establishing the treatment contract versus the right to refuse treatment, protecting confidentiality versus patient protection, protecting autonomy versus asserting beneficence, treatment termination versus open-ended treatment, and cost versus benefit of care. Ethical challenges with homebound elderly patients are unique because of patient characteristics as well as features of the treatment environment.

Objective: To characterize the clinical course of pathologically diagnosed hippocampal sclerosis dementia (HSD). Background: Dementia associated with HSD is incompletely characterized. Previous studies suggest similarities to both Alzheimer disease (AD) and frontotemporal dementia (FTD). Methods: Case-control analysis of the clinical course of patients with HSD, FTD, and AD from a neuropathology autopsy series conducted by a university hospital. Case histories were reviewed. Cumulative prevalence of behavioral, cognitive, psychiatric, and language symptoms were compared between groups, as was time of symptom onset. Clinical diagnostic criteria for FTD and AD were applied to case histories. Sensitivity and specificity of clinical FTD diagnostic criteria (Report of the Work Group on FTD and Pick’s disease) were computed. Results: Cumulative prevalence of symptoms in HSD was most similar to that of FTD and differed from AD. Behavioral abnormalities such as decreased grooming and inappropriate behavior were more prevalent in HSD and FTD than AD. Hyperorality, inappropriate behavior, and decreased interest had earlier onset in HSD and FTD. Cognitive symptoms of disorientation, dyscalculia, apraxia, and agnosia were more prevalent in AD, as were psychiatric symptoms of hallucinations, delusions, and aggression. Most HSD patients met diagnostic criteria for FTD. Criteria sensitivity was 64.0% and specificity was 73.7%. Conclusions: FTD is a clinical syndrome associated with heterogeneous neuropathology. The clinical course of HSD is more similar to that of FTD than AD. These findings, together with the neuropathologic data presented in the accompanying article, support expanding the scope of FTD (Pick complex) to include HSD.

This issue provides a clinical overview of dementia, focusing on prevention, diagnosis, treatment, practice improvement, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, https://mksap.acponline.org/, and other resources referenced in each issue of In the Clinic.