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The article presents a case study of a 70-year-old woman who had been suffering from major depression for 35 years and had been stable on fluoxetine 20 milligrams per day for more than 10 years. Her current episode of depression began when she was administered with subcutaneous exenatide for diabetes mellitus. She experienced worsening depression one month after starting the new drug. The article cites the relationship between the start of therapy with exenatide and the onset of symptoms.

Rats display conditioned flavor preferences (CFP) for fats. Previous studies demonstrated that whereas expression of an already-acquired corn oil (CO)-CFP was mildly reduced by dopamine (DA) D1, DA D2, NMDA or opioid receptor antagonists, the acquisition or learning of CO-CFP was eliminated by NMDA antagonists, and significantly reduced by DA D1 and D2, but not opioid antagonists. Previous studies of fructose-CFP demonstrated that muscarinic (scopolamine) and nicotinic (mecamylamine) cholinergic receptor antagonists and GABA B (baclofen) receptor agonism reduced the expression of this acquired response, and that scopolamine, but not mecamylamine or baclofen eliminated the acquisition or learning of this response. The present study examined scopolamine, mecamylamine or baclofen effects upon expression or acquisition of CO-CFP. For expression, rats were trained over 10 sessions with CS+ (3.5% CO) and CS- (0.9% CO) flavored solutions without drugs. Two-bottle choice tests with CS+ and CS- flavors in 0.9% CO examined preferences following vehicle, scopolamine (1-10mg/kg), mecamylamine (1-8mg/kg) and baclofen (1.5-5mg/kg). In acquisition, eight groups of rats received vehicle, scopolamine (1, 2.5mg/kg), mecamylamine (4, 6mg/kg), baclofen (3, 5mg/kg) or a limited intake vehicle control 0.5h prior to all 10 CS+ and CS- training sessions followed by six 2-bottle CS+ and CS- choice tests in 0.9% CO. CO-CFP expression (percent CS+ intake) was significantly but marginally reduced by scopolamine (70%), mecamylamine (85%) and baclofen (74%) relative to vehicle (98%). CO-CFP acquisition was eliminated (41%) by scopolamine relative to vehicle (88%) and limited control (98%) conditions. Neither mecamylamine nor baclofen altered CO-CFP acquisition. Thus, the muscarinic cholinergic receptor system is essential for acquisition (learning) of both fat-induced and sugar (fructose)-induced preferences. In contrast, muscarinic, nicotinic and GABA B receptors were minimally involved in the expression (maintenance) of fat- and fructose-CFP., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Rats display both fructose-conditioned flavor preference (CFP) and quinine conditioned flavor avoidance (CFA). Dopamine (D1 and D2), muscarinic and nicotinic, but not NMDA or opioid receptor antagonists reduced fructose-CFP expression. Dopamine D1, dopamine D2, muscarinic or NMDA, but not opioid or nicotinic receptor antagonists reduced fructose-CFP acquisition. Dopamine D1, NMDA, nicotinic or opioid, but not dopamine D2 or muscarinic receptor antagonists enhanced quinine-CFA acquisition. Baclofen (BAC), a GABAB receptor agonist, alternately enhances or reduces feeding under specific conditions. The present study examined whether systemic BAC administration mediated fructose-CFP expression and acquisition or quinine-CFA acquisition. Fructose-CFP expression studies trained rats with one flavor (CS+) in 8% fructose and 0.2% saccharin and a second (CS-) flavor in 0.2% saccharin, followed by vehicle (VEH) and BAC (0.5-5 mg/kg) preceding 2-bottle (CS+, CS-) 0.2% saccharin choice tests. Fructose-CFP acquisition studies administered VEH or BAC (3 or 5 mg/kg) prior to CS+ and CS- training sessions followed by six 2-bottle (CS+, CS-) 0.2% saccharin choice tests. Quinine-CFA acquisition studies administered VEH or BAC (3 or 5 mg/kg) prior to CS- (8% fructose+0.2% saccharin) and CS+ (fructose+saccharin+0.030% quinine) training sessions followed by six 2-bottle (CS-, CS+) fructose+saccharin choice tests. BAC (3 mg/kg) minimally (66%) reduced fructose-CFP expression. BAC failed to alter fructose-CFP acquisition. Quinine-CFA acquisition was enhanced by the 5 mg/kg BAC dose (15-25%) relative to VEH (34-48%). These data implicate GABAB receptor signaling in acquisition of quinine avoidance with minimal or no effects upon fructose preferences., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Objective: To identify nursing home (NH) standards related to sexual activity and sexual relationships for residents through a nationwide survey of directors of nursing (DONs)., Methods: A national survey was distributed online and was completed by 366 DONs of skilled nursing facilities. The DONs answered questions concerning policies and experiences related to sexual activities of their residents including types of resident sexual activity they have encountered, perceptions about residents with dementia engaging in sexual activity, and policies pertaining to sexual activity including masturbation., Results: The results of the survey demonstrated that the vast majority (71.2%) indicated that there had been issues regarding residents' sexual activities in their facilities with over one-half (58%) of the DONs reporting situations of resident with resident sexual activity and 60% with situations of resident masturbation. More than one-half (56.6%) require a family or designated representative to approve sexual activity for a cognitively impaired resident. For a cognitively intact resident, 12.4% of facilities still require family or designated representative to approve sexual activity. However, despite the prevalence of sexual activity, the majority of NHs (63.4%) actually do not have policies dealing with resident sexual activity. Of the NHs with policies, 58.6% have written policies in place, with 11.2% requiring a physician order to allow sexual activity and 9.5% requiring a physician order to restrict sexual activity., Conclusions: Issues related to sexual activity in NH residents are quite prevalent, however, the rates of policies related to sexual activity are low and the policies and restrictions are not uniform. Our study suggests nursing homes should have a clear policy addressing resident sexual activity. It would be beneficial for such a policy to be communicated to residents and their families as part of an admission package instead of waiting for sexual interest to be noticed. This would enable residents to engage in sexual activity with understanding and support rather than hiding., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Rats display both conditioned flavor preference (CFP) for fructose, and conditioned flavor avoidance (CFA) following sweet adulteration with quinine. Previous pharmacological analyses revealed that fructose-CFP expression was significantly reduced by dopamine (DA) D1 or D2 antagonists, but not NMDA or opioid antagonists. Fructose-CFP acquisition was significantly reduced by DA D1, DA D2 or NMDA antagonists, but not opioid antagonists. Quinine-CFA acquisition was significantly enhanced and prolonged by DA D1, NMDA or opioid, but not DA D2 antagonists. Cholinergic interneurons and projections interact with DA systems in the nucleus accumbens and ventral tegmental area. Further, both muscarinic and nicotinic cholinergic receptor signaling have been implicated in sweet intake and development of food-related preferences. Therefore, the present study examined whether systemic administration of muscarinic (scopolamine: SCOP) or nicotinic (mecamylamine: MEC) cholinergic receptor antagonists mediated fructose-CFP expression, fructose-CFP acquisition and quinine-CFA acquisition. For fructose-CFP expression, rats were trained over 10 sessions with a CS+ flavor in 8% fructose and 0.2% saccharin and a CS- flavor in 0.2% saccharin. Two-bottle choice tests with CS+ and CS- flavors mixed in 0.2% saccharin occurred following vehicle, SCOP (0.1-10mg/kg) and MEC (1-8mg/kg). For fructose-CFP acquisition, six groups of rats received vehicle, SCOP (1 or 2.5mg/kg), MEC (4 or 6mg/kg) or a limited intake vehicle control 0.5h prior to 10 CS+ and CS- training sessions followed by six 2-bottle CS+ and CS- choice tests in 0.2% saccharin. For quinine-CFA acquisition, five groups of rats received vehicle, SCOP (1 or 2.5mg/kg) or MEC (4 or 6mg/kg) 0.5h prior to 8 one-bottle CS- (8% fructose+0.2% saccharin: FS) and CS+ (fructose+saccharin+quinine (0.030%: FSQ) training sessions followed by six 2-bottle CS- and CS+ choice tests in fructose-saccharin solutions. Fructose-CFP expression was significantly reduced by SCOP (2.5-10mg/kg: 65-68%) and MEC (4-8mg/kg: 67-73%) relative to vehicle (89-90%), that occurred only when antagonist doses reduced total saccharin intake but in which CS+ intake was still significantly higher than CS- intake. Fructose-CFP acquisition was eliminated by SCOP at doses of 1 (40-54%) and 2.5 (45-58%)mg/kg, and was accompanied by a failure to observe CS+ and CS- intake differences during testing relative to vehicle (85-92%) and limited control (74-88%) conditions. In contrast, MEC failed to alter fructose-CFP acquisition. Quinine-CFA acquisition was significantly enhanced and prolonged by MEC at 4 (18-24%) and 6 (11-13%) mg/kg relative to vehicle (34-48%). In contrast, SCOP failed to alter quinine-CFA acquisition. These data implicate the cholinergic receptor system in mediating acquisition (learning) of sugar-induced preferences and quinine-induced aversions with muscarinic receptor signaling controlling the former and nicotinic receptor signaling controlling the latter., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: To use a nationwide survey to assess changes in antipsychotic utilization patterns and usage policies in nursing homes (NHs) in the United States since the introduction of the black box warning by the FDA., Design/setting/participants: A survey was distributed online and was completed by 250 directors of nursing of NH. The directors of nursing answered questions concerning policies about and use of antipsychotic medications., Measurements/results: The most commonly reported intervention to manage symptoms in residents with dementia since the black box warning was to lower doses of antipsychotics. Over half of facilities report obtaining more frequent psychiatry/psychology consults. One-hundred seven facilities have a policy regarding informing family members of residents about the black box warning. Most facilities (63.6%) with a policy require family to sign consent. In the NH setting, the presence or absence of a policy did not correlate with the reported change in use of antipsychotics or types of alternative interventions., Conclusion: Notably, a large number of NH facilities have policies regarding informed consent on the use of antipsychotics. However, in our study, the rate of use of antipsychotics did not change in many facilities since the black box warning. In addition, having a policy did not correlate with decreased antipsychotic use or with use of alternate agents or nonpharmacologic methods to address symptoms. The results of this survey suggest that NH administrators should worry less about the legal exposure of using antipsychotics and focus on actions that result in improved patient care., (Copyright © 2011 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.)

The purpose of this study is to determine the prevalence of tobacco use in patients diagnosed with dementia or cognitive impairment in an outpatient setting as they may be unsafe smokers and present safety risks to themselves and others. We conducted a retrospective chart review of new patients between 1/06 and 8/07 who were diagnosed with dementia or cognitive impairment in a geriatric outpatient practice. The data collected included age, gender, tobacco use patterns and mini-mental state examination (MMSE) score. Data was analyzed using SAS 9.1 for Windows (SAS Institute, Cary, NC). Former tobacco use rates in our study were similar to nationwide published rates for elderly over 65 (39.9% vs. 39.5%, respectively, p=0.99). However, only two patients in our study (1.32%, 95%CI=0.16-4.70) were current tobacco users compared with published census data that 10.2% of those over 65 are current smokers nationwide (p<0.001). Our study revealed a much lower rate of current tobacco use in our series of cognitively impaired patients. Further research is needed to explore the reasons for decreased smoking in those with cognitive impairment and its clinical implications., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Delusions, hallucinations and other psychotic symptoms can accompany a number of conditions in late life. As such, elderly patients are commonly prescribed antipsychotic medications for the treatment of psychosis in both acute and chronic conditions. Those conditions include schizophrenia, bipolar disorder, depression and dementia. Elderly patients are at an increased risk of adverse events from antipsychotic medications because of age-related pharmacodynamic and pharmacokinetic changes as well as polypharmacy. Drug selection should be individualized to the patient's previous history of antipsychotic use, current medical conditions, potential drug interactions, and potential side effects of the antipsychotic. Specifically, metabolic side effects should be closely monitored in this population. This paper provides a review of aripiprazole, a newer second generation antipsychotic agent, for its use in a variety of psychiatric disorders in the elderly including schizophrenia, bipolar disorder, dementia, Parkinson's disease and depression. We will review the pharmacokinetics and pharmacodynamics of aripiprazole as well as dosing, diagnostic indications, efficacy studies, and tolerability including its metabolic profile. We will also detail patient focused perspectives including quality of life, patient satisfaction and adherence.

Objective: To identify nursing home standards related to items brought in from the community for residents through a nationwide survey of directors of nursing. Specifically we examined the policies with regard to food, cigarettes, alcoholic beverages, and over-the-counter medications., Methods: A national survey was distributed online and was completed by 299 directors of nursing of skilled nursing facilities. The directors of nursing were asked about policies regarding whether family and friends of residents are permitted to bring in items such as food, cigarettes, alcohol, and over-the-counter medications. Specifically, questions were related to monitoring, staff involvement, safety precautions, and policy implementation., Results: The results of the survey demonstrated a consistent policy practiced among facilities. Items commonly restricted for all residents included over-the-counter medications, alcohol, and cigarettes. On the other hand, food was significantly less likely to be restricted., Conclusion: Despite overall strict policies regarding the monitoring of access to over-the-counter medications, alcohol, and cigarettes by nursing home residents, ingestion of outside food remains fairly unrestricted. This is especially concerning given the growing number of residents with end-stage congestive heart failure, diabetes, dysphagia, or food allergies where access to outside food could result in an adverse event. Perhaps, facilities need to identify at-risk residents and better communicate to residents and their families regarding dietary restrictions on outside food.

We report a case of quetiapine-induced dysphagia in a geriatric patient which improved with discontinuation of the antipsychotic. The patient had developed dysphagia while being treated with antipsychotics for bipolar disorder. The patient's dysphagia showed significant improvement when she was taken off quetiapine. We review the available literature on antipsychotic-related dysphagia and suggest that clinicians need to be aware of the potential for this syndrome even with lower potency antipsychotics.

Objective: To identify nursing home standards related to resident smoking through a nation wide survey of directors of nursing., Methods: A national survey was distributed online and was completed by 248 directors of nursing. The directors of nurses answered questions concerning resident smoking including the criteria utilized to determine an unsafe resident smoker. For those residents identified as unsafe, the questions asked were specifically related to monitoring, staff involvement, safety precautions and policy., Results: The results of the survey demonstrated a consistent policy practiced among facilities across the United States. The monitoring of nursing home residents is based on a resident's mental acuity, physical restrictions and equipment requirements. Once a resident was identified as a smoker at risk of harm to self or others, staff involvement ranged from distributing cigarettes to direct supervision. In addition, the majority of facilities required residents to wear fire resistant aprons and provided a fire extinguisher in smoking areas., Conclusion: Monitoring policies of nursing home residents who smoke starts with identifying those residents at risk based on an assessment of mental acuity, physical restrictions and equipment requirements. Those that are identified as being at risk smokers have their cigarettes controlled and distributed by nursing staff and are supervised by facility staff when smoking. This policy is implemented through written policy as well as staff education. Despite some discrepancies in the actual implementation of policies to supervise residents who smoke, the policies for assessment for at-risk smokers requiring monitoring is consistent on a national basis.

Objective: To report a case of rapidly occurring hyperglycemia that occurred in a geriatric patient 3 days after treatment with olanzapine., Case Summary: An 89-year-old man was admitted for dementia with behavioral disturbance and psychosis and was started on olanzapine 2.5 mg twice daily. Due to paranoia and agitation, the dose was increased to 5 mg twice daily after 2 days. Subsequently, he developed hyperglycemia (fasting blood glucose 138 mg/dL) that resolved when olanzapine was stopped and recurred (fasting blood glucose 150 mg/dL) after 2 days of rechallenge with olanzapine 2.5 mg twice daily. In addition, his overall medical status worsened, as he developed concurrent acute renal failure and became more confused and lethargic. The hyperglycemia once again resolved with discontinuation of the drug., Discussion: We postulate that the rapid onset of hyperglycemia and the resulting medical sequelae were due to olanzapine. An objective causality assessment revealed that the adverse drug event was probable. There have been numerous case reports of hyperglycemia with olanzapine in the literature, but none reported hyperglycemia within days of initiation of the medication. Although weight gain often coincides with hyperglycemia in patients taking atypical antipsychotics, it does not seem to be a necessary causal factor. Recent data in animal studies have indicated that olanzapine and clozapine rapidly impair whole-body insulin sensitivity in a dose-dependent manner., Conclusions: Clinicians treating elderly patients with olanzapine should be aware of the potential for rapidly developing hyperglycemia and monitor such patients accordingly.

We report a case of second- and third-degree burns in an elderly nursing home resident with dementia who was smoking in her room. This case highlights the risks of smoking by residents in long-term care settings. It also raises awareness to the issues involving smoking cessation and restriction of smoking privileges in the long-term care setting.

We report two cases of serotonin syndrome in elderly patients during treatment of psychotic depression with atypical antipsychotics and antidepressants. The first case is a 69-year-old man who was admitted for depression with psychosis and treated with trazodone, risperidone, and sertraline. Subsequently, he developed myoclonus, tremor, cogwheel rigidity, and diaphoresis. The second case is a 72-year-old female initially admitted to a medical inpatient unit for a change in mental status that presented as increased confusion, lethargy, slurred speech, and a fever of 101.5 degrees. She had been on phenelzine and quetiapine. In both cases, all symptoms resolved within 24 hours of the psychotropics being stopped. In both cases, we believe that serotonin syndrome was produced by a combination of an antidepressant and an atypical antipsychotic. There have been several case reports of serotonin syndrome from similar combinations of antidepressant and atypical antipsychotic treatment. Clinicians treating elderly patients with a combination of serotonergic antidepressants and atypical antipsychotics for psychotic depression should be aware of the potential for serotonin syndrome.

Background: The newer atypical antipsychotics have gained prominence as first-line oral agents to treat severe agitation, but their use in the psychiatric emergency service (PES) setting has been limited because of the unavailability of parenteral formulations. The advent of parenteral formulations of atypical antipsychotics, beginning with ziprasidone in 2002, might afford an alternative treatment option., Objective: The objective of this article was to determine the effectiveness and tolerability of i.m. ziprasidone used to treat agitation in elderly patients., Methods: In this data analysis, the PES database at the Department of Psychiatry and Behavioral Science, School of Medicine, State University of New York, Stony Brook, New York, was searched for records of patients aged > or = 65 years who received a single 20-mg dose of i.m. ziprasidone for the treatment of acute agitation. Efficacy data from these patients were compared with those from an age- and gender-matched sample that received conventional treatment (CT group) with i.m. haloperidol, with or without lorazepam. Data were also included from a previous naturalistic outcomes study to determine the effectiveness and tolerability of i.m. ziprasidone in patients treated at the PES at Stony Brook. Additional records were identified using a search of pharmacy and restraint records for PES-treated geriatric patients who received i.m. ziprasidone over a 2.5-year period beginning in late 2002, when i.m. ziprasidone became available. In some patients in the ziprasidone group, the effects of the drug on agitation were assessed prospectively by blinded psychiatrists using the Behavioural Activity Rating Scale (BARS) (1--difficult or unable to arouse to 7--violent, requires restraint). Also included in the analysis were data concerning use of rescue medication (oral or parenteral) other than the study drug within 2 hours of initial treatment, restraint time, and adverse events (changes in vital sign measurements and electrocardiography [ECG])., Results: The database revealed 15 patients who received ziprasidone (9 men, 6 women; age range, 65-87 years) and 20 patients who were included in the CT sample (13 men, 7 women; age range, 65-88 years). In the 6 cases rated on the BARS, the mean (SE) baseline score was high (6.8 [0.1]), with a decrease to 4.0 (0.4) (P < 0.05) at 45 minutes after study drug administration and to 2.8 (0.4) (P < 0.01) at 120 minutes. Rescue medication was needed in 4 ziprasidone cases and 2 CT cases (P = NS), and mean (SE) restraint times did not vary significantly between groups (ziprasidone [n = 12], 85 [15] minutes; CT [n = 17], 83 [12] minutes). No clinically significant effects on blood pressure or heart rate were noted, and no cardiac or other adverse events were reported. ECG results with ziprasidone (n = 3) or CT (n = 6) were unremarkable., Conclusions: The results of this data analysis of the effects of i.m. ziprasidone suggest that this agent was similarly effective compared with CT and was well tolerated in this geriatric population with acute agitation presenting to a PES. Ziprasidone might be an effective, well-tolerated treatment option for acute agitation in elderly patients presenting to a PES.