The
Canadian Journal of Psychiatry
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| Volume
47 |
Ottawa,
Canada, October 2002 octobre
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Number
8
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Guest Editorial
Geriatric Psychiatry: Complex Challenges, Promising Treatments
Kenneth I Shulman, MD, SM, FRCPsych, FRCPC1
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In this issue, readers of The Canadian Journal of Psychiatry are fortunate
to have 3 outstanding reviews by internationally renowned investigator-clinicians
(2 of whom are Canadians) focusing on the rapidly growing geriatric population.
Two papers deal with the cognitive aspects of dementia, discussing its
early detection by screening methods and its effective treatment in both
early and later stages. The third paper addresses the use of electroconvulsive
therapy (ECT) in old age—a treatment now more fully accepted, not only
within the scientific community but also, hopefully, within the general
population.
Given the demographic imperative, dementia remains one of the major public
health concerns of the coming generation (1). Dementia’s economic costs
and impact on quality of life make it a vital concern for clinicians and
policymakers. Dr Nathan Herrmann’s review of cognitive pharmacotherapy
presents a cautiously optimistic perspective for a condition that had previously
been thought to be hopeless and amenable only to supportive measures. Consequently,
it is significant that cognitive enhancers also show evidence of improved
functional ability, behaviour, and overall quality of life, together with
reduced caregiver burden. While initial data focused on the efficacy of
cognitive enhancers in treating the mild-to-moderate stage of dementia
(assessed as Mini-Mental State Examination [MMSE] scores of 10 to 26),
recent evidence highlights their usefulness in more severe cases. Further,
there is evidence that dementias other than Alzheimer’s disease (that is,
Lewy body dementia and vascular dementia) may also benefit from treatment
with cholinesterase inhibitors. Frontotemporal dementia, which is not
associated with a cholinergic deficit, is unfortunately not affected by
these agents. With regard to practice guidelines, Dr Herrmann’s approach
is realistic. Although preliminary data support the practice of switching
cognitive enhancers if the first drug is not well tolerated or is ineffective,
he cautions that the desperation of caregivers will make them more than
willing to undertake treatments that are not well established, and these
"promising new agents" should not be oversold.
Lorentz and colleagues from the University of Washington address practical
and scientific issues related to effective cognitive screening. It is important
to identify dementia early for several reasons (2). The first is to provide
a coherent explanation to patients and families for the observed changes
in cognition, behaviour, mood, and functioning that are associated with
dementia. Second, a great deal of planning is essential for individuals
and families, including the preparation of a power of attorney for personal
care and property, a will for orderly distribution of assets, and a living
will for end-of-life care. Further, the identification of dementia highlights
increased risks for delirium and focuses on the need to assess driving
ability. Finally, the recent availability of effective treatment with cognitive
enhancers (as described by Dr Hermann) makes it even more important to
treat dementia early. For all these reasons, effective cognitive screening
as a first step in diagnosing dementia is an essential element in our clinical
armamentarium.
It bears emphasizing that screening is not in any way a diagnostic test
but simply a signal for further assessment and investigation for the possible
diagnosis of dementia. For screening to be implemented by front-line clinicians,
it needs to be quick, acceptable to patients, and easy to score and administer,
while retaining reasonable psychometric properties. Lorentz and others
document this very well in their review of the Mini-Cog, which is a combination
of the clock test and a 3-word recall. While multiple scoring systems have
emerged in the literature for clock drawing, most are excessively cumbersome
and complicated and have bewildered clinicians in recent years. A simple
scoring approach described by Lorentz and others and also recommended by
Borson and others (3) is the system used by the Consortium to Establish
a Registry for Alzheimer’s Disease (CERAD) (4). In terms of psychometric
properties, this approach seems to be as valid as the more detailed scoring
systems and, hence, should be considered much more desirable. Finally,
readers can review the pros and cons of various other brief cognitive screens
that use innovative methodologies.
Countering the traditional nihilism associated with old-age psychiatry,
Flint and Gagnon’s critical review of ECT in late-life depression highlights
the potential for recovery, even in severe and refractory cases. These
authors point out that the elderly are most likely to receive ECT because
they are less tolerant of psychotropics and because psychotic depression
is not an uncommon presentation in late life. Their paper reviews many
of the technical issues relevant to ECT, including electrical dose, electrode
placement, and frequency and number of treatments. Many issues are specific
to old age, including the increase in seizure threshold with aging and
its impact on the dose of electricity administered. Moreover, the dose
of electricity affects both efficacy and side effects, and it is this balance
that is a challenge in clinical practice. Flint and Gagnon note the complex
bidirectional relation of cognition and ECT in old age. Depression itself
can produce cognitive impairment, and there are many instances of ECT resulting
in improved cognition after the initial side effects have subsided.
We are reminded that there are no absolute contraindications to ECT, only
relative ones. From a practical point of view, Flint and Gagnon recommend
a twice-weekly frequency and discuss the positive and negative aspects
of high-dose unilateral, compared with bilateral, ECT. Because follow-up
reveals that more than 50% of elderly patients relapse post-ECT, they raise
the issue of continuation and maintenance ECT but highlight practical obstacles
to implementing these treatments. The careful, evidence-based approach
described by Flint and Gagnon regarding the use of ECT in the elderly should
encourage clinicians.
The 3 papers in this In Review section represent a high level of research
and clinical expertise. One can only hope that this level of academic scholarship
and clinical awareness will continue for the next generation, in which
care of the elderly will be an even greater challenge and priority for
the health care system.
References
1. Canadian Study of Health and Aging Working Group. Canadian study of health and aging: study methods and prevalence of dementia. CMAJ 1994;150:899–913.
2. Shulman KI. Clock-drawing: is it the ideal cognitive screening test? Int J Psychiatry 2000;15:548–61.
3. Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The Mini-Cog: a
cognitive ‘vital signs’ measure for dementia screening in multi-lingual
elderly. Int J Geriatr Psychiatry 2000;15:1021–7.
4. Morris JC, Heyman A, Mohs RC, Hughes JP, van Belle G, Fillenbaum GG,
and others. The consortium to establish a registry for Alzheimer’s disease (CERAD), part I. Clinical and neuropsychological assessment of Alzheimer’s disease. Neurology 1989;39:1159–65.
1. Richard Lewar Chair in Geriatric Psychiatry, Sunnybrook and Women’s College Health Sciences Centre, University of Toronto, Toronto, Ontario.
Address for correspondence: Department of Psychiatry, FG-05, Sunnybrook and Women’s College Health Sciences Centre, 2075 Bayview Ave, Toronto, ON M4N 3M5
e-mail: ken.shulman@swchsc.on.ca
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