Med Check

Electroconvulsive therapy (ECT) may be a safe and effective treatment for agitation and behavioral symptoms in elderly patients with dementia. Manjola Ujkaj, M.D., Ph.D., and colleagues conducted a systematic retrospective chart review on all patients admitted to the Geriatric Neuropsychiatry Unit at McLean Hospital in Massachusetts from 2004 to 2007. They identified 16 patients with dementia who were treated with ECT for agitation, and three clinicians independently evaluated the patients' charts for mood and psychotic symptoms before and after the treatment. The patients received on average nine courses of ECT, mostly bilateral treatments. Fourteen (88 percent) of the 16 patients had significant improvement in agitation. One patient had no improvement, and the other had worsening agitation. The mean scores on the Pittsburgh Agitation Scale before and after ECT were 11.0 and 3.9, respectively, which was statistically significant. The frequency of irritability, depression, anxiety symptoms, and delusion were also significantly decreased after treatment. Eleven of the patients had temporarily increased confusion after the ECT. One person discontinued ECT after two courses because of intolerance.


A gene related to a folate-metabolizing enzyme may affect how well patients with depression respond to antidepressants. Brenda Jamerson, Pharm.D., and colleagues at Campbell and Duke universities examined common single-nucleotide polymorphisms (SNPS) in a number of genes that code for proteins involved in folate processing in the body. The genetic samples had been collected from 207 patients receiving treatment for major depression, aged 60 or older, who had no dementia. The researchers identified two SNPS, RS1801131 in the methylene tetrahydrofolate reductase (MTHFR) gene and RS1979277 in the serine hydroxymethyltransferase 1(SHMT1), that were significantly associated with patient response to antidepressant medications. Patients who carried certain SNPS were more likely to reach remission after antidepressant treatment than were those with different genetic variations in the same genes. Despite the small sample size, the authors noted, this association between folate-related genes and response to antidepressants in elderly patients may provide a foundation for further investigation into possible links between nutrition, genetics, and depression treatment. The study was funded by a grant from the National Institute of Environmental Health Sciences.


Current consensus in schizophrenia research and treatment uses the age of 40 as the cut-off between early- and late-onset schizophrenia, which are generally considered two distinct types of the disorder. Ipsit Vahia, M.D., and colleagues from the University of California at San Diego used statistical models to analyze data from 389 patients with schizophrenia and confirmed that age 40 is an appropriate separation between two clusters, based on symptoms identified through the Positive and Negative Syndrome Scale (PANSS), Hamilton Rating Scale for Depression, and Digit Symbol-Coding scores. Patients with onset later than age 40 had significantly better PANSS positive and Digit Symbol Coding scores than did those with earlier onset. The results suggested that “early-onset schizophrenia may be phenotypically distinct from late-onset forms,” but both types “appear more similar than different,” the researchers concluded. The study was supported by grants from the National Institute of Mental Health and Department of Veterans Affairs (VA).


Using the national VA database, researchers from VA medical centers in Cleveland, Philadelphia, and Ann Arbor, Mich., led by Peijun Chen, M.D., Ph.D., reported on the prescribing patterns for use of antipsychotic drugs to treat Parkinson's disease (PD) with psychosis and dementia. In Fiscal 2002, 57 percent of the more than 5,000 PD patients with psychosis in the VA database were prescribed an antipsychotic, of whom 93 percent received second-generation antipsychotics and 19 percent received first-generation antipsychotics at some point. Clozapine was prescribed for only 1.8 percent of these patients. In almost 1,500 patients with both dementia and psychosis, 49 percent were prescribed an antipsychotic. The proportions of first- and second-generation antipsychotic use were similar to those prescribed for patients with PD and psychosis. The authors concluded that a diagnosis of comorbid PD was “independently associated with antipsychotic use in patients with dementia and psychosis,” which reflects the severity of psychosis in PD patients. In addition, they noted that clozapine “appears to be vastly underutilized in clinical practice,” and other high-potency and second-generation drugs were used frequently despite their potential to worsen parkinsonism and the lack of evidence for their efficacy in elderly patients with PD. ▪