Journal of the Academy of Consultation-Liaison Psychiatry最新文献

Introduction: Traumatic brain injury (TBI) is associated with greater risk and earlier onset of dementia. This study investigated whether later-life changes in subjective cognition and behavior - potential markers of AD - could be observed in cognitively unimpaired older persons with a history of suspected mild TBI (smTBI) earlier in life and whether changes in cognition and behavior mediated the link between smTBI and daily function.

Methods: Data for 1392 participants from the Canadian Platform for Research Online to Investigate Health, Quality of Life, Cognition, Behaviour, Function, and Caregiving in Aging (CAN-PROTECT) were analyzed. A validated self-reported brain injury screening questionnaire was used to determine history of smTBI. Outcomes were measured using the Everyday Cognition (ECog-II) scale (for subjective cognitive decline - SCD), MBI Checklist (MBI-C, for mild behavioural impairment - MBI), and Standard Assessment of Global Everyday Activities (SAGEA, for function). Inverse probability of treatment weighted logistic and negative binomial regressions were used to model smTBI (exposure) associations with SCD+ and MBI+ statuses, and ECog-II and MBI-C total scores, respectively. Mediation analyses were conducted using bootstrapping.

Results: History of smTBI was linked to higher odds of SCD+ (OR=1.45, 95%CI: [1.14-1.84]) or MBI+ (OR=1.75, 95%CI: [1.54-1.98]), as well as 24% (95%CI: [18%-31%]) higher ECog-II and 52% (95%CI: [41%-63%]) higher MBI-C total scores. Finally, SCD+ and MBI+ statuses mediated approximately 45% and 56%, respectively, of the association between smTBI history and poorer function, as indicated by higher SAGEA total scores.

Discussion: smTBI at any point in the life course is linked to poorer cognition and behavior even in community-dwelling older persons without MCI or dementia. Older persons with smTBI may benefit from early dementia risk assessment using tools that measure changes in cognition and behavior. Interventions for declining cognition and behavior may also be beneficial in this population to address functional impairment.

Background: Palliative care (PC) is the standard of care for patients with serious medical illnesses, or those conditions associated with high risk of mortality and negative impact on quality of life (QOL). Electroconvulsive therapy (ECT) is the gold standard treatment for certain psychiatric conditions, which may co-occur with serious medical illnesses. However, the use of "palliative ECT" (PECT) in this context is understudied.

Methods: We conducted a descriptive retrospective cohort study reviewing the indications, outcomes, and regimens of PECT. We included patients who had an ECT consultation, in addition to either a PC consultation or a do-not-attempt-resuscitation code status between 2018 and 2023.

Results: Thirty-one patients met our inclusion criteria, and 21 received ECT. The cohort was predominantly female (70%) with a mean age of 67.6 (range 25-90). Catatonia (64.5%) and treatment-resistant depressive disorder (35.5%) were the most common indications for ECT. At the time of ECT consultation, 16 patients (51.6%) had a serious medical illness, including cancer (19.4%) or end-organ disease (22.6%). Fourteen patients had major neurocognitive disorder (MNCD) (45.2%). Surrogate decision-makers consented for ECT in 64.5% of cases. All 21 patients who received ECT experienced psychiatric symptom improvement. ECT was associated with reduced mortality risk in 5 (23.8%) cases. Five patients initially misdiagnosed with MNCD experienced recovery in cognitive function after ECT, and the diagnosis was revised to depression-related cognitive dysfunction. Eight patients retained a comorbid MNCD diagnosis but experienced a mean Montreal Cognitive Assessment (MoCA) improvement of 5 points (range 0 to 17) with ECT.

Discussion: This work highlights the use of ECT among patients with serious medical illnesses, identifying cases when ECT was beneficial or deemed unsuitable. Patients with serious medical illnesses who also had an indication for ECT experienced improved QOL with ECT. Misdiagnoses, such as confusing depression-related cognitive dysfunction and catatonia for MNCD, were effectively addressed through ECT. The findings underscore the importance of cross-specialty collaboration between C-L psychiatry and PC.

Conclusions: Patients who receive PECT experience reduced suffering and improved QOL. PECT may be helpful in scenarios of life-threatening psychiatric illnesses, terminal medical illnesses with comorbid treatment-refractory psychiatric illnesses, and diagnostic uncertainty with MNCD.

Background: The End of Life Option Act (EOLOA) legalized medical aid in dying (MAID) in California in 2015. University of California, San Francisco Health initially implemented a policy requiring a mandatory mental health assessment of all patients seeking MAID, though this was not required by the EOLOA. State-level statistics on EOLOA are available, but less is known about outcomes at individual institutions and how institutional policy affects outcomes for patients seeking MAID.

Objectives: Investigators examined the factors contributing to patients' decisions to request MAID and how the mandatory mental health assessment impacted determinations of decisional capacity and access to MAID.

Methods: Retrospective chart review was conducted on a sample of patients who had pursued MAID or been prescribed MAID medications between June 2016 and May 2020 obtained by a combination of purposive sampling (n = 78) and systematic electronic health record sampling (n = 22). Descriptive statistics were used to examine demographic factors, neuropsychiatric diagnoses and rating scales, factors contributing to patients' decision to request MAID, and outcomes of the psychiatric evaluation process.

Results: Of the 78 patients in the purposive sample who had initiated EOLOA requests, 67% had MAID medications prescribed. Zero patients were found to lack decisional capacity due to a current psychiatric condition. Many patient records were missing relevant data including neuropsychiatric rating scale scores and factors contributing to patients' decision to request MAID. The neuropsychiatric rating scale scores and diagnoses that were present did not suggest a high prevalence of severe psychiatric illness in the sample.

Conclusions: The findings from this study suggest that mandatory mental health assessments for all patients requesting MAID at a single academic medical center did not identify patients who lacked decisional capacity to pursue MAID, and potentially created access barriers to seriously ill patients seeking this intervention. Generalizability of findings may be limited by the fact that mental illness burden was low in the studied sample. Results from this study contributed to changes in EOLOA institutional policy at University of California, San Francisco, including elimination of the mandatory mental health assessment for EOLOA candidates in favor of a conditional mental health assessment based on certain clinical criteria.

Background: Catatonia is a frequently missed diagnosis on medical wards, delaying effective treatment or permitting accidental use of neuroleptics that can exacerbate the condition. Thyroid storm has rarely been associated with catatonia in case reports, with no prior reviews synthesizing this research.

Objective: We present a case of catatonia during thyroid storm following administration of low-dose haloperidol, followed by a review of previously published cases and discussion of their common factors and potential mechanisms.

Methods: We first describe a case of a 37-year-old woman with untreated hyperthyroidism and bipolar disorder admitted for mania in the context of thyroid storm. She developed catatonic symptoms after receiving each of two doses of haloperidol. We then present a systematic review of the literature, drawn from the OVID Medline, PsycINFO, and Embase databases, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify case reports of catatonia presenting in association with hyperthyroidism.

Results: Seventeen cases were identified-10 in published reports and seven in poster abstracts. The degree of evidence for catatonia varied, with few cases using formal scales. Several cases, including ours, reported recent administration of neuroleptics with dopamine antagonism (29%), usually at relatively low doses or with subsequent tolerance of neuroleptics when euthyroid. Other common factors included a history of psychiatric symptoms (41%) or presence of thyroid autoantibodies (41%).

Conclusions: These results are consistent with clinical and preclinical evidence that hyperthyroidism might potentiate dopamine blockade, and they encourage clinicians to minimize neuroleptic use in this population. Other theories have also been proposed for catatonia's association with hyperthyroidism, including direct thyrotoxic effect, autoimmune reaction, and mediation via another secondary psychiatric syndrome (e.g., mania). Clinicians should be aware of the potential for catatonia in thyroid storm, with or without neuroleptic use.

Background: Mild behavioral impairment (MBI) has been associated with global brain atrophy, but the regional neural correlates of MBI symptoms are less clear, particularly among community-dwelling older individuals without dementia.

Objective: Our objective was to examine the associations of MBI domains with gray matter (GM) volumes in a large population-based sample of older adults without dementia.

Methods: We performed a cross-sectional study of 1445 community-dwelling older adults in the Atherosclerosis Risk in Communities Study who underwent detailed neurocognitive assessment and brain magnetic resonance imaging in 2011-2013. MBI domains were defined using an established algorithm that maps data collected from informants on the Neuropsychiatric Inventory Questionnaire to the 5 MBI domains of decreased motivation, affective dysregulation, impulse dyscontrol, social inappropriateness, and abnormal perception/thought content. We performed voxel-based morphometry analyses to investigate associations of any MBI domain symptoms with GM volumes. We additionally performed region-of-interest analyses using adjusted linear regression models to examine associations between individual MBI domains with a priori-hypothesized regional GM volumes.

Results: Overall, the mean age of participants was 76.5 years; 59% were female, 21% were of Black race, and 26% had symptoms in at least one MBI domain. Participants with normal cognition comprised 60% of the population, and 40% had mild cognitive impairment. Compared to individuals without any MBI domain symptoms, voxel-based morphometry analyses showed that participants with symptoms in at least one MBI domain had consistently lower GM volumes in the cerebellum and bilateral temporal lobes, particularly involving the hippocampus. In adjusted region-of-interest models, affective dysregulation domain symptoms were associated with lower GM volume in the inferior temporal lobe (β = -0.34; 95% confidence interval = -0.64, -0.04), and impulse dyscontrol domain symptoms were associated with lower GM volume in the parahippocampal gyrus (β = -0.06; 95% confidence interval = -0.11, 0.00).

Conclusions: In this community-dwelling population of older adults without dementia, MBI symptoms were associated with lower GM volumes in regions commonly implicated in early Alzheimer's disease pathology. These findings lend support to the notion that MBI symptoms may be useful in identifying individuals at risk for future dementia.

Background: Despite rapid shifts in consultation-liaison psychiatry (CLP) training in residency, including increasing general residency training requirements from the Accreditation Council for Graduate Medical Education, greater utilization of advanced practice providers, and effects of the coronavirus-2019 pandemic, the Academy of Consultation-Liaison Psychiatry has not updated recommendations for residency training in CLP since 2014. A national survey of residency program directors in 2021 suggested many changes to the structure of CLP rotations at individual programs over the past decade.

Objective: These recommendations are intended to guide residency program directors toward optimizing CLP training for all residents, including those who will eventually pursue CLP fellowship.

Methods: We convened a workgroup of 8 Academy of Consultation-Liaison Psychiatry members holding leadership positions in residency and fellowship education on local and national levels. The project was approved by the Academy of Consultation-Liaison Psychiatry Executive Council and conducted via a three-stage iterative process.

Results: Consensus was reached on 34 recommendations across four domains, including structural issues, faculty supervision, formal curriculum and evaluations, and elective experiences. Residents must spend sufficient time on CLP rotations to achieve relevant milestones. Given that consultants are expected to offer unique insight, the ideal placement of core CLP rotations comes at a time in residency where residents are able to provide expert opinion and lead teams. Faculty expertise in CLP and availability to provide direct supervision and oversight to trainees are essential. A separate and formal CLP didactic curriculum should exist, and elective opportunities should be offered to supplement training.

Conclusions: Establishing a strong CLP foundation for all residents is essential for ensuring competency in providing psychiatric care for medically complex patients and collaborating with our colleagues in other specialties, as well as fostering trainee interest in pursuing a career in CLP.

Background: Catatonia is a psychomotor syndrome associated with neurotransmitter disturbances, common in both psychiatric and medical settings. Hypoactivity of the GABA_A receptor is one of the predominant theories behind the pathophysiology of catatonia, affecting both motor functioning and emotional regulation. Benzodiazepines such as lorazepam are considered the first-line treatment for catatonia. However, up to 27% of catatonia cases fail to respond to benzodiazepines alone. Zolpidem, which can be used as a challenge, monotherapy, or augmentation agent, serves as a promising pharmacological agent for catatonia due to its unique pharmacodynamic and pharmacokinetic profile.

Objective: We sought to systematically examine the evidence behind zolpidem's use among adult patients to understand its clinical utility in the management of catatonia against prevailing treatments such as lorazepam and electroconvulsive therapy.

Methods: We conducted a systematic review using search terms related to zolpidem and catatonia in PubMed, EMBASE, and Web of Science. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and identified 29 studies, including case studies and case series that met inclusion criteria.

Results: We reviewed 35 cases in which zolpidem was used for catatonia management (age: mean = 51.5 ± 21.0 standard deviation years; 68.6% female; Bush Francis Catatonia Rating Scale: mean = 22.2 ± 9.0 standard deviation). Proportions of positive responses for zolpidem on catatonia varied by treatment approach: 91% as a challenge agent (n = 10), 100% as a first-line monotherapy agent (n = 3), 57% as a first-line combination therapy agent (n = 4), 70% as a second-line monotherapy agent (n = 7), and 100% as a second-line augmentation agent (n = 4). In total, 28 out of the 35 reported cases of catatonia (80%) responded positively to zolpidem.

Conclusions: An 80% positive response rate for zolpidem in lysing catatonia is encouraging but may be an overestimate due to reporting bias of case-level data. Results may be explained by zolpidem's selectivity for the α₁ subunit of the GABA_A receptor. Thus, zolpidem may be an underutilized catatonia treatment and prove useful in situations when benzodiazepines fail or when electroconvulsive therapy access is limited. Given that current literature on the use of zolpidem for catatonia is limited to case reports, more robust research in this area is warranted.