Sexuality and the patient with dementia

Caretakers in a geropsychiatric medical unit offering care to patients with dementia diagnoses were surveyed regarding their views of the sexual conduct of their patients. The majority of them described difficulties in managing patients who displayed sexual behaviors. Sexually active and interested patients were both male and female. The majority of the sexual encounters observed by caretakers was not considered to be consensual. Exploitation and sexual assault of vulnerable individuals who lack any way of defending themselves was a concern expressed. Caretakers' views of patient characteristics that predict sexual behavior and effective strategies to discourage sexual approaches of vulnerable patients are discussed.     

General practitioners and mental disorders

This article presents the results of a mail survey about mental illness in general practice carried out in France in 1981 on a sample of 353 general practitioners. The research had two main objectives: The first was to understand the general practitioners perceptions of the manner in which they dealt with their patients suffering from psychiatric or psychologic disorders. The second was to test several hypothesis concerning the relationship between the frequency of diagnoses of mental disorders by the general practitioner and her or his links with the field of psychopathology and with the mental patients. The findings of the survey confirm the main hypothesis: the way general practitioners diagnose mental illness is significantly related to their interest in the subject of psychopathology and in their mental patients. Moreover, these results show how general practitioners claim that psychological problems are part of their field and that they do not feel at all uneasy when confronted with patients suffering from mental disorders. They frequently deal with these patients with mental disorders and believe that they are qualified to practice psychotherapy.     

A study of the accumulation of long-stay patients in a general hospital psychiatric department.

A survey of all admissions of patients under the age of 65 years during the first 6 years of a General Hospital Psychiatric Department identified 16 'long-stay' patients (a year or more of continuous inpatient care) and 8 'medium-stay' patients (at least 6 months inpatient care in any period of a year). The most common diagnoses were organic brain disorders among long-stay patients, and affective disorders among medium-stay patients. There was no consistent accumulation of long-stay patients: those with functional disorders were usually discharged to hostel accommodation, while those with organic brain disorders died or were transferred to inpatient care in other hospitals.     

Lewy body dementia: case report and discussion

BACKGROUND: Lewy body dementia is a common but frequently underdiagnosed cause of dementia often mistaken for the more familiar entity of Alzheimer disease. Clinically the distinction is important, because it can have profound implications for management. METHODS: The medical literature was searched using the keywords "Lewy bodies," "Lewy body dementia," "Alzheimer dementia," and "parkinsonian disorders." A case of Lewy body dementia is described. RESULTS: An elderly man had long-standing diagnoses of Alzheimer disease and Parkinson disease. After he was evaluated thoroughly, the diagnosis was revised to Lewy body dementia, leading to changes in treatment that were associated with dramatic improvement in the patient's mental status. Evidence from the literature suggests that Lewy body dementia can be diagnosed in primary care settings based on clinical criteria. The physician should be alert to this diagnosis, and special attention should be paid to dementia patients who exhibit parkinsonism, hallucinations, fluctuating cognition, or prominent visuosperceptual deficits. CONCLUSIONS: The diagnosis of Lewy body dementia has important implications. It is associated with a high incidence of neuroleptic sensitivity, necessitating great caution in the use of these common antipsychotic agents. Early studies indicate cholinesterase inhibitors can be beneficial for treating the hallucinations and behavior disturbances that afflict these patients and might also improve cognition.     

Dementia and cognitive impairment are not associated with earlier mortality after percutaneous endoscopic gastrostomy

BACKGROUND: Studies have shown varying results with regard to risk factors for mortality after percutaneous endoscopic gastrostomy (PEG). Objectives: To examine the time to death in patients with dementia or significant cognitive impairment (SCI) due to neurologic injury who had undergone PEG compared with patients without either of these diagnoses, and to examine risk factors for 30-day mortality after PEG. METHODS: Patients who had undergone PEG over a 2-year period were identified. Local medical records and the Social Security Death Index were reviewed to ascertain the patients' age, gender, serum albumin, diagnoses, presence or absence of dementia or SCI, presence or absence of complications related to PEG, and length of survival after PEG. The Charlson Comorbidity Index (CCI) was calculated based on the medical diagnoses at the time of PEG. RESULTS: One hundred ninety patients were identified. Forty-five carried a diagnosis of dementia and/or SCI compared with 145 who did not. Median survival of patients with dementia or SCI was 53 days compared with 78 days in patients without these diagnoses (P=.85). Age (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.04-1.12) and albumin (OR 0.43, 95% CI 0.22-0.84) were associated with 30-day mortality, whereas gender (OR 1.2, 95% CI 0.47-2.90), CCI (OR 1.1, 95% CI 0.86-1.32), and presence of PEG-related complications (OR 1.6, 95% CI 0.36-6.76) were not. CONCLUSIONS: Age and serum albumin are risk factors for 30-day mortality after PEG. Patients with dementia or SCI do not have a significantly shorter survival after PEG than patients with intact cognitive function.     

Cognitive disorders appearing before the age of 65 in patients of the Alzheimer Centre of the VU Medical Centre: diagnoses and clinical characteristics

OBJECTIVE: To obtain a profile of the causes and clinical characteristics of cognitive disorders in patients referred to a memory clinic before the age of 65 years. DESIGN: Retrospective case-note study. METHOD: Data were collected from 127 subjects with objective cognitive disorders who visited the Alzheimer Centre of the VU Medical Centre in Amsterdam, the Netherlands, in the period from 1 January 2001 to 31 December 2003 with an onset of complaints before the age of 65. Besides the diagnoses, we investigated the clinical presentations, the occurrence of cardiovascular risk factors, the family history, and the presence of noncognitive neurological signs. RESULTS: The most common causes of cognitive decline under the age of 65 were Alzheimer's disease (46%) and frontotemporal dementia (23%). Vascular dementia was seen in 5% and dementia with Lewy bodies in 2%; 9% had mild cognitive impairment but no dementia. Hypertension and a positive family history for dementia were each present in 40% of the patients. Non-cognitive neurological abnormalities were found only in cases of non-Alzheimer dementia. During the period under investigation, the number of patients with objective cognitive disorders increased more than did the number without a cognitive disorder. CONCLUSION: Within the population of a memory clinic, Alzheimer's disease was the most frequent cause of cognitive decline under the age of 65, followed by frontotemporal dementia. The distribution differed from causes of dementia at an older age, where vascular dementia had the second place.     

Screening for dementia: family caregiver questionnaires reliably predict dementia

INTRODUCTION: Because of increasing numbers of patients with diseases that cause dementia, primary care physicians must use efficient assessment procedures in their clinics. Important advantages of screening for dementia include determination of the patient's cognitive capacity to participate competently in his/her own medical care and early diagnosis, which enables administration of medications that preserve some cognitive functions. METHODS: A study was conducted to determine whether questionnaires completed by a family caregiver about a patient could differentiate between those with dementia and those with other neurological disorders that do not cause dementia. Clinical and demographic information gleaned from more than 330 consecutive multidisciplinary outpatient dementia clinic assessments were entered into an Institutional Review Board-approved database and analyzed post hoc to answer several research questions. RESULTS: Three questionnaires completed by family caregivers about patients were able to differentiate reliably between patients with dementia with a variety of degenerative disorders and patients without dementia with other neurological disorders that often are mistaken for dementia. When these questionnaires are combined with a patient test (Mini-Mental State Examination), an accurate prediction of which patients suffer from a true degenerative disease that causes dementia was robust (effect size of R2 = 0.81, P <.0001 for the multiple logistic regression analysis). DISCUSSION: These instruments assist the primary care physician to determine which patients seem to suffer from a disease that causes dementia and need further assessment by the physician or at a specialized dementia clinic. The ultimate goal is to assure that patients receive appropriate medical management as early in the disease process as possible.     

Hypersexual Behavior in Frontotemporal Dementia: A Comparison with Early-Onset Alzheimer’s Disease

The basis of hypersexual behavior among patients with dementia is not entirely clear. Hypersexual behavior may be a particular feature of behavioral variant frontotemporal dementia (bvFTD), which affects ventromedial frontal and adjacent anterior temporal regions specialized in interpersonal behavior. Recent efforts to define hypersexual disorder indicate an increasing awareness of heightened sexual activity as a source of personal distress and functional impairment, and clarification of hypersexuality in bvFTD could contribute to understanding the neurobiology of this behavior. This study reviewed 47 patients with bvFTD compared to 58 patients with Alzheimer’s disease (AD) for the presence of heightened sexual activity to the point of distress to caregivers and others. Hypersexual behavior occurred in 6 (13 %) bvFTD patients compared to none of the AD patients. Caregivers judged all six bvFTD patients with hypersexual behavior as having a dramatic increase in sexual frequency from premorbid levels. All had general disinhibition, poor impulse control, and actively sought sexual stimulation. They had widened sexual interests and experienced sexual arousal from previously unexciting stimuli. One patient, with early and predominant right anterior temporal involvement, was easily aroused by slight stimuli, such as touching her palms. Although previously considered to be predominantly disinhibited sexual behavior as part of generalized disinhibition, these patients with dementia illustrate varying degrees of increased sexual desire. We conclude that bvFTD is uniquely associated with hypersexuality; it is more than just cognitive impairment with frontal disinhibition but also involves alterations in sexual drive, possibly from right anterior temporal- limbic involvement in this disease.     

Quality assurance of outcome in mental health care: a model for routine use in clinical settings.

A problem-oriented method of quality assurance of clinical outcome was used in 1,384 patients who were assessed and treated over 8 years by 41 nurse therapist trainees. The clinical audit suggested that for most diagnoses patients' improvement after treatment was usually satisfactory. Though the system was developed to monitor the progress of patients with anxiety, sexual and habit disorders having behavioural psychotherapy, it could also be applied to other disorders like depression and to other treatments. The method is simple enough for routine use, and computerisation would put it within the grasp of most clinics and training programs for all mental health care professionals.     

The validity of clinical diagnoses of dementia in a group of consecutively autopsied memory clinic patients

Background: Epidemiological studies show that up to 10 % of individuals aged 65 years and older suffer from dementia, most commonly from dementia of the Alzheimer Type (DAT) [1]. Clinicopathological studies are critical to our understanding of this disease and improving the accuracy of clinical diagnoses.Objectives: Our objectives were to examine the validity of clinical diagnoses of DAT, to determine the prevalence of different forms of dementia in this sample, and to investigate the relationship between age at death and polymorbidity.Subjects and method: Clinical data were available from 221 patients who had been examined at the Basel Memory Clinic between 1986 and 1996. From this population, 34 % (75 patients) were autopsied in the Department of Pathology, University Hospital Basel, and neuropathological examinations were additionally performed on 62 (83 %) of these patients. Clinical and neuropathological data were retrospectively compared.Results: 67.8 % of the neuropathologically examined patients received a definitive diagnosis of AD (Alzheimer’s disease), vascular dementia (VaD) or mixed dementia (AD and VaD). AD alone or with other histopathological hallmarks of dementia was the most prevalent neuropathological diagnosis (63 %). VaD was deemed the only cause of dementia in only 4.8 % of patients. The sensitivity for DAT was 75.9 %, the specificity 60.6 %. Increasing age was associated with an increasing number of clinical and neuropathological diagnoses.Conclusion: The sensitivity and specificity of the clinical diagnoses of DAT found in our study are similar to previous reports (2–5). Older patients had more etiologies of their dementia than younger patients. This study reaffirms the need for internationally accepted criteria for clinical and neuropathological diagnoses, as well as further clinical-neuropathological investigations to further refine the clinical diagnostic process.     

Applicability of diagnostic recommendations on dementia in family practice.

OBJECTIVE: To evaluate the applicability of the Dutch dementia guideline's recommendations, including the diagnostic criteria used by family practitioners, and to explore characteristics in both patients and family practitioners which are associated with the use of these recommendations. DESIGN: An observational study was set up with a sample of 64 family practitioners who were instructed to use the Dutch national dementia guideline on incident-suspected dementia patients. The applicability was expressed as the percentage of recommendations applied. The use of diagnostic criteria was checked by comparing the family practitioners diagnoses with the diagnoses received by integrating the registered symptoms according to the DSM-III-R criteria. Associations between the number of recommendations applied, and demographic and clinical features were explored. MAIN OUTCOME MEASURES: (i) guideline applicability (ii) integrated use of DSM-III-R criteria. RESULTS: 107 patients were included. The average application rate of the guideline's 31 diagnostic key recommendations was 86% or 24.8 (SD 3.6). The family practitioners diagnoses were consistent with the expected DSM-III-R diagnoses in 26% of the cases (kappa = 0.1). A greater number of patients in a practice was positively associated with the use of recommendations. A need for referral by the family practitioners, and patients' denial of dementia were negatively associated with the use of recommendations. The presence of dementia and a patient's age were negatively associated with the use of the DSM-III-R criteria. CONCLUSIONS: The applicability of the diagnostic recommendations of the national Dutch dementia guideline in a representative sample of family practitioners was promising. Nevertheless, the diagnostic criteria of the DSM-III-R, which were part of the dementia guideline, provided little or no guidance to the family practitioners in their diagnostic decision-making. Clinical and demographic variables explained some of the variation in the use of recommendations.     

Questioning the ability to drive in patients with cognitive disorders

The relatives of an 81-year-old man questioned whether he was fit to drive, but he refused to discuss the matter. His son sent a written notice to the Dutch Driving License Centre (CBR) and the physicians were about to do so when the man fell and spent one night lying on the floor in his house. The man was hospitalised and his son took his car keys away. The approach to assessing the ability to drive in patients with cognitive disorders and dementia is a difficult matter, especially when a patient is unaware of his or her illness. At this time, licensed drivers with cognitive disorders are not obliged to report the disorder to the CBR. The CBR considers patients with dementia unfit to drive without further investigation, whereas patients with cognitive disorders must pass a driving test. This may become problematic with the early diagnosis of dementia that is preferred today. On the other hand, caregivers may have to announce a patient to the CBR when they become unfit to drive due to dementia.     

Substance Use and Mental Health Disorders Among Heterosexual Identified Men and Women Who Have Same-Sex Partners or Same-Sex Attraction: Results from the National Epidemiological Survey on Alcohol and Related Conditions

This study examined sexual orientation discordance, a mismatch between self-reported sexual identity and sexual behavior or sexual attraction, by describing the characteristics, substance use disorders, and mental health risks of heterosexual identified individuals who endorsed this pattern of sexual identification, behavior, and attraction. Using data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), we created three groups based on participants’ reported sexual identity and either their sexual behavior or sexual attraction: heterosexual concordant, homosexual concordant, and heterosexual discordant. Bivariate models assessed the relationship of discordant status and demographic correlates, lifetime substance use disorders, and mental health diagnoses. Logistic regression models tested associations between both behavior discordance and attraction discordance and the likelihood of having lifetime disorders of substance use, major depression, and generalized anxiety. Results of this study provided evidence of varying levels of substance use and mental health disorder risk by gender, discordance status, and discordance type. Behavioral discordance was associated with increased risk of mental health and substance use disorder among women (compared to heterosexual concordance). Findings among men were less consistent with heightened risk of alcohol and inhalant use only. Attraction discordance was notably different from behavioral discordance. The odds of substance use and mental health disorders were the same or lower compared with both the heterosexual and homosexual concordance groups. Future research should begin to test theoretical explanations for these differences.     

Women’s Views of their Sexual Difficulties: Agreement and Disagreement with Clinical Diagnoses

There is controversy about how to conceptualize sexual problems in women. Our purpose in this study was to compare ICD-10 diagnoses of sexual dysfunction in women with whether or not the woman perceived she had a sexual problem, her views on its origins, and its impact on her life. Participants (N = 401, M age, 37.8 years) were consecutive attendees to general practices in London, England. Our main measures were an ICD-10 diagnosis of sexual dysfunction and the woman’s own perception of a sexual problem. Based on reported symptoms and behavior, 38% of women had at least one ICD-10 diagnosis of sexual dysfunction. Prevalence fell to 18% in women who also perceived they had a problem and to 6% in women who regarded the problem as moderate or severe. A total of 73 (18%) women were assigned an ICD-10 diagnosis and agreed that they had a problem, 80 (20%) were assigned a diagnosis but reported no problem, 78 (19%) had no diagnosis but reported a sexual problem, and 170 (42%) had no diagnosis and reported no problem. For women with sexual partners, reported sexual satisfaction was lowest in those assigned an ICD-10 diagnosis who also perceived they had a problem and highest in those with no diagnosis and no perceived problem. Relationship and emotional difficulties were the most common perceived causes of sexual difficulties, whether or not an ICD-10 diagnosis was assigned. There were three aspects to sexual difficulties in women. The first concerned symptoms and behavior that clinicians used to make a diagnosis, the second was the woman’s own perception that she had a sexual difficulty, and the third was her level of sexual satisfaction. All three appear to be important and may explain why published prevalence rates of sexual dysfunction and associated factors are so conflicting.     

Long-term follow-up of rural involuntary clients

A cohort of 72 persons who had entered a rural Oregon county's involuntary treatment system in 1979 through 1982 was followed for six years. While schizophrenia was the most frequent diagnosis, several other conditions were represented including adjustment disorders, organic mental disorders, and substance abuse. The majority (55%) of persons with organic mental disorders died as did 12% of the individuals with schizophrenia. The overall mortality rate was three times the expected figure (p=.002). During the follow-up period, only 39% of the initial cohort received treatment from a community mental health program whereas 28% were newly admitted (involuntarily) to a state mental hospital. Hospital recividism was most likely among individuals who had had prior involuntary treatment. At least in rural areas, the civil commitment system seems to serve both “infrequent” and “persistent” users. Infrequent users mainly have diagnoses of adjustment disorders and/or substance abuse. Persistent users chiefly have diagnoses of organic mental disorders, mood disorders, or schizophrenia. Modifying the involuntary treatment system to take account of this heterogeneous population's diverse needs is discussed.     

Experience of sexuality in patients with psoriasis and constitutional eczema]

In order to determine the effect of chronic skin disorders on sexuality a cross-sectional study was carried out in the Dermatological Outpatient Clinic of Leiden University Hospital. Fifty-two patients with psoriasis and 25 patients with atopic dermatitis filled in a questionnaire which included items on sexual responsiveness and satisfaction. The response rate was 84%. One-third of the patients, especially those with psoriasis, had problems with dating and starting sexual relationships, and were embarrassed in these relationships. The sexual responsiveness of both male and female patients was below that in the normal population. Women appeared to have more problems in this area then men. Their sexual satisfaction was lower than in the average Dutch population, whereas in men this trend was found to be reversed. Sexual responsiveness did not correlate with the extent of the skin disease or location around genital areas, but was associated with self-esteem and the number of emotional complaints. In the treatment of patients with chronic skin disorders attention should be paid to sexual problems that may arise. Groups that are especially affected are females and young psoriatics who have their first sexual relationship.     

The Role of Clinical Neuropsychology in the Study of Sexuality and Disability

Human sexuality is the way people experience themselves and each other as sexual beings. Clinical neuropsychology is an area of psychology that specializes in the diagnostic assessment and treatment of patients with brain injury or neurocognitive deficit. Specific neuropsychological correlates of sexuality have been researched in the past, including sex differences in cognitive abilities and sexual orientation. Although some consistent differences between sex and sexual orientation have been found, the majority of these differences appear to be due to an interaction of biological predisposition and sociological factors. Additionally, neuropathological correlates of sexual disorders have been found and future research into the neuropsychological correlates of sexual offenders (i.e., rapists, child molesters) is warranted. Although neuropsychology has been peripherally involved in research concerning human sexuality, there is a more prominent role for clinical neuropsychologists who are uniquely trained to provide assistance in the diagnosis and treatment of sexual deviance and sexual dysfunction/disability.     

Depressionen im Alter

Depression is the most frequent psychiatric disorder in old age. Some patients have had depressive episodes or other psychological disorder in an earlier part of their life span. Older people show more somatic or cognitive complaints compared to younger depressives. Risk factors for depression in old age are (incident) physical disorders, sleep disorders or loss of spouse. Depression worsens course and prognosis of comorbid somatic disorders. A major consequence is the high suicide rate in the elderly. Depression is also a risk factor for other disorders like dementia or institutionalisation. The interplay between depression and dementia and other organic brain disorders is complex und still unresolved. Depression in the elderly is a challenge for our health system. Recognition and treatment rates are still too low. Integrative treatment plans for depression with comorbid physical disorders or in various settings should be developed. With the growing elderly population the available evidence for treatment urgently has to be increased. In current practice drug therapies--mostly inadequate--dominate. Psychotherapy should be promoted and the number of old age psychotherapists increased.     

The utility of PET brain imaging in the initial evaluation of dementia

Given the challenges and benefits of timely and accurate diagnosis of neurodegenerative disorders and the importance of appropriate subsequent treatments, physicians and patients alike desire tools that aid in diagnosing dementia as early and as precisely as possible. One of these tools may be functional brain imaging, specifically positron emission tomography (PET). Recent technological advancements, ongoing research studies, and approval for reimbursement by various insurance companies and Medicare, under certain circumstances, have led to an increased interest in the use of this tool in the evaluation of dementia. This article will review PET brain imaging in the initial assessment and diagnosis of dementia, including its place in current guidelines and role in diagnostic algorithms, its applicability in differentiating among various dementia syndromes and major psychiatric disorders, and some of the controversies surrounding its utility in general clinical practice.     

Sexual problems of male patients in family practice.

OBJECTIVES: Little is known about men's expectations of their family physicians regarding sexual disorders. Our goal was to evaluate the frequency of sexual problems among male patients in family practice and to assess their need for help. STUDY DESIGN: We performed a cross-sectional survey based on structured questionnaires answered by patients and physicians in German family practices. POPULATION: We approached 43 family physicians; 20 (43%) participated. On a single day all men 18 years and older visiting the participating practices were approached, and 307 (84%) took part in the survey. OUTCOMES MEASURED: Patients were asked about their frequency and type of sexual problems, their need for help, and their expectations of their physicians. The physicians described their perceptions and management of sexual problems in family practice. RESULTS: Nearly all patients (93%) reported at least 1 sexual problem from which they suffered seldom or more often. The most common problems were low sexual desire (73%) and premature ejaculation (66%). Occupational stress was considered causative by more than half of the men (107/201). Forty-eight percent considered it important to talk with their physicians about sexual concerns. However, most physicians initiated a discussion about sexual concerns only seldom or occasionally. There was a nonsignificant correlation between the physicians' assumed knowledge and the patients' wish to contact them in case of sexual problems (rho=0.26). CONCLUSIONS: The high frequency of self-reported sexual disorders and the hesitancy of family physicians to deal with this topic signals a neglected area in primary health care. Certain conditions, such as occupational stress, which may be associated with sexual concerns, should encourage the physician to initiate discussions about sexuality.