Presentation of a clinical case and use of a bibliography from the following search engines: PubMed, Science direct, Medscape.

This case is about a 62-year-old woman, hypertensive and obese, who had a gastric by-pass complicated by deficiency neuropathy and Gayet Wernicke’s encephalopathy. While neurological symptoms were improved by treatment with B1 and B12 vitamins, carbamazepine and clomipramine, a state of psychomotor excitation persisted and prompted a psychiatric consultation. The diagnosis of a maniac episode was retained and the patient was put under mood stabilizer treatment.

Etiological research discussed three cases:

A mania induced by Vitamin B12 deficiency, associated to neurological symptoms with impaired memory, paresthesia, and ataxia.

A mania induced by treatment with clomipramine.

A primary mania in an obese woman. This possibility is not uncommon. Indeed, several studies have confirmed the frequency of comorbidity of mood disorders and obesity.

Patients diagnosed with neurocognitive disorders have behavioral disturbances, like aggression, self-harming behaviors, psychomotor agitation, impulsivity, that are difficult to manage in a population with comorbidities, pharmacodynamic and pharmacokinetic specific features.

To evaluate the comparative efficacy of pregabalin and trazodone in patients diagnosed with neurocognitive disorders that associate behavior disturbances.

We selected a group of 30 patients, admitted in our department, diagnosed with neurocognitive disorders, who also presented severe behavioral symptoms of sufficient importance to necessitate specific treatment. Patients received either trazodone (100-200 mg flexible daily dose) or pregabalin (75-150 mg flexible daily dose) for 4 weeks. All participants in this trial were assessed weekly using Global Assessment of Functioning (GAF), Mini Mental State Examination (MMSE), Instrumental Activities of daily Living Scale (IADL) and Neuropsychiatric Inventory (NPI).

Patients receiving pregabalin had a better efficacy/tolerability rapport, reflected in the lowest rate of discontinuation due to side events (p<0.05), while the improvements in behavioral symptoms (NPI) were only slightly superior in the pregabalin group (p=0.112). There were no significant inter-group differences regarding cognitive deterioration after 4 weeks (overall -0.7+/-0.1 points on MMSE), while GAF scores increased slightly in both groups (+5.6+/-1.2 at week 4). IADL scores improved in both groups but didn’t reach the level of significance (p=0.135).

Patients with behavior disturbances associated to neurocognitive disorders may benefit from pregabalin or trazodone treatment, although there are marked differences regarding individual responses and the overall impact on the NPI are relatively small.

To describe a case report of a patient who had been diagnosed Behavioral Variant Frontotemporal Dementia (bvFTD) in our department, and literature review.

Internet-based literature search using PubMed, Google Scholar and UpToDate databases. The search terms included were: “Frontotemporal Dementia”, “Behavioral Variant Frontotemporal Dementia”, 'Frontotemporal Lobar Degeneration”.

52 years-old female patient without previous psychiatric history. 2 years before the psychiatric interview is described a progressive change of behavior, including apathy, inertia, dependency of her husband to perform domestic work, decreased social engagement and emotional detachment. About 2 weeks before the clinical interview, and with associated urinary complaints, it is referred cleaning rituals causing significant distress and interfering seriously with daily life, hypochondriacal concerns surrounding the urinary complaints, food restriction and food fads, and mental rigidity. Finally, 1 week before the interview, paranoid delusions and intensification of the impulsive behavior with verbal and physical aggression to strangers and her husband.

Frontotemporal dementia (FTD) is the second most common young-onset dementia and is clinically characterised by disturbances in behavior, personality, executive functions and/or language. FTD represents a heterogeneous group of different clinical syndromes. The bvFTD is the most common presentation of FTD, with progressive change in personality and behavior. The common differential diagnoses to take into consideration are the psychiatric disorders: depression, obsessive-compulsive disorder and bipolar disorders. The diagnosis is made primarily on the basis of clinical features. Pharmacologic and nonpharmacologic therapy is aimed to control behavioral symptoms’, once there’s no effective disease modifying treatment.

The aging of the population is a characteristic phenomenon of Western countries and soon in Tunisia. An average of 20% of the population aged over 60 is expected in 2029.

Depression in the elderly is frequent, especially among those living in institutions.

• To determine the prevalence of depression among the elderly living in institution.

• Assess the impact of sociodemographic factors on the prevalence of depression in the elderly in institution.

A cross-sectional descriptive study in Manouba institution for the elderly. Depression screening by Geriatric Depression Scale (GDS 15).

The independence in daily life activities was assessed by the scale Activities of Daily Living (ADL)

Collection of the socio-demographic characteristics by a predetermined questionnaire.

• • Forty-two subjects were included in the study.

• • Participants had an average age of 71.5.

• • Seventy-three percent of participants were males.

• • Seventeen percent had depression, 45.2% had a probable depression against 37.8 % that had no depression.

• • Sixty-six point two percent were autonomous.

• • Factors significantly associated with depression were: female gender (p = 0.048), and the urban origin (p = 0.05).

• • In the institutionalized elderly, the degree of autonomy is not a factor influencing depression.

Screening for depression in the institutionalized elderly is particularly essential in patients at risk.

The theory of gerotranscendence, a developmental theory of positive aging was proposed by Lars Tornstam in 1989. It was based on the empirical researches done by him in late 1970s and early 1980s and work of other theorists. Tornstam began to explore aging with a phenomenological qualitative approach. Tornstam’s earlier work on aging revealed that aging is a natural developmental process towards maturity and wisdom.

To understand the ageing phenomena in terms of growth through cosmic and transcendent means.

Try to present a purely positive prospect on aging to a certain group of people experiencing a change during aging and provide an explanation for the miserable experiences in later life.

We have searched case reports, case series, cohorts and prospective studies, cross sectional data, review articles and research articles from search engines like PubMed, Medline and Google scholar.

The theory of gerotranscendence found that transcendent signs in old provide an interpretative framework to accept these signs as part of normal aging. It helps in development of a positive attitude in approaching older people.

The theory of gerotranscendence presents a positive view on aging. Tornstam has supported his perspective with various qualitative and quantitative research studies. The theory has also been adopted by many scholars and applied in a number of contexts. However, there is a need to further explore this theory in old age people suffering from depression and identify ways to promote gerotranscendence in them.

Living alone, limited personal social networks are, according to theliterature, factors that contribute to experience loneliness. It is known thatthe last stage of the life cycle is strongly marked by generational loss, beingmarked in this phase, beyond the network shrinkage, reducing opportunities forrenewal along with lower energy to activate, mobilize and maintain active linksof the network (Sluzki, 1996).

To determine the predictors of loneliness in a resident population in centralPortugal.

300 elderly people (mean age = 74.03/SD = ± 8.511) were surveyed. The sample wasassessed with the UCLA Loneliness scale, EQ5D, Lubben social networks and asmall sociodemographic questionnaire. The UCLA Loneliness presentedreliability, measured by the Cronbach's alpha coefficient (0.905).

To determine loneliness predictors a binary logistic regression was performed, with seven independent variables “age”, “sex”, “seeyour family”, “having spouse”, “Lubben socialnetworks”, “level of education” and “EQ5 health”. Thefull model containing all predictors was statistically significant, c2(15, N = 300) = 86.801, p <0.001. The model as a whole explained 26.1% (Cox and Snell R2) and 39.2% (R2 Nagelkerke) variation and correctly classified84.3% of cases. Logistic regression showed that “age” (p = 0.055), “sex” (p = 0.091), “sees his family”(p = 0.023), “spouse” (p <0.001), “Lubben socialnetworks”(p = 0.027),“level of education ”(p = 0.038)and“ health EQ5 ”(p<0.001) were loneliness predictors.

Given these results social intervention for active citizenship, networked, withthe elderly population is suggested.

Depression is highly prevalent in most dementias and it is associated with significant functional and cognitive decline, chronicity and high rates of medical comorbidity and mortality. The nature of the link between depression and dementia is still unclear. Given the projected growth of the older segment of the population, a better understanding of the link between them is important, especially for possible treatment and prevention.

To review the complex relationship between late life depression and dementia, to discuss the underlying mechanisms and implications for the diagnosis and treatment of both conditions.

Review of the relevant literature published in the Medline database

There is evidence to support the notion of depression as a risk factor as well as a prodromal symptom of dementia. It also shows that both conditions show similar neurobiological changes, either indicating shared risk factors or a common pattern of neuronal damage. The likely underlying biological mechanisms include vascular disease, hippocampal atrophy, increased deposition of β-amyloid plaques and inflammatory changes. These processes are not mutually exclusive and more likely synergistic, which explains the substantial variability of findings from the literature.

This work highlights that strategies to promote prevention, early diagnosis and adequate treatment of depression may have a major impact in reducing the risk or delaying dementia in older adults. Additionally, more conclusive research on the underlying neurobiological pathways, may pave the way for more effective treatment of both depression and dementia.

Charles Bonnet is a syndrome first described by the same-named naturalist and philosopher in 1769 after observing his grandfather, who suffered with the syndrome. It is characterized by the presence of complex, repetitive and persistent visual hallucinations that occurs in elderly people without cognitive impairment and with a significant visual loss associated. Its prevalence is estimated around 10-15% however it is believed to be underdiagnosed.

To describe, through the follow-up of a case report, the difficulties to make an accurate diagnosis of this syndrome and to select the most appropriate treatment.

A case report of a patient followed in an ambulatory mental health clinic.

Before the appearance of visual hallucinations in the elderly, the most frequent diagnosis suggested is cognitive impairment. Full, exhaustive neurological examination with visual field test, including pharmacological and medical history, as well as relevant additional tests help lead to correct diagnosis.

Interventions to reassure the patient, treat underlying visual disease and improve social factors allow symptom control.

The incidence of mental health problems in people with intellectual disability (ID) varies but is higher than the general population. Often individuals with ID and comorbid mental health issues are admitted to General Adult Psychiatric beds highlighting difficulties with communication, the deficit in skills and lack of confidence of mainstream staff. This lead to the development of the Mental Health Outreach Service in 2008 as a pilot to address the needs of the increasing number of adults with intellectual disability and mental health problems being admitted to mainstream psychiatric wards within Lothian.

Present evidence of an Outreach Service for individuals with ID and mental health issues, the functioning of the team and the impact on preventing admissions.

To describe the functioning of the MHIST Team and present the demographic profile of the clients on the caseload.

Data was reviewed from the referral and discharge information for the MHIST Team over the period of 2011-2013.

During the review period the MHIST Team had an average caseload of 51 patients per year, mixed between community and hospital. The length of involvement ranged from 3 days to 1379 days depending on the reason for referral, diagnosis and time for transfer to specialist ID bed.

It is beneficial to have a dedicated Outreach Team within an ID Service to reduce or prevent admissions through intensive support and in certain cases support hospital admissions into General Psychiatry by aiding communication, skills and education and support of the mainstream nurses.

To present a case series of de-novo central nervous system (CNS) tumours in adults with intellectual disabilities (ID).

Three cases of de-novo brain tumours in adults with (ID) were identified. The casenotes were reviewed and compared with the current evidence base of CNS tumours.

Three women aged 44-50 were identified with CNS tumours. Two cases with mild ID and one with severe ID. The first presented with depression. Cranial imaging was unremarkable. She experienced a seizure due to a benign meningioma. The woman had Bipolar Affective Disorder and diabetes mellitus presented with Parkinson’s Disease. Intracranial scanning revealed a diencepahlic tumour. The third woman had dysphagia and vertigo. Imaging identified two meningiomas.

The prevalence of primary CNS tumours in people with ID is uncertain. The presentation and histopathology of the three tumours varies. In all three, diagnosis was delayed perhaps due to diagnostic overshadowing. Establishing the characteristics of primary CNS tumours in adults with ID and their presentation should progress our knowledge. Further epidemiological research is required to establish the prevalence of tumours in adults with ID. The clinical management of CNS tumours in adults with ID must include exploration of the best interests of the person and the implications for end-of-life care. The authors acknowledge the limitations of a case series and recommend a national cohort as an epidemiological sample.

Problem behaviour is one of the most common reasons for admission to psychiatric hospitals in people with intellectual and developmental disabilities (IDD). A psychopharmacological approach is the most applied treatment strategy. But evidence for its effectiveness is small. Hence, there is a growing interest in alternative approaches, e.g. in educational and systematic treatment of problem behaviour.

This study looks at the relation between problem behaviour and socio-emotional development in combination with the level of cognitive functioning.

Our study sample was composed of n=20 in-patients of a psychiatric unit specialized in mental health for people with IDD who were admitted due to behavioural problems. In the first step we divided the patients with the described problem behaviour into a group with more specific advices for a typical psychiatric disorder (e.g. depressed mood and social withdrawal as typical for a depressive episode) and a second group with non-specific behaviour (e.g. aggression without reason). Within these both groups we compared patients in their relation between cognitive impairment and socio-emotional level in a retrospective study design.

Patients with unspecific problem behaviour had a less developed socio-emotional level compared to cognitive functions.

A disharmonic relation between cognitive and socio-emotional levels may result in unspecific problem behaviour. These findings may be relevant for specialized treatment options and underline the need to opt, if at all, more carefully for psychopharmacological treatment strategies in patients with problem behaviour not due to a psychiatric diagnosis.

Being admitted into hospital is a stressful and worrying time for any patient. This is even more significant for patients with learning disabilities who are in a vulnerable position. During my experience in an acute medical ward, I came across patients with learning disability and saw the difficulties surrounding their care. This involved problems with communication including consent and assessment of mental capacity.

The aims are to 1) explore the impact of learning disability in accessing physical health care and health inequalities associated with it 2) explore the issue of capacity assessment 3) to look at the legal frameworks available.

Literature search including data from Pubmed and NHS evidence was done to assess the health inequalities experienced by people with learning disabilities. The legal framework including Mental Capacity Act (2005) and Deprivation Of Liberty Safeguards (2009) were also looked into.

People with learning disability experience stigma when accessing acute health care. The clinicians’ knowledge of communication systems and legal framework available to support patients with learning disability is limited.

Healthcare professionals must have training for better understanding of learning disability and the challenges of working with people with learning disability. It is important to identify and address barriers in communication. Attitudes and beliefs of health care providers are important in providing optimal care for some of the most vulnerable members of society.

Determine the prevalence of personality disorders in an inpatient developmental delay population.

Find individual-biological-social factors that may be associated with personality disorder.

A cross-sectional study of 14 patients admitted to a Spanish developmental delay unit. Standard procedures were followed in all the measurements (i.e., socio-demographics, etc) as well as in the evaluation of developmental delay, Axis I and Axis V.

As expected all patietns have been diagnosed with developmental delay while the 64% were males. The 50% of them had diagnosed with mild developmental delay, 43% with moderate and 7% with severe symptoms. The mean age was 31.14±9.65 years and the mean hospitalization in the unit was 29.36±18.96 months. The mean Axis V score (0-100) among the 14 patients was 45.07±11.

Among the patients, the highest prevalence of Axis I disorders, had other disorders (64%), followed by impulse control disorders (43%), psychoses (21%), mood disorders (14%) and substance abuse (7%).

The 29% of the sample have been diagnosed with personality disorder, and specifically the 50% was diagnosed as Cluster B. There was a significant difference on personality disorder Cluster B among males and females (0% vs 40%, p=0.04). Moreover a strong association among female gender and personality disorder Cluster B was evaluated (r= −0.54, p=0.04).

Conclusions:

More than the half of the patients had diagnosed with mild and moderate symptoms of developmental delay. Among them, the personality disorder Cluster B, seems to be related wtih the female gender.

Behavioural symptoms are the first reason of psychiatric assessment in patients with intellectual disabilities (ID), and also the most frequent cause of psychopharmacological treatment. Different rates of prevalence of these symptoms appear in literature data (10-60%). Paliperidone has shown effectiveness in the treatment of behavioural symptoms in patients with autism and asperger syndrome, with significant reduction in ABC-I subscale scores.

Objectives:

Study paliperidone effect in behavioural symptoms' improvement in patients with intellectual disabilities of diverse etiology.

10 outpatients with intellectual disabilities and behavioral symptoms were selected and treated with paliperidone. Sociodemographic and clinical data (type of intellectual disability, previous antipsychotic and paliperidone dose) were registered. Agitation subscale Aberrant Behavior Checklist (ABC-I) scores were compared prior and 4 weeks after psychopharmacological treatment change. Otherwise we assessed clinical improvement with Clinical Global Impression-Improvement (CGI-I).

All patients were similar in clinical and sociodemographic characteristics. Paliperidone mean dose was 8,4 mg/day (3-18 mg/day), changing from risperidone (44,4%), olanzapine (44,4%) and levomepromacine (11,1%). Mean reduction in ABC-I scores with paliperidone treatment was 6,2 points [with most significant improvement in items like irritability (1,2 points), aggressions (1,1 points) and slams (0,9 points)]. CGI-I scores showed a much better improvement in 60% patients, mildly betterin 30% patients and slightly better in 10% patients. No significant adverse effects leaded to treatment discontinuation.

1. 1. Paliperidone is an effective and safe treatment in behavioral symptoms associated to intellectual disabilities.

2. 2. Paliperidone treatment reduces ABC-I subscale scores, with most significant improvement in irritability and aggressions.

Managing people with intellectual disabilities (ID) withproblem behaviours in the community presents a challenge to ID services. Community models as alternatives to hospital care exist. Problems behaviourscan have an impact on quality of life putting community placements at risk. Mental illness is a known aetiological factor predisposing to problembehaviours. Varied service strategies have been developed to manage challengingbehaviour. We present data on a community-based service that manageschallenging behaviour through an objective, multi-disciplinary approach.

To evaluate the multi-disciplinary challengingbehaviour service over a three-year period.

A casenote survey of adults with ID admitted to the Assessment and Intervention Team, a challenging behaviour service operating inthe London Borough of Haringey.

Over the three-year period the 65 adults weremanaged by AIT. 44 were male and 21 were female. The age range was 21 – 64years of age. The level of ID was Mild ID 61%, Moderate 39%. Diagnoses includedpsychotic disorder (25%); mood disorder (20%); developmental disorder (40%);dementia (10%); challenging behaviour (45%). Six people (11%) were admitted tohospital during their time with AIT. The length of care under AIT ranged fromfour to fourteen months.

AIT managed effectively people with IDliving in the community who presented with complex problems putting theirplacement at risk. The most common reasons for the behaviours included mentalillness and ‘challenging behaviour’. People with developmental disorders were abig proportion. Community alternatives are effective with positive benefits tothe person.

The problem of employment of people with intellectual disabilities is present in many countries. The literature on this topic draws attention to the fact that the improvement of the situation in this area is conditioned by changes in government policies, practices of employers and adequate preparation to undertake professional duties by persons with intellectual disabilities.

The objective of this review was to explore the changes in vocational rehabilitation forms in Poland.

The analysis of documents and accessible literature was done.

As one of the ways to solve this problem since 1991 in Poland the so called Workshops of Vocational Therapy have been created. According to the regulations the Workshops were designed for adults with intellectual disabilities, aged over 16 years with a total incapacity of gaining an employment, for which occupational therapy was a form of social rehabilitation. The further step in this process was the establishment of Vocational Activation Centers, with which high hopes were associated. They were expected to be an intermediate link in the creation of career paths from rehabilitation forms ultimately to open labor market. In practice it turned out that the creation of these Centers in Poland has been too slow.

This raised the necessity to change the attitude from the concept of matching the participant to work and to the new environment, which frequently ends as a trauma, to the concept of matching jobs to people. New initiatives and new rehabilitation programs are developed based on this attitude.

Epilepsy is prevalent in people with intellectual disabilities (ID) and autism spectrum disorder (ASD). Valproic acid (VPA) treatment is associated with weight gain, and changes in glucose and lipid metabolism.

To study the metabolic features of adults with ID and ASD.

Aim: We investigated interactions of body mass index (BMI), fasting blood-glucose (FBG) and total-cholesterol levels with epilepsy and VPA treatment in these populations.

Medical charts of 77 adults with ID and 80 adults with ASD were reviewed for epilepsy diagnosis, VPA treatment, BMI, FBG and total-cholesterol.

People with epilepsy had lower BMI and FBG than people without epilepsy (BMI: 23.18±5.43 vs. 25.61±5.74 kg/m² respectively, F(1,140) =6.64; p=0.011, FBG: 72.53±11.26 vs. 79.98±14.64 mg/dl respectively, F(1,135) =10.46; p=0.002). Furthermore, in the ID group, there were more obese (BMI >30 kg/m²) adults without epilepsy than adults with epilepsy [11(29.7%) vs. 2(5.7%), respectively, Fisher’s exact test: OR=6.981 (95%CI 1.42-34.31); p=0.0125]. In the ASD group, there were more underweight (BMI <18.5 kg/m²) adults with epilepsy than adults without epilepsy [6(20.7%) vs. 1 (2.5%) respectively, Fisher’s exact test: OR=0.192 (95%CI 0.049-0.76); p=0.0169].

People treated with VPA had lower total-cholesterol levels than untreated people (156.56± 26.13 vs. 172.42±33.82 mg/dl, respectively, F(1,150) =7.44; p=0.007), but did not differ in BMI and FBG.

Adults with ID or ASD and epilepsy had lower BMI and FBG levels than adults with ID or ASD without epilepsy. Surprisingly, adults treated with VPA had unaltered BMI and FBG, and lower total-cholesterol levels than their untreated counterparts.