Although evidence shows that selective serotonin reuptake inhibitor (SSRI) antidepressants cause less orthostasis and interfere less with psychomotor function than do tricyclic antidepressants (TCAs), a recent pharmacoepidemiologic study found them comparable in increasing elderly patients' risk for falling (Thapa et al., 1998). For patients also receiving multiple cardiovas-cular medications, however, the study did substantiate a lower risk for falls with SSRIs relative to TCAs.

 The study was a retrospective analysis of the records of 180 days of treatment for 2,428 nursing home residents who were either antidepressant nonusers or had newly prescribed antidepressants (665 received TCAs or other heterocyclic antidepressants, 612 SSRIs and 304 received trazodone [Desyrel]). 

 In the 1,460 person-years studied, 3,524 falls were documented. The elderly institutionalized patients receiving SSRIs were found to have had 80% more falls, and those receiving a TCA had twice the number of falls, than did matched patients not receiving an antidepressant. These findings are consistent with a study published earlier that found no significant difference between TCAs and SSRIs in the associated increased rates of hip fractures subsequent to falls (Liu et al., 1998).

 These studies implicate the different antidepressant classes with a similarly heightened risk of elderly patients falling. More important, they illustrate the disparities between drug responses observed in the elderly and those assumed to occur from studies with younger adults. In an editorial accompanying the Thapa et al. study, Jerry Avorn, M.D., of the Harvard Medical School, noted that conventional trials conducted against placebo in younger patients can provide sufficient information to approve an antidepressant for the market. But, he added, "It leaves the practitioner hungry for more clinically relevant data, which may be very difficult to find" (Avorn, 1998).

 Drug studies that are conducted with younger adults are difficult to apply to the elderly because of differences in drug disposition and response, and the greater susceptibility of the elderly to side effects. "How might a drug's effect change when it is used in older patients, particularly frail ones?" Avorn asked. "Its risks may be higher, its efficacy lower."

 The pressing need for depression treatment studies to be conducted in the elderly is evident from the high prevalence of depression in this age group that can be responsive to appropriate antidepressanttreatment (NIH, 1991), and the increased mortality associated with untreated depressive symptoms.  In a study conducted by the Osteoporotic Fractures Research Group published in the October 1998 

, elderly women with six or more symptoms of depression had a 24% mortality rate over seven years. A matched sample with no depressive symptoms had a 7% mortality rate over the same period, and those with three to five symptoms had a 17% rate (Whooley and Browner, 1998). Adjusting for potential confounding factors such as history of myocardial infarction, stroke or diabetes, the investigators found depressive symptoms correlated with an increased risk of death from cardiovascular diseases and noncancer, noncardiovascu-lar diseases, but not with deaths from cancer.

 Clinical data from depression studies in the elderly can guide effective antidepressant treatment and monitoring to reduce morbidity and mortality from both the depressive disorder and from adverse reactions to the medication. Such data are anticipated, for example, from the first clinical trial of an antidepressant in the treatment of depression in patients 75 years of age and older, now being conducted with citalopram (Celexa) in 200 patients in 10 centers in the United States. In addition to multiple instruments to gauge antidepressant efficacy, the drug safety in this trial is being determined through adverse event monitoring, laboratory measurements, physical examination, and vital sign and electrocardiogram monitoring. This trial will also include magnetic resonance imaging of each patient at baseline.

 



 Purushottam B. Thapa, M.S., M.P.H., and colleagues from the division of pharmaco-epidemiology, department of preventive medicine at Vanderbilt University School of Medicine in Nashville, Tenn., identified their study cohort from computerized records of two pharmacies consulting with 80 nursing homes. They approached the 55 facilities having the most frequent use of SSRIs. Of those, 54 agreed to participate and 53 had records of adequate quality. 

 Patients over 65 years of age were identified as new users of antidepressants when beginning the medication for other than somatic symptoms such as migraine, after a period of at least 90 days without antidepressant medication. Nonuser controls were randomly selected from residents meeting all other criteria for cohort eligibility. The number of falls during the study period were ascertained from incident reports and medical records.

 The baseline characteristics of the antidepressant user and nonuser groups were distinctly different. Relative to the nonusers, those using antidepressants had greater mobility, greater use of psychotropic and other types of drugs, and roughly twice as many falls in the 90-day lead-in period, which suggested a greater baseline risk for falls. Considering the possibility that the depression or its correlates, rather than the antidepressants, might increase the rate of falls by increasing the level of disability, the investigators controlled for an extensive set of reasons for baseline impairment, but found the correlation with antidepressants persisted.

 Using Poisson regression models to adjust rate ratios of falling for the subjects' characteristics (such as age, sex, body-mass index, ambulatory status and previous falls, incontinence, cognitive impairment, use of physical restraints and use of certain other medications including anticonvulsants, antipsychotics and sedatives) the investigators determined that the rate ratio of falls relative to nonusers was highest with TCAs at 2.0, followed by 1.8 with SSRIs and 1.2 with trazodone. The rate of falls with TCAs and SSRIs increased with increased daily dosage.

 Recognizing that cardiovascular disease can increase the severity of orthostasis caused by TCAs, Thapa and colleagues also assessed the rate of falls in relation to the number of cardiovascular medications being taken. The 2.0 rate ratio of falls with TCAs in patients taking no cardiovascular medications rose to 3.3 in patients taking three or more. There was, however, no such increased rate of falling with an increased number of cardiovascular medication taken by users of either SSRIs or trazodone. Thus, the little difference between the rate of falls occurring with TCAs and SSRIs in patients who did not receive cardiovascular medications grew substantially to favor the safety of SSRIs in elderly patients on multiple cardiovascular medications.

 Avorn pointed out some methodological difficulties inherent in such an observational study. Since the antidepressants were not randomly assigned, for example, the SSRIs might have been prescribed to those patients who were deemed at most risk for falling, under the assumption that the SSRIs contribute less to the risk. In addition, reliance on the documentation procedures in the nursing home is likely to be less accurate than outcome monitoring in a prospective study. "If an elderly person falls in a nursing home and no one records it," Avorn posed, "does it still make a sound in the database?"

 Despite such methodological limitations, Avorn found the conclusions to be validly drawn. While the SSRIs pose less risk than TCAs for causing falls in the frail elderly who are receiving cardiovascular medications, both the SSRIs and TCAs are associated with a dose-dependent increased risk of falls in the elderly in general. Elderly patients receiving these antidepressants should, therefore, be appropriately monitored, assisted and advised to stand and ambulate with care.

 The "fear of falling," however, should not preclude appropriate antidepressant treatment that can avert the morbidity and mortality of depressive illness.


Avorn J (1998), Depression in the elderly--Falls and pitfalls. N Engl J Med 339(13):918-920.

Liu B, Anderson G, Mittmann N et al. (1998), Use of selective serotonin reuptake inhibitors or tricyclic antidepressants and risk of hip fractures in elderly people. Lancet 351(9112):1303-1307.

NIH Consensus Development Panel in Depression in Late Life (1993), Diagnosis and treatment of depression in late life. Psychopharmacol Bull 29(1):87-100.

Thapa PB, Gideon P, Cost TW et al. (1998), Antidepressants and the risk of falls among nursing home residents. N Engl J Med 339(13):875-882. See comments.

Whooley MA, Browner WS (1998), Association between depressive symptoms and mortality in older women. Study of Osteoporotic Fractures Research Group. Arch Intern Med 158(19):2129-2135.

Articles

Although evidence shows that selective serotonin reuptake inhibitor (SSRI) antidepressants cause less orthostasis and interfere less with psychomotor function than do tricyclic antidepressants (TCAs), a recent pharmacoepidemiologic study found them comparable in increasing elderly patients' risk for falling.

Assessing Antidepressant Safety in the Elderly

We lower a plastic tray on his ribs
as if food can stop the dying:
cold potato scooped like a snowball,
canned spinach oozing green,
microwaved chicken thigh.
I've watched anorectic men clog
N-G tubes with brown rice
and Kombacha mushroom tea,
listened to wives plead
just make him take a few bites,
withstood lectures on macrobiotics
delivered by a Camel chain-smoker.
No, I've never seen hospital food
stop the dying.

Some days, worn and hungry,
I take refuge in smooth noodles,
glistening black beans and red chilis,
sweet white sesame balls 
the size of prayers,
fragrant sips of jasmine tea.
And I think about the sick men
dissolving like tailpipes in the sea,
what they long to devour,
how we die without appetite
and the way we live with hungers
that consume our hearts like another kind of dying.

Hospital Food

For decades, physicians have railed against the inequities of malpractice laws, lobbying for statutory changes that would insulate them from injustices, both real and perceived. In an ironic twist, extending tort liability has become the latest weapon against managed care companies and the medical directors who often make utilization review determinations. As a result, managed care companies are now rushing to embrace the once scorned external review and independent appeals processes in a last-ditch effort to stave off reforms requiring them to justify health care decisions in front of judges and juries.

In Texas, the HMOs failed to see the handwriting on the wall. They have been unable to overturn Senate Bill 386, a measure that went into effect last year allowing HMOs to be held liable for malpractice if they made negligent benefits decisions affecting care. In September, proponents of the law won their first round when a federal judge ruled that most of the provisions did not violate federal pre-emptions under the Employee Retirement Income Security Act of 1974 (ERISA) (

Corporate Health Insurance Inc., et al. v The Texas Dept. of Insurance, et al

., U.S.D.C., Southern District of Texas, Houston Division, Civil Action No. H-97-2072).

A month later, the family of Joseph W. Plocica, a 68-year-old Fort Worth man who committed suicide after a serious bout with depression, became the first plaintiffs to sue under Senate Bill 386, claiming that a managed care organization and its officials had negligently forced his discharge from a psychiatric hospital by denying benefits. According to the complaint filed in 

Kathryn A. Plocica, et al. v NYLCare of Texas Inc., et al.,

 Tarrant County District Court, 141st Judicial Dist., No. 141-175780-98, Plocica's HMO refused to authorize additional hospitalization despite the protests of his treating psychiatrist, Harold Eudaly Jr., M.D. After being discharged in July of 1998, Plocica is said to have ingested a half-gallon of antifreeze in a suicide attempt that eventually lead to his death.

That the first case under the new Texas law involved a psychiatric patient comes as no surprise to Bernard Gerber, M.D., a psychiatrist with Quest HealthCare in Houston and chair of the managed care committee of the Texas Society of Psychiatric Physicians (TSPP). The circumstances alleged in the Plocica lawsuit, Gerber said, mirror a common refrain from psychiatrists in Texas who often struggle to obtain care for their patients from recalcitrant utilization reviewers.

"It's not surprising that the first lawsuit would be a psychiatric case. From our vantage point, psychiatric care has always been the stepchild in terms of benefits and coverage. The patients have always been discriminated against," Gerber said. "Managed care has continued that trend."

The new law puts medical directors and other physician reviewers in a dilemma, Gerber said, because, despite their denials, they have taken on the role of making medical treatment decisions. With HMOs now accountable for negligent determinations, managed care doctors have moved toward giving more credence to treating physicians, which is a positive development.

Gerber concedes an expansion of the malpractice laws to increase and improve the quality of care received by the mentally ill and other individuals is an ironic development. Both the TSPP and the Texas Medical Association (TMA) lobbied heavily for the bill. Ultimately, the "less Draconian micro management of psychiatric care" the law encourages, Gerber said, should mean broader access and quality without significantly affecting overall cost.

"When the TMA argued for the legislation, it was a matter of fairness," said Gerber, who also serves on its committee for Psychiatric Health Care and Mental Retardation. "If someone is making these kinds of decisions they need to be as equally accountable as anybody else making medical decisions."

Rocky Wilcox, J.D., the TMA's general counsel, said that the new law has not set off internecine struggles between treating and reviewing physicians. Under prior state appellate decisions, physicians making what amounted to medical decisions for HMOs could be held liable for malpractice. What the new law does is bring the managed care company itself into the fray, making it accountable for benefits decisions that deny care.

Wilcox is surprised that more cases haven't been filed to date, saying that the law is new and still under appeal to higher federal courts. That cases brought under the law could be dismissed several years down the line if the law is not upheld by appellate courts may be causing plaintiffs' attorneys to stick with more traditional malpractice theories, Wilcox said. Nevertheless, he agreed that the expansion of malpractice liability was meant to level the playing field among those parties making medical decisions, and to assure that tort law was "consistently applied."

That sentiment is spreading throughout the country. In October, for instance, a Connecticut federal judge ruled, in what is being hailed as a landmark decision, that an HMO should not be shielded by ERISA from claims that it negligently denied psychiatric care to 16-year-old Nitai Moscovitch, who later committed suicide. Meanwhile, federal officials at the Labor Department have filed a friend-of-the-court brief with the U.S. Supreme Court in 

Unum Life Insurance Co. of America v Ward

, urging the high court to allow individuals to sue under state insurance laws when care is improperly denied.

Last August it appeared that efforts to reform the managed care industry in California were doomed, but following the recent election of Democrat Gray Davis as governor, and with the prospect that Democratic majorities in the legislature will likely resurrect HMO liability measures, the managed care industry is scrambling. In December, a group of HMOs, all members of the California Association of Health Plans (CAHP), agreed to voluntarily implement independent appeals processes to handle disputed claims.

According to CAHP officials, the program should mitigate concerns that managed care organizations place financial interests over issues of patient care. "This effort is aimed at addressing the single greatest fear that people have-that in some critical circumstance they may be denied care that they may need," said Walter Zelman, CAHP's president, in a December 1998 

 interview. "And this is aimed at addressing that fear."

Meanwhile, the fear the managed care organizations may actually be addressing is the prospect that they have offered too little too late. Legislators in California and other states, along with the federal government, are expected to take up the issue of HMO liability again this year, and with widening public support for greater accountability it is increasingly likely that new regulations will limit managed care's ability to deny care without some legal exposure. 

(At press time, we learned the Plocica lawsuit  has been moved  from state to federal court 

[Plocica v. NYLCare of Texas, Inc., N.D., Tex. No4-98CV1021-E, 11/18/98].  

NYLCare has argued that the patient was covered under a Medicare plan that did not fall within the reach of the state law, according to an article in Health Care Policy (Dec. 7).  Plocica attorney George Parker Young said they will seek to convince the federal court to remand the case back to the state court-Ed.)

HMO Liability: Legal Barriers Are Finally Breaking Down

The most intimate details of boxer Mike Tyson's life are easily accessible by the average person. Partly due to the publicity that surrounds his sometimes triumphant, but more often tragic, pugnacity, there is another, more sinister reason that Tyson has become an open book: Tyson's psychiatric evaluation was posted on the Internet, making it available to any of the six billion people on the planet who care to look.

As psychological and mental health issues increasingly take center stage in high profile criminal and civil proceedings, the ability to satiate inquiring minds often means trashing privacy and confidentiality at the altar of the public's right to know. Tyson isn't the only one whose psychological profile has been splayed out before an audience of billions in cyberspace. Although partially redacted, confessed Unabomber Theodore Kaczynski's psychiatric evaluation was also posted to the Web.

What influence the increased scrutiny of forensic psychiatric reports will have on the criminal and civil justice systems is still, for the most part, speculative, but these recent wholesale disclosures have created a whirlwind of controversy fueled by uncertainties.

When Ronald Schouten, M.D., J.D., director of law and psychiatry service at Massachusetts General Hospital and an assistant professor of psychiatry at Harvard Medical School, delivered the report "Independent Medical Evaluation of Michael Gerard Tyson" to the Nevada State Athletic Commission, he implored the commission to keep the contents confidential, to little avail. 

"We are opposed to the public disclosure of Mr. Tyson's diagnoses and the complete clinical information contained in this report," Schouten wrote in an Oct. 12, 1998, letter to the commission, a copy of which was obtained by 

 from the Internet. "We are providing you with more clinical detail than is our practice in similar matters and remain opposed to the dissemination of this personal information to anyone other than commission members."

Following the hearing that ultimately reinstated Tyson's boxing license, Schouten said in an interview with 

 that he was concerned that disclosures in the Tyson case could set a dangerous precedent in other situations involving high-profile individuals. 

"The commission felt an obligation, based on its legal position, that personal, clinical information, that should remain private, should be handed out to the news media and posted on the Internet," Schouten said. "As a model, it will send a message that may well have a chilling effect in terms of people's willingness to participate in the public sector. Are we going to extend this to politicians? Are we going to extend this to other people who need medical evaluations? Where do we draw the line?" 

According to Schouten, it is time for a national dialogue on issues of confidentiality and the circumstances under which disclosure is in the public interest.

Even astronaut John Glenn was allowed to decline public disclosure of elements of his medical evaluation, Schouten said, but if the Nevada State Athletic Commission's lead is followed, the right to elect privacy could be threatened. 

"Is our model from now on that if individuals are in the public sector and they're applying for a privilege, or they're doing something that is publicly funded, that they automatically give up all their rights to privacy?" commented Schouten. If society is ready to deny confidentiality to public figures, he warned, it better be ready to give up confidentiality for every individual, because no one knows where the line will ultimately be drawn.

Schouten is not concerned that increased scrutiny by the public will somehow corrupt or undermine psychiatrists or other mental health practitioners who perform forensic psychological evaluations. To the contrary, he said that it may inhibit evaluators from including unnecessary details. "Where forensic psychiatrists will be more circumspect is in the amount of personal detail they put into a report, and that's as it should be. People would be and should be more careful because this is personal information that may end up in the public domain, but which may not be relevant to the forensic issue."

Saul J. Faerstein, M.D., a Beverly Hills, Calif., private practice forensic psychiatrist and an assistant clinical professor of psychiatry at the University of California Los Angeles School of Medicine, narrowly ducked a stewing controversy of his own. As O.J. Simpson's psychiatrist during the period immediately following the former football star's arrest for a double murder, he was inundated with media attention. He told Psychiatric Times that widespread public disclosures generated by the Internet, and by cameras in the courtroom, can't help but have a chilling effect on the forensic evaluation process.

Under the threat that psychiatric evaluations may be broadly disseminated, Faerstein said, practitioners could hold things back, phrase things differently or not be as forthcoming, factors that would diminish the credibility and validity of the evaluators' statements. When a report is kept confidential, and disclosure is limited to individuals involved in the proceeding, "I feel free to say things in those kinds of reports that I might not say if I thought it was going to be published in 

tomorrow," Faerstein said. With the deteriorating confidentiality, however, "I would be very hesitant to do some of the things that I may have done in the past," Faerstein added. The concern over how much detail to provide in a report has always existed, but the problem has become magnified by the increased likelihood of public disclosure.

Equally chilling is the effect broad disclosure has on the person being evaluated. "It makes it even more likely that there will be limitations placed on what's spoken and what's revealed during the examination," Faerstein said. Ultimately, he is concerned that, unless better safeguards are legislated, both the civil and criminal justice systems could be undermined. Although the press has always reported on public proceedings, Faerstein said that he has "always come down on the side of maintaining confidentiality and trying to secure the parameters of confidentiality. The Internet makes it more apparent that the consequences [of public disclosure] are greater because the exposure is greater."

But Phillip J. Resnick, M.D., a professor of psychiatry at Case Western Reserve University School of Medicine in Cleveland, and one of the government's forensic experts in the Unabomber case, said that psychiatrists conducting evaluations realize that their reports could become public. He added that the reports are more likely to be disseminated as the notoriety of the case increases. Although he recognizes that there is a "quantum level" leap between newspaper reports and the availability of the actual evaluation on the Internet, "It's still a public document."

"I've worked on a lot of high-profile cases and I'm accustomed to newspaper coverage of reports and testimony, so I'm not as shocked," said Resnick, whose career spans 25 years. "My style, personally, has always been to be very careful of the report, and to proofread it and be satisfied that it represents my best product, so there hasn't been any change in my work. But I think from the standpoint of protecting the defendant's personal life, I might be a little more discreet now and only put in background that I could justify as relevant to the referral issue."

Recognizing that there must be a balance between privacy and freedom of expression, Resnick said that he didn't believe that broader dissemination of evaluations on the Internet or through televised proceedings would necessarily corrupt the civil or criminal justice systems. Nevertheless, some evaluators may end up becoming more discreet and may exclude some private details that they may have once included. As some of these nuances could have been helpful to the courts, there could be some impact on the judicial process.

Larry R. Faulkner, M.D., president of the American Academy of Psychiatry and the Law (AAPL) and the vice president for medical affairs and dean of the school of medicine at the University of South Carolina in Columbia, believes broader dissemination of evaluations means that psychiatrists must be more careful about conforming to practice guidelines and making sure "whatever was done is presented in a way that is defensible." Psychiatrists have always practiced under the shadow that their reports or entries in medical records could end up disclosed to others in a way that was never anticipated. While there may be a downside to the broad dissemination offered by technology, he also says the benefit may be that psychiatrists will exercise more care in what they write after an examination.

Nevertheless, Faulkner said, a person's evaluation should be confidential and disclosed only to those with an interest in the proceedings. "There ought to be stringent guidelines adopted for who else is entitled to see this information," he added.

But according to Paul S. Appelbaum, M.D., professor and chair of the department of psychiatry at the University of Massachusetts Medical School, secretary of the American Psychiatric Association, and a former president of AAPL, the danger is that if psychiatrists restrain their observations out of fear of broad dissemination, the reports, and the resulting decisions could be less valid. 

"It holds the potential for changing the interaction with the subject of an evaluation in two ways," Appelbaum said. "One is that an evaluator may be more circumspect about getting into issues that, though potentially relevant, may also be embarrassing or compromising and arguably tangential to the overall purpose of the evaluation. The other impact we can't ignore is the effect on the subject of the evaluation. To the extent that people are faced with the prospect not merely of sharing what are often very intimate details with an evaluator...but also with the prospect that their evaluations may be freely available to everyone with a computer and a modem anywhere in the world, I would think that can't help but have a chilling effect on subjects' willingness to participate in these evaluations."

As psychological and mental health issues increasingly take center stage in high profile criminal and civil proceedings, the ability to satiate inquiring minds often means trashing privacy and confidentiality at the altar of the public's right to know. Tyson isn't the only one whose psychological profile has been splayed out before an audience of billions in cyberspace.

Peering Through the Looking Glass: Forensic Examinations and Privacy Issues

When treating agitation in the elderly, the optimization of certain behavioral techniques may enhance medication therapies or sometimes eliminate the need for them, said Kevin Gray, M.D., during his presentation "Hugs Not Drugs: Behavioral Techniques for Agitation in the Elderly" at the recent U.S. Psychiatric & Mental Health Congress. 

Gray, director of the Memory Disorders Clinic at the Veterans Affairs North Texas Health Care System, began by describing some general misconceptions both physicians and caregivers have about people suffering from dementia.

"[When discussing] dementia," Gray explained, "there's a great deal of focus on cognitive impairment and the fact that people's mental capacities are stolen from them by the dementing illness...Yet, fundamentally, the dementias are disorders not just of cognition, but of behavior and personality...If you look at demented individuals, regardless of the diagnosis, you will see that almost all of them have associated personality and behavior changes; and at least half of them will become agitated at some point during the course of their illness."We have all sorts of views of older people," Gray told his audience. "Some appear very kind and benign. Then we have the ones that make our beepers go off and our phones ring." 

In the past, physicians didn't intervene much in the early stages of the disease process, Gray said. "We [physicians] sort of shrugged our shoulders until things went badly, and then we tranquilized [the patients] with powerful drugs."

Gray advised clinicians to look more closely at the behavioral causes behind a demented older person's problem behavior, and has summarized a method he devised to facilitate the evaluation process-the Keys to E-Z Evaluation (Table). The keys include, for example, identifying the problem behavior and the timing and frequency of such behavior. Only after weighing all the components of the E-Z Evaluation, said Gray, should the physician make a recommendation.

After the evaluation is complete, Gray continued, management of the agitated elder is required. Gray uses two behavioral management keys: general environmental assessment and targeting specific problem behaviors. By performing an environmental assessment, physicians can help patients' families understand the principles of environmental management: serenity, safety, structure and sanity.

Serenity means managing affect, said Gray. In other words, it's not what the physician or caregiver says, but how it is said. He explained that in a demented individual, the ancient parts of the brain that have to do with friend or foe, fight or flight, still work quite well, even as language breaks down and logic becomes unavailable. Thus, it is crucial that caregivers display a pleasant countenance and speak in a pleasant tone to the patient. It also is important not to overstimulate the patient-regardless of the environment. Speaking in a calm, clear voice, perhaps with gentle touching, can achieve a calm atmosphere. As words start to lose their meaning, caregivers should use as many modalities as they can to communicate effectively. Arguing is useless, because logic cannot be understood.

Within the rubric of safety lies childproofing, said Gray. He suggested that physicians advise caregivers to make all medications inaccessible, put away power tools and automatic weapons, take small appliances off the kitchen counter, install smoke alarms, check stairs and handrails, put a fence around the swimming pool, and discourage the patient from driving a car-something that is especially hard if the patient has been driving for 50 or more years. It might be a good idea to disable home shopping services on television, too, he added. The phone can be programmed to ring only once, or even silently, and can be equipped with a hidden answering machine to pick up messages. Mail can be a problem, he noted, especially when it involves sweepstakes mailers, since demented patients are unable to recognize deception.

Through structure, said Gray, physicians and caregivers can entrain new habit and motor memories. These memories are dopami-nergically mediated and available even at a time when "our magnificent neocortex is failing dismally," he added.

"One of the things that I've structured is prompted voiding or so-called scheduled voiding," he said. "Encouraging [patients] to toilet when they first get up or every three hours is a way to get around...accidents."

Sanity in the environment is very important. "You have heard the old saying, 'Don't pay attention, it's the liquor talking,'" said Gray. "I try to take the same tack and tell my families, 'Don't pay attention, it's the Alzheimer's talking.' So a caregiver doesn't have to convince me that she's not really sleeping with the preacher, as her spouse may have just informed me.

"Also realize that the patient's language may get saltier and the personality a little more detached as the disease progresses. Sometimes, dementia patients say things that can be quite hurtful, such as 'You're so stupid,' or 'That's the ugliest hat I've ever seen.' I advise my families that it's the disease talking, and these things need to roll off them to the extent that they're able to allow it."

In the early stages of dementia, cues such as reminding patients what day and year it is can help with memory, Gray said. However, as the disease progresses, he cautioned, cueing doesn't last. Reminiscing with the patient is helpful, because ancient memories are burned in deeply and remain available, said Gray. Caregivers should talk about the old days, but also realize that as time goes on, these memories will become less available.

Regarding language, Gray recommended that clinicians and caregivers speak slowly and simply, and ask questions that require only a yes or no answer. He recommended further that they present only one idea at a time, since presenting demented patients with too many choices can be overwhelming. Nonverbal cues, such as body language, also work well. A powerful nonverbal cue is the handshake, according to Gray. Many times just extending a hand is enough to encourage a recalcitrant patient to accompany their caregiver. 

During a visit to the physician's office, clichs can serve as social lubrication, and keep things upbeat. "Hey, I like that tie." "Where'd you get those shoes?" This sort of general social conversation can keep the tone of the interview at a very pleasant level, said Gray.

Loss of executive cognitive functions becomes obvious as the patient becomes increasingly unable to engage in activities that require planning, anticipation, sequencing, orchestration, goal-directed activity, response inhibition and abstraction. For example, Gray said, patients may be able to make toast for breakfast, but unable to manage the planning required to prepare a meal.

Signs of the dysexecutive state include disinhibition and poor judgment. This includes disrobing, sexual displays and hoarding. With a disrobing problem, it is helpful to alter the way clothing is worn, Gray advised. For example, he suggested that if there is a drawstring, it should be turned to the back, or double-knotted. For inappropriate sexual displays, he advised redirection, limitation, looking for antecedents, privacy and distraction with manual activities. 

The notion of hoarding is important, Gray said. "Folks [go] on patrol, touring, picking up sugar packs, picking up dentures [and] putting them in, putting on glasses, but they may be [someone else's] glasses. 

"Apathy also falls under the dysexecutive state. If a patient is apathetic, the best thing to do is try to engage them. If they're playing cards, play cards with them, or if they're raking the yard, rake with them," he said.

Gray touched briefly on effective ways clinicians can address psychiatric syndromes. With someone suffering from delusions and hallucinations, he advised, "Don't argue, don't confront, don't deny; give honest, noncommittal answers. Try to understand patient explanations." 

He recommended optimizing sensory output with things such as improved lighting, glasses and hearing aids. Caregivers should remain visible and available, and help the patient focus on familiar aspects of the situation by using voice endearments and favorite belongings. Minimizing opportunities for failure and self-harm, and maximizing physical comfort can help in cases of depression. Engaging the patient in, and encouraging them to perform, simple, familiar, successful tasks may also ease their distress. 

For someone suffering from anxiety, Gray recommended reassurance, affection and distraction, and keeping patients' hands busy in a serene milieu. He warned that asking for explanations may worsen the situation.

With agitated patients, said Gray, clinicians should advise caregivers to sit with the individual, assess their needs and pains, and look for possible environmental triggers. Irritable patients can often be distracted and redirected if caregivers plan demanding activities for patients' best time of day. To curb yelling and screaming, caregivers should manage affects and not overreact. They might try using music, perhaps asking the patient to sing along; or encourage tactile activity. 

Resistant patients, said Gray, respond best if the caregiver focuses on positive aspects and rewards, and is willing to compromise. It is important to remind and assist, not take over, and always be ready to gently try again. 

For catastrophic reaction, Gray said, "It is important to keep calm, manage affects, reduce choices and stimuli; look for environmental triggers; and distract with tasks." 

For aggression, Gray suggested looking for cues that the patient is decompensating and letting the patient relax. Clinicians need to be receptive and patient, and lead the patient to a quiet area.

In conclusion, Gray asked physicians to remember the person with the hardest job of all-the caregiver."Studies estimate that between 50% to 75% of the caregivers of demented individuals have significant episodes of clinical depressive symptoms that may require antidepressant medication," said Gray. "Be sure they know about adult day care, respite care and any other options that may help them."

When treating agitation in the elderly, the optimization of certain behavioral techniques may enhance medication therapies or sometimes eliminate the need for them. Clinicians should look more closely at the behavioral causes behind a demented older person's problem behavior.

Optimizing Behavioral Techniques Can Ease the Burden of Care

Aware that there is a "rush to hold all providers delivering mental health and chemical dependency services accountable for the accessibility, quality and satisfaction of such services," the American Managed Behavioral Healthcare Association (AMBHA) recently released the second version of its Performance Measures for Managed Behavioral Healthcare Programs (PERMS 2.0). 

AMBHA members manage the mental illness and substance abuse disorder health plan benefits for some 100 million enrollees. Since AMBHA's formation in 1994, one of its primary goals has been "to promotehealth plan, management agent and provider accountability through performance measurement."

PERMS 2.0 was produced by the AMBHA Committee on Quality Improvement and Clinical Services, chaired by Clarissa Marques, Ph.D. AMBHA members worked with a team from Harvard University to draft the technical specifications.

Membership organizations within AMBHA will be asked to submit data relevant to the PERMS 2.0 measures, according to Pamela Greenberg, M.P.P., AMBHA's executive director. Harvard researchers will analyze the data.

The goal is the release of one-fourth of the data generated by PERMS 2.0 by the second quarter of 1999, said Greenberg. The data will be aggregated into an industry-level database available for external policy development and internal benchmarking.  

Individual AMBHA members can choose to release data specific to their own organizations, Greenberg added.

Examples of some PERMS 2.0 measures for access to care include the number of inpatient discharges for Mental Health and/or Substance Abuse (MH/SA) treatment and average length of stay, and the percentage of members receiving inpatient and outpatient MH/SA services. 

Examples of quality indicators are ambulatory follow-up within seven and 30 days of inpatient discharge for MH/SA diagnoses, readmission rates for MH/SA diagnoses (30, 90, 365 days), the percentage of board certified psychiatrists, the availability of providers with bilingual language skills, the engagement rates for treatment of depression and substance abuse, the availability of psychotherapy and/or medication management for patients with schizophrenia, and having one family visit for children undergoing mental health treatment. 

Most of these measures have been designed to be in compliance with the Health Plan Employer Data and Information Set (HEDIS), developed by the National Committee for Quality Assurance (NCQA). A set of more than 75 standardized quality performance measures of access, process and patient satisfaction, HEDIS is used by more than 90% of the nation's health plans.

Along with the behavioral health measures, PERMS 2.0 includes consumer satisfaction measures based on questions that appeared in the first version of PERMS and questions from the Consumer Assessment of Health Plans Study developed by the U.S. Agency for Health Care Policy Research. Included in PERMS 2.0 are such questions as "With the choices that were available to you through your health plan, was it easy to find a mental health or substance abuse treatment provider?" and "Did your mental health or substance abuse treatment provider encourage you to use self-help or consumer-run programs such as clubhouses and drop-in community support centers?"

AMBHA also will be testing leadership measures, "measures clearly in an early developmental stage," in PERMS 2.0. These include the number and percentage of admissions that are involuntary, prescribing of antipsychotic medications for nonpsychotic conditions, and concurrent prescribing of two or more psychotherapeutic/active medications for those aged 65 and older. 

One week after the release of PERMS 2.0, the NCQA released the final specifications for the 1999 Health Plan Employer Data and Information Set (HEDIS 99). 

HEDIS 99 includes new behavioral health care measures, including one assessing whether health plans are effectively managing patients with moderate to severe cases of depression and who are being treated with antidepressant medication. Specifically, the antidepressant measure looks at whether follow-up visits are sufficiently frequent to ensure optimal medical management (e.g., to adjust dosages, check tolerance) and how many patients are still on their medications after 12 weeks and after six months. Other relevant measures included in the HEDIS 99 are follow-up after hospitalization for mental illness, advising smokers to quit, availability of behavioral health care providers and a new membership satisfaction survey. Many of the measures will be included in NCQA's accreditation program which begins in July  1999. NCQA also has developed standards for its Managed Behavioral Health Accreditation Program.

AMBHA Committee on Quality Improvement and Clinical Services (1998), PERMS 2.0: Performance Measures for Managed Behavioral Healthcare Programs. Washington, D.C.: American Managed Behavioral Healthcare Association. 


American Managed Behavioral Healthcare Association (1998), Performance measures, second version, announced for managed behavioral healthcare programs. Press release issued Aug. 24, 1998.


National Committee for Quality Assurance (1998), NCQA releases final HEDIS 1999 specifications; additions focus on member satisfaction, cardiac care and behavioral health. Press release issued Sept. 8, 1998.