The dentate gyrus is hypothesized to function as a “gate,” limiting the flow of excitation through the hippocampus. During epileptogenesis, adult-generated granule cells (DGCs) form aberrant neuronal ...connections with neighboring DGCs, disrupting the dentate gate. Hyperactivation of the mTOR signaling pathway is implicated in driving this aberrant circuit formation. While the presence of abnormal DGCs in epilepsy has been known for decades, direct evidence linking abnormal DGCs to seizures has been lacking. Here, we isolate the effects of abnormal DGCs using a transgenic mouse model to selectively delete PTEN from postnatally generated DGCs. PTEN deletion led to hyperactivation of the mTOR pathway, producing abnormal DGCs morphologically similar to those in epilepsy. Strikingly, animals in which PTEN was deleted from ≥9% of the DGC population developed spontaneous seizures in about 4 weeks, confirming that abnormal DGCs, which are present in both animals and humans with epilepsy, are capable of causing the disease.
► Direct evidence that selective disruption of the dentate gyrus causes epilepsy ► PTEN deletion from as few as 9% of granule cells is sufficient to cause epilepsy ► Findings suggest a plausible mechanism of epileptogenesis
Abnormal hippocampal granule cells are hypothesized to be critical for temporal lobe epileptogenesis, but direct supporting evidence has been limited. Here, Pun and colleagues demonstrate that selective disruption of granule cells by PTEN deletion is sufficient to cause the disease.
To compare citalopram and risperidone for the treatment of psychotic symptoms and agitation associated with dementia, with a priori hypotheses that risperidone would be more efficacious for psychosis ...and citalopram for agitation.
A 12-week randomized, controlled trial in nondepressed patients with dementia hospitalized because of behavioral symptoms (N = 103) was conducted at the University of Pittsburgh Medical Center. Participants were consecutively recruited on an inpatient unit if they had at least one moderate to severe target symptom (aggression, agitation, hostility, suspiciousness, hallucinations, or delusions). Once they improved sufficiently, they were discharged to nursing homes, personal care homes, or residential homes for continued treatment. Planned pre-post and mixed model analyses of the main outcome measures of Neurobehavioral Rating Scale and Side Effect Rating Scale at baseline and at weekly/biweekly intervals were conducted.
Completion rates did not differ for citalopram and risperidone (overall completion rate: 44%). Agitation symptoms (aggression, agitation, or hostility) and psychotic symptoms (suspiciousness, hallucinations, or delusions) decreased in both treatment groups but the improvement did not differ significantly between the two groups. There was a significant increase in side effect burden with risperidone but not with citalopram such that the two groups differed significantly.
No statistical difference was found in the efficacy of citalopram and risperidone for the treatment of either agitation or psychotic symptoms in patients with dementia. These findings need to be replicated before citalopram or other serotonergic antidepressants can be recommended as alternatives to antipsychotics for the treatment of agitation or psychotic symptoms associated with dementia.
Job satisfaction is important for nursing home staff and nursing home management, as it is associated with absenteeism, turnover, and quality of care. However, we know little about factors associated ...with job satisfaction and dissatisfaction for nursing home workers.
In this investigation, we use data from 251 caregivers (i.e., Registered Nurses, Licensed Practical Nurses, and Nurse Aides) to examine: job satisfaction scores of these caregivers and what characteristics of these caregivers are associated with job satisfaction. The data were collected from two nursing homes over a two and a half year period with five waves of data collection at six-month intervals. The Job Description Index was used to collect job satisfaction data.
We find that, overall nursing home caregivers are satisfied with the work and coworkers, but are less satisfied with promotional opportunities, superiors, and compensation. From exploratory factor analysis three domains represented the data, pay, management, and work. Nurse aides appear particularly sensitive to the work domain. Of significance, we also find that caregivers who perceived the quality of care to be high have higher job satisfaction on all three domains than those who do not.
These results may be important in guiding caregiver retention initiatives in nursing homes. The finding for quality may be especially important, and indicates that nursing homes that improve their quality may have a positive impact on job satisfaction of staff, and thereby reduce their turnover rates.
Abstract This retrospective, observational report describes an innovative quality improvement process, Phase-based Care (PBC), that eliminated wait times and achieved positive clinical outcomes in a ...community mental health center’s (CMHC) mood disorder clinic without adding staff. PBC accomplishes this by eliminating the ingrained cultural practice of routinely scheduling stable patients at rote intervals of 1–3 months, regardless of clinical need or medical necessity. Based on four organizational transformations and using mathematical algorithms developed for this process, PBC re-allocates therapy and medical resources away from routinely scheduled appointments and front-loads those resources to patients in an acute phase of illness. To maintain wellness for patients in recovery, lower frequency and intensity approaches are used. This report describes the development of the PBC methodology focusing on the Rapid Recovery Clinic (RRC) comprised of 182 patients with a primary diagnosis of a mood disorder, the largest of the 14 PBC clinics created. Over an 18-month period, wait times were reduced from several months to less than one week and recovery rates, meaning no longer in an acute phase, were 63% and 78% at weeks 6 and 12, respectively for patients who engaged in the program.
Until recently, conventional antipsychotics were the standard pharmacotherapy for psychosis and behavioral disturbances associated with dementia. This double-blind, placebo-controlled study compared ...the acute efficacy of the selective serotonin reuptake inhibitor citalopram and the neuroleptic perphenazine with placebo for the treatment of psychosis and behavioral disturbances in nondepressed patients with dementia.
Eighty-five hospitalized patients with at least one moderate to severe target symptom (aggression, agitation, hostility, suspiciousness, hallucinations, or delusions) were randomly assigned to receive either citalopram, perphenazine, or placebo under double-blind conditions for up to 17 days.
Patients treated with citalopram or perphenazine showed statistically significant improvement on several Neurobehavioral Rating Scale factor scores. Compared to those receiving placebo, only patients treated with citalopram showed significantly greater improvement in their total Neurobehavioral Rating Scale score as well as in the scores for the agitation/aggression and lability/tension factors. Side effect scores were similar among the three treatment groups.
Citalopram was found to be more efficacious than placebo in the short-term hospital treatment of psychotic symptoms and behavioral disturbances in nondepressed, demented patients.
The aim of this study is to compare the Empirical Behavioral Rating Scale (E-BEHAVE-AD), Neurobehavioral Rating Scale (NBRS), and Neuropsychiatric Interview (NPI) in detecting behavioral disturbance ...and psychotic symptoms in dementia and characterizing changes in response to treatment.
Eighty-seven subjects in the randomized controlled trial "Continuation Pharmacotherapy for Agitation of Dementia" were included in this analysis. We compared the detection in, and changes of, both agitation and psychosis, using these three instruments. A receiver operating characteristic analysis was performed to compare the performance of the three instruments in detecting global improvement.
The instruments were equally likely to detect agitation. The NBRS was most likely to detect psychosis. Although the NPI best detected improvement in agitation, the instruments were equal for detecting improvement in psychosis. In the receiver operating characteristic analysis for overall clinical improvement in response to treatment, there were no differences in the areas under the correlated curves for the three instruments, but they demonstrated different sensitivity and specificity at different cutoff points for target symptom reduction. The E-BEHAVE-AD performed best at a cut point of 30% target symptom reduction and the NBRS and NPI both performed best at 50%.
The E-BEHAVE-AD, NBRS, and NPI were more similar than different in characterizing symptoms but differed in detecting response to treatment. Differences in sensitivity and specificity may lead clinicians to prefer a specific instrument, depending on their goal and the expected magnitude of response to any specific intervention.
There is a shortage of mental health professionals to care for a growing geriatric population. Though not mutually exclusive, clinical and didactic educational experiences promote cognition, whereas ...affective knowledge (attitude) is promoted through nonclinical exposure to seniors. This study evaluates the relative impact of cognition and attitude on career interests among healthcare students.
We developed 13 interactive, video documentary "lessons" on late-life mental health presenting didactic material along with stories of actual patients and families. Four of these lessons were viewed at 1-week intervals by 42 students from medical school and graduate programs of social work, psychology, and nursing. Knowledge, attitudes, and inclinations toward working with seniors were assessed.
Both cognition and attitudes toward seniors improved. Linear regression shows that change in attitude, not cognition, predicts interest in working with seniors.
Educational experiences that promote affective learning may enhance interest in geriatric careers among healthcare students.
Seniors with a history of emotional trauma decades earlier can experience a recurrence of posttraumatic stress disorder symptoms when transitioning to a nursing home. We present the case of an ...86-year-old male Holocaust survivor admitted to a nursing home for physical therapy and rehabilitation 6 weeks after the death of his wife; the patient was expressing a persistent death wish. Despite the multiple risk factors for depression, his distress was specifically related to the reemergence of nightly posttraumatic nightmares. Over the course of 1 week of treatment with 1 mg prazosin at bedtime, his nightmares and his death wish completely resolved. He achieved his rehabilitation goals and was discharged to a community setting. This report highlights the importance of considering posttraumatic stress disorder in nursing home residents with a history of emotional trauma, and understanding how to address these symptoms pharmacologically and nonpharmacologically.
Preparedness for death as a predictor of post-bereavement adjustment has not been studied prospectively. Little is known about pre-death factors associated with feeling prepared prior to the death of ...a loved one.
Our aim was to prospectively assess the role of preparedness for death as a predictor of post-bereavement adjustment in informal caregivers (CGs) who experienced the death of their loved one and to identify predictors and correlates of complicated grief, depression, and preparedness for death among informal CGs.
We conducted a prospective, longitudinal study using data collected for a randomized trial testing the efficacy of an intervention for CGs of recently placed care recipients (CRs). Subjects were 217 informal CGs of care recipients recently placed in nursing homes, and they were followed for 18 months. CGs were assessed in person by certified interviewers at 6-month intervals. Eighty-nine CGs experienced the death of their loved one in the course of the study. Measurements used included preparedness for death, advance care planning (ACP), complicated grief, depression, and sociodemographic characteristics.
CGs who reported feeling more prepared for the death experienced lower levels of complicated grief post-bereavement. A multivariate ordinal logistic regression model showed that spouses as opposed to adult child CGs were less prepared for the death, depressed CGs were less prepared, and patients who engaged in ACP had CGs who felt more prepared. CR overt expressions about wanting to die was also related to higher levels of preparedness in the CG.
We show prospectively that preparedness for death facilitates post-bereavement adjustment and identify factors associated with preparedness. ACP can be an effective means for preparing informal CGs for the death of their CRs.
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