Indications for the Use of Atypical Antipsychotics in the Elderly

There has been an expanding role for the new generation atypical antipsychotic agents (clozapine, risperidone, olanzapine, and quetiapine) in elderly patients. Their efficacy in the treatment of psychoses associated with schizophrenia is now well established. But psychoses occur in other conditions. This paper will review the current research examining the use of the atypical agents in the treatment of psychoses in the elderly in three somewhat overlapping conditions: schizophrenia, dementia, and Parkinson's disease, as well as in the amelioration of a variety of movement disorders. In the elderly, any of the atypicals can be used to treat schizophrenia, although clozapine may be a second line agent because of its side effect profile. Risperidone may be the drug of choice for the treatment of psychoses and behavioral disturbances in dementia. Clozapine is a primary choice and quetiapine an alternative for the treatment of psychoses in Parkinson's disease; while clozapine and possibly risperidone may be preferred for the initial treatment of some movement disorders. The differential effectiveness of these agents across treatment indications may, in part, be related to their differing affinities at several neurotransmitter receptors. Examination of these relationships in large scale longitudinal studies may help in the development of effective tailored treatments for the elderly.     

Jung's views on causes and treatments of schizophrenia in light of current trends in cognitive neuroscience and psychotherapy research I. Aetiology and phenomenology

Jung's writings on schizophrenia are almost completely ignored or forgotten today. The purpose of this paper, along with a follow‐up article, is to review the primary themes found in Jung's writings on schizophrenia, and to assess the validity of his theories about the disorder in light of our current knowledge base in the fields of psychopathology, cognitive neuroscience and psychotherapy research. In this article, five themes related to the aetiology and phenomenology of schizophrenia from Jung's writings are discussed:1) abaissement du niveau mental; 2) the complex; 3) mandala imagery; 4) constellation of archetypes and 5) psychological versus toxic aetiology. Reviews of the above areas suggest three conclusions. First, in many ways, Jung's ideas on schizophrenia anticipated much current thinking and data about the disorder. Second, with the recent (re)convergence of psychological and biological approaches to understanding and treating schizophrenia, the pioneering ideas of Jung regarding the importance of both factors and their interaction remain a useful and rich, but still underutilized resource. Finally, a more concerted effort to understand and evaluate the validity of Jung's concepts in terms of evidence from neuroscience could lead both to important advances in analytical psychology and to developments in therapeutic approaches that would extend beyond the treatment of schizophrenia.     

‘The Good Mother and Her Clinging Child’: Patterns of Anchoring in Social Representations of Dementia Caregiving

This paper discusses the findings of a study that examined the processes of anchoring in the understanding of dementia caregiving using 29 interviews conducted in Germany with wives and daughters caring for a relative with dementia and 43 newspaper articles pertinent to the research objective. The concept of anchoring from Social Representations Theory was complemented by elements from cognitive linguistics to analyse the social representations (SRs) that served as source domains to determine what the target domain of dementia caregiving means, entails and requires. The analysis revealed three prevalent patterns of anchoring dementia care in SRs of child care and the good mother. The first pattern ascribed the role of the helpless clinging child needing his mother to the dementia patient, the second emphasised that the dementia caregivers' responsibility for caring, just like motherhood, should take precedence over all other interests and the third consisted of dementia caregivers deriving the perception of being the most suitable caregiver from the mother's natural aptitude for caring. The conclusions reached by the different patterns are argued to contribute to dementia caregivers overexerting themselves and not using support services. The clinical implications for targeting such adverse effects of the anchoring will be discussed. Copyright © 2013 John Wiley & Sons, Ltd.     

God’s Faithfulness and Dementia: Christian Theology in Context

Christian theology concerns the practical, contextual realities of life in the church and the world. What does this mean for a person with dementia? While much dementia care focuses on deficits, this article promotes a different starting point: God’s faithfulness rather than our forgetfulness. Using case studies from residential aged care, opportunities for meaningful pastoral care are explored, inviting us to see in the person with dementia a deep connection with ourselves. Drawn from a theological understanding of God as three persons—Father, Son and Holy Spirit—“person-centered care” invites us into relationships of mutuality and reciprocity not dependent on words. Pastoral care of families is manifest through personal relationships where all aspects of dementia, including death and dying, can be discussed openly. Grounded in God’s faithfulness, the first and final word is love. Hope lies in the belief that we have already been found. We are blessed by the grace of God, called into community where the insightful and the forgetful flourish together.     

A Spiritual Journey Into the I-Thou Relationship: A Personal Reflection on Living With Dementia

This article is a personal reflection of the author’s spiritual journey after diagnosis with dementia. It draws on biblical texts to illustrate moments of trauma, then adjustment, and finally joy. The article concludes with a reflection on the experience of dementia as being “transformed by the renewing of your mind” (Rom.12:8). It suggests an approach in which the increasing disability caused by dementia may be regarded as “walking in the cool of the day” with God in the Garden of Eden (Gen. 3:8).     

My Glorious Opportunity: How My Dementia Has Been a Gift

This article is a personal reflection on the experience of living with dementia. Jennifer Bute is a former family practitioner who has early-onset Alzheimer’s disease. The article presents some basic principles for living well with dementia and offers some deep and personal reflections on what it means, how it can be understood theologically, and how all of us together can help one another to live well with dementia.     

Psychosis,symbol, affectivity 2: another perspective on the treatment of psychotic disorder

This is the second of two papers concerning our study into an integrated approach to psychotic disorders conducted at the University Psychiatry Unit of Palermo’s Polyclinic over approximately 15 years; this paper concentrates on the clinical phenomena. The study aimed to find the best possible treatment and to improve the prognosis of this patient group. We have explored the efficacy of a range of psycho-therapeutic (cognitive-behavioural, systemic-relational, psychodynamic, group and others), psycho-pharmaceutical, psychiatric rehabilitative and psycho-educational treatments, with a hermeneutic approach instead of a systematic one. The study’s conclusions, described in the paper, are that all psychotic functions start with a nuclear psychic issue connected to emotional development. We describe how the most significant symptoms of acute psychotic manifestations (delusions and misperceptions) make use of an encrypted psychological meaning that can be decoded through the patient’s symbolic language. This language is a key element in diagnosis and in the choice of treatment. The paper describes how we revised our understanding of psychosis from being a brain disease to being a process aimed at the rearrangement of psychic functioning. Our significant results are described.     

Social cognition and social functioning in patients with amnestic mild cognitive impairment or Alzheimer’s dementia

The aim of the present study was to examine social cognition and social functioning in a group of amnestic mild cognitive impairment (aMCI) and Alzheimer’s dementia (AD) patients. Thirty one people with aMCI, 29 individuals with AD, and 45 healthy older adults participated in the study. Facial expressions of happiness, anger, fear, disgust, and surprise presented in different intensities had to be labelled. Mentalizing was assessed using first-order belief theory of mind (ToM) stories and everyday social functioning by the Inventory of Interpersonal Situations (IIS), completed by an informant. aMCI patients were impaired in recognizing the emotions anger, disgust, and fear, while AD patients were impaired in recognizing the emotions anger, disgust, and surprise. More importantly, no significant differences between aMCI and AD patients were found on overall emotion recognition. Both the aMCI and AD patients were impaired on the ToM task, but no differences between the aMCI and AD patients were found. On everyday social functioning, only the AD patients showed impairments. No associations between the IIS and ToM were found, but the IIS and emotion perception were significantly correlated. Regression analysis taking all potentially confounding variables into account showed that only mood, but not the social-cognitive task performance or any other cognitive variable, predicted social functioning. aMCI and AD patients demonstrated impairments in mentalizing and facial emotion perception, and showed decrements in everyday social functioning. Informing caregivers about these deficits may help them to understand deficits in social cognition that may be present already in the MCI stage of Alzheimer’s disease.     

Effects of daily maladaptive coping on nightly sleep in mothers

Objective: We examined effects of daily rumination and suppression in response to stressors on objective and subjective sleep among mothers.

Design: Participants were 183 mothers, including chronically stressed mothers of children with an autism spectrum disorder (M-ASD; n = 92) and age-matched mothers of neurotypical children (M-NT; n = 91). In an intensive longitudinal design, participants provided reports of daily rumination and suppression, nightly objective actigraphy-defined sleep and nightly subjective sleep quality for seven consecutive days at baseline, 9 months and 18 months.

Main Outcome Measures: Total sleep time, sleep fragmentation, sleep onset latency, and subjective sleep quality.

Results: Among M-NT with above average depressive symptoms, higher daily rumination was associated with shorter total sleep time. Rumination was associated with more sleep fragmentation among M-NT at the trend level. Rumination was not associated with sleep onset latency among M-NT, or with any sleep outcomes among M-ASD. Suppression was not associated with any sleep outcomes.

Conclusion: We provide novel evidence of the effect of rumination on objectively measured sleep duration among M-NT. Coping was not related to sleep among M-ASD. Given the prevalence of poor sleep among mothers, future work should examine modifiable factors perpetuating sleep disturbance.