The Persistence of Traumatic Memories in World War II Prisoners of War by Rintamaki et al. in the current issue of the Journal of the American Geriatrics Society reminds us as health professionals caring for elderly people of the importance of appreciating traumatic events throughout the life span. The authors identified a convenience sample of 157 prisoners of war (POWs) of the European and Pacific theaters from World War II (WWII). More than 60 years later, nightmares and flashbacks are common. For many, these symptoms have increased in frequency or intensity since retirement. Rintamaki and colleagues report that 30% to 40% of the POWs of the European theater, and 62% to 73% of POWs from the Japanese theater experience the key symptoms of intrusive recollections, dreams, and flashbacks, although only 12% and 34% of those POWs meet diagnostic criteria for posttraumatic stress disorder (PTSD). These data make the distinction that symptoms after trauma do NOT necessarily constitute a psychiatric disorder. Depending on the severity of the trauma, these experiences could be considered a normal human response, noting that more that half of the Pacific theater veterans report them. The presence of posttrauma symptoms in the absence of a psychiatric disorder is an important contribution of this article. Many of these veterans continue to live productive, wholesome, and fulfilled lives in spite of the presence of these distressing sequelae, yet the fact that these experiences continue puzzle and distress them. The effect of traumatic events on emotional and physiological functioning has been documented for centuries. Samuel Pepys chronicled the physical and emotional symptoms of what we now call PTSD in the aftermath of the Great Fire of London in the 17th century. Although the clinical experiences described remain consistent, the terminology changed with each major military campaign. Approximately 20 years after the end of the Civil War, the terms ‘‘irritable heart’’ or ‘‘soldier’s heart’’ were used to describe physiological anxiety symptoms in the absence of overt heart disease in combat veterans. After World War I, veterans who were emotionally affected after their combat experiences were described as ‘‘shell shocked.’’ During WWII, Kardiner initially attempted to reconcile the psychiatric syndrome referred to as ‘‘combat fatigue’’ with traditional Freudian theory of repressed sexual drive in combat veterans, although he relinquished that position and proposed that these symptoms constitute a ‘‘physioneurosis,’’ in contrast to the classical Freudian ‘‘psychoneurosis.’’ Early in the Vietnam War, symptomatic veterans were described as having the ‘‘Vietnam Vets Syndrome.’’ Eventually, it was acknowledged that posttraumatic symptoms throughout history are similar, and the diagnosis of PTSD was added to the lexicon. Although much of the research on posttraumatic stress involves combat veterans or POWs, civilians exposed to traumatic events are similarly affected. Forty years after WWII, Holocaust survivors living in the United States and in Israel reported disrupted sleep patterns and frequent nightmares. Survivors of traffic accidents, fires, floods, rape, sexual abuse, and kidnapping report similar symptoms after these civilian traumas. What is the clinical importance of this study to healthcare professionals in their daily work? After all, there are few surviving WWII POWs, and their numbers are ever diminishing. All elderly patients have been through decades of challenges and stressors, both in war and in civilian life. For some, traumatic experiences have been integrated into their view of themselves and can serve as a sources of strength. Others immersed themselves in their work to avoid the intrusive memories and images. As retirees are faced with less structured time, loss of friends and family can result in the re-emergence of posttraumatic symptoms even decades later. More than half of the respondents in the current study report an increase in symptoms since retirement. The re-emergence of intrusive thoughts and nightmares can be extremely distressing and equally confusing. In clinical practice, patients are typically unwilling to spontaneously discuss these symptoms with their healthcare practitioners. Patients may feel shame that they are emotionally weak, and they assume that others with similar histories do not experience these symptoms after all these years. It is important to realize that avoidance is one of the core symptoms of PTSD. Initiating a discussion with a healthcare professional is likely to arouse more distress and increase symptoms and is thus avoided. Patients will feel comfortable asking for ‘‘sleeping pills’’ or ‘‘nerve pills’’ DOI: 10.1111/j.1532-5415.2009.02609.x

Background: 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. Methods: In this investigation, we use data from 251 caregivers to examine: what job satisfaction domains are important and what characteristics of these workers are associated with job satisfaction. Results: We find that, overall nursing home caregivers are satisfied with the work and coworkers, but are less satisfied with promotional opportunities, superiors, and compensation. Nurse aides appear particularly sensitive to pay and promotion, whereas other staff appear more sensitive to co-workers and promotion. Of significance, we also find that caregivers who perceived the quality of care to be high have higher job satisfaction than those who do not. Conclusion: Results such as these may be important in guiding caregiver retention initiatives in nursing homes.

OBJECTIVE:This study determined if actors could portray depressed patients to establish the interrater reliability of raters using the Hamilton Depression Rating Scale (HDRS).METHOD:Actors portrayed depressed patients using scripts derived from HDRS assessments obtained at three points during treatment. Four experienced raters blindly viewed videotapes of two patients and two actors. They guessed if each interviewee was a patient or an actor and rated the certainty of their guesses. For each interview, they also rated the realism of the portrayal and completed the HDRS.RESULTS:Experienced raters could not distinguish actors and patients better than chance and were equally certain of their right and wrong guesses. Actors and patients received high scores on the realism of their portrayals. The HDRS scores of the actor-patient pairs were correlated.CONCLUSIONS:Actors can effectively portray depressed patients. Future studies will determine if actors can accurately portray patients with anxiety and psychosis.

ABSTRACT In spite of their prevalence and persistence, why are behavioral and psychological symptoms of dementia difficult for clinicians to assess and manage? This paper provides an overview of the methodological challenges encountered in measuring behavioral disturbances of dementia. Specifically, conceptual constructs of behavioral and psychological symptoms of dementia, the strengths and weaknesses of the currently existing rating instruments, analytic methodologies, and the utility of technological devices are outlined in the service of formulating future directions in behavioral and psychological symptoms of dementia assessment research.

OBJECTIVE:Use of cognitive, psychiatric and behavioral domains to assess the effectiveness of a pharmacological or behavioral intervention in the treatment of neurodegenerative disorders (e.g., Alzheimer disease) aids the identification of specific types of impairment or distress in behavioral status and quality-of-life issues in this population. With confirmatory approaches to subscale development readily available, we can obtain a more precise understanding of the sub-components of a scale, potentially providing the basis for selecting behavioral and/or quality-of-life outcome measures that may be more sensitive to the effects of pharmacological or behavioral interventions.METHODS:The authors illustrate the use of a confirmatory factor-analytic approach to verify scale sub-domains of the Neurobehavioral Rating Scale (NBRS) in elderly patients with dementia. With data collected from two groups of patients being treated for significant psychiatric and behavioral symptoms, authors investigated the relationships among scale items in order to test several competing models, including a general one-factor model, a first-order multifactor model, and a second-order factor model.RESULTS:The first-order model, with seven factors, provided the best fit to the correlations among items in the NBRS, indicating the multidimensionality of problematic behaviors and symptoms exhibited by dementia patients.CONCLUSION:Authors advocate the use of a confirmatory factor-analytic approach to verify scale sub-domains in other, more widely used rating scales for patients with dementia.

Objective Mental health education for the staffs of nursing homes is difficult to provide and often inadequate. The objectives of this study were to design and assess a curriculum of staff training on depression and dementia that is accessible, educational, and relevant. Design A core curriculum of 12 computer-based interactive video training modules was created in a television news-documentary format to educate nursing home staffs. A randomized trial of the first six modules, which are dedicated to mental health and aging, was conducted at a computer site (CS), a “lecture site” (LS), and control site (CON). Setting Three not-for-profit nursing facilities in Western Pennsylvania. Participants The certified nursing assistants, and other nursing staff participated in the study as part of their required training. Intervention Nursing staffs at the two intervention sites (CS and LS) were mandated to participate in monthly educational sessions. At the CS, the computer program scheduled staff members each month for 45 minutes of individual, self-paced training using the interactive video modules. At the LS, staff members were scheduled to attend a 45-minute monthly lecture with identical learning objectives delivered by an advanced degree nurse educator. A videotape of the lectures was shown at two additionally scheduled times during the month to accommodate all shifts. Measurements Compliance and satisfaction with training were monitored at both intervention sites. Knowledge was assessed at the CS, LS, and CON, before each monthly training session, and with a cumulative post-training exam, administered at the end of the 6-month study. Results Over the 6-month period, training compliance was 66% and 22% at CS and LS, respectively (P < 0.001). Satisfaction with training and the relevance of training were rated significantly higher at the CS (P < 0.0001). Before the study, assessed knowledge was similar at the CS, LS, and CON. After 6 months, the CS scored significantly higher than the LS and CON in terms of knowledge (P < 0.005). Conclusion Individual, self-paced, interactive video education for nursing home staff resulted in greater compliance and satisfaction with training compared to staff receiving lectures. Knowledge of core concepts was greater for staff of the computer site compared to the staffs of either the lecture or control sites at the end of this 6-month study. Mental health education for the staffs of nursing homes is difficult to provide and often inadequate. The objectives of this study were to design and assess a curriculum of staff training on depression and dementia that is accessible, educational, and relevant. A core curriculum of 12 computer-based interactive video training modules was created in a television news-documentary format to educate nursing home staffs. A randomized trial of the first six modules, which are dedicated to mental health and aging, was conducted at a computer site (CS), a “lecture site” (LS), and control site (CON). Three not-for-profit nursing facilities in Western Pennsylvania. The certified nursing assistants, and other nursing staff participated in the study as part of their required training. Nursing staffs at the two intervention sites (CS and LS) were mandated to participate in monthly educational sessions. At the CS, the computer program scheduled staff members each month for 45 minutes of individual, self-paced training using the interactive video modules. At the LS, staff members were scheduled to attend a 45-minute monthly lecture with identical learning objectives delivered by an advanced degree nurse educator. A videotape of the lectures was shown at two additionally scheduled times during the month to accommodate all shifts. Compliance and satisfaction with training were monitored at both intervention sites. Knowledge was assessed at the CS, LS, and CON, before each monthly training session, and with a cumulative post-training exam, administered at the end of the 6-month study. Over the 6-month period, training compliance was 66% and 22% at CS and LS, respectively (P < 0.001). Satisfaction with training and the relevance of training were rated significantly higher at the CS (P < 0.0001). Before the study, assessed knowledge was similar at the CS, LS, and CON. After 6 months, the CS scored significantly higher than the LS and CON in terms of knowledge (P < 0.005). Individual, self-paced, interactive video education for nursing home staff resulted in greater compliance and satisfaction with training compared to staff receiving lectures. Knowledge of core concepts was greater for staff of the computer site compared to the staffs of either the lecture or control sites at the end of this 6-month study.

Objective: 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.Method: 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.Results: 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.Conclusions: 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.

OBJECTIVE:To conduct the first randomized study comparing the efficacy of an antidepressant alone versus an antidepressant plus a neuroleptic in the treatment of late-life psychotic depression.METHOD:The efficacy of nortriptyline plus placebo versus nortriptyline plus perphenazine was compared in 36 patients aged 50 years or older presenting with a major depressive episode with psychotic features (DSM-III-R criteria). Patients were started openly on nortriptyline treatment titrated to therapeutic levels. They were then randomly assigned under double-blind conditions to addition of perphenazine or placebo. Outcomes were compared in the 2 treatment groups using measures including the Hamilton Rating Scale for Depression (HAM-D) and the Brief Psychiatric Rating Scale (BPRS); side effects were assessed with the Geriatric Movement Disorder Assessment.RESULTS:Both treatments were well tolerated. Of the 36 randomly assigned patients, 2 (1 in each group) dropped out due to treatment-related adverse effects. Four additional patients dropped out for administrative reasons. Thirty patients received nortriptyline for at least 4 weeks combined with either perphenazine (N = 14) or placebo (N = 16) for at least 2 weeks (median = 9 weeks). There was no significant difference between the completers in the 2 treatment groups when comparing their scores on the HAM-D, the BPRS, its psychoticism subscale, or any side effects measure. Rates of response (defined as resolution of both depression and psychosis) did not differ significantly in the 2 groups (nortriptyline-plus-perphenazine group, 50% vs. nortriptyline-plus-placebo group, 44%).CONCLUSION:When treating older patients with psychotic depression, the addition of a moderate dose of a traditional neuroleptic to a tricyclic antidepressant was well tolerated but did not improve efficacy. This finding supports existing data suggesting that the pathophysiology (and thus the required treatment) of psychotic depression may be different early and late in life.

BACKGROUND:Psychotic symptoms in subjects with Alzheimer disease (AD+psychosis, AD+P) are a marker for a distinct phenotype characterized by more rapid cognitive and functional decline and a liability to aggressive behaviors. We recently found that AD subjects homozygous for long alleles (l) of an insertion/deletion polymorphism in the promoter region of the serotonin transporter (5-HTTPR) had elevated rates of aggressive behavior.OBJECTIVE:To examine whether the 5-HTTPR ll genotype confers an increased risk of AD+P, and of the combined AD+P/aggressive phenotype.METHODS:The 5-HTTPR genotype was determined in 332 subjects diagnosed with possible or probable AD. All subjects received structured psychiatric assessments and were categorized with regard to their history of aggressive behaviors and psychotic symptoms.RESULTS:Consistent with other reports, AD+P was associated with a significant increased risk for aggressive behavior. AD+P and aggression were both significantly associated with 5-HTTPR ll genotype and with an increased l allele frequency. Subjects with the combined behavioral phenotype (AD+P and aggressive behavior) had the highest rate of ll genotype and highest l allele frequency.CONCLUSION:The 5-HTTPR l allele appears to confer risk for the combined AD+P/aggressive phenotype. Confirmation of this association in a similar behaviorally well-characterized independent sample is needed.

BACKGROUND Aggressive behavior in Alzheimer disease (AD) has been linked to dysfunction of serotonin neurotransmission. Homozygosity for the long variant (*L) of an identified biallelic polymorphism of the serotonin transporter promoter region (5-HTTPR) is associated with increased expression of the transporter protein and increased speed of response to serotonin reuptake inhibitor treatment. OBJECTIVE To determine whether the *L/*L genotype and the *L allele are associated with an increased risk of aggressive symptoms in patients with AD. DESIGN Case-control study. SETTING University hospital geriatric psychiatry inpatient program and Alzheimer disease research center. SUBJECTS Fifty-eight patients with AD with a history of aggressive behavior and 79 never-aggressive patients with AD with comparable severity of cognitive impairment. MAIN OUTCOME MEASURES The 5-HTTPR genotype and allele frequency. RESULTS The *L/*L genotype was significantly associated with aggression in patients with AD (odds ratio, 2.8; 95% confidence interval, 1.2-6.5). Similar results were obtained for *L allele frequency. CONCLUSION The 5-HTTPR*L allele and *L/*L genotype may predispose patients with AD to develop aggressive behavior.

‘Minor’ depression affects up to 50% of residents in long‐term care facilities and is associated with considerable discomfort, disability and risk of morbidity. Despite the prevalence of this problem, few studies addressing the treatment of these patients have been conducted. In an open clinical trial, 12 nursing home residents who met the DSM‐IV description for minor depressive disorder were treated with sertraline for 6 weeks. Adverse effects and clinical response were monitored. All residents tolerated their medication without any significant side‐effects. At the completion of the study, the Hamilton Depression Rating Scale and Global Assessment Scale change scores both indicated significant improvement and 75% of the residents met criteria for ‘remission’. This preliminary study provides evidence that nursing home residents with minor depression tolerated treatment with sertraline and improved clinically. Copyright © 2000 John Wiley & Sons, Ltd.

The authors have previously reported that in elderly patients treated with low doses of perphenazine, few extrapyramidal symptoms (EPS) developed in those who were not poor CYP2D6 metabolizers. The authors hypothesized that this atypical side effect profile is due to perphenazine's principal metabolite, n-dealkylperphenazine (DAPZ), which is usually present in vivo at concentrations 1.5 to 2 times that of the parent drug. Perphenazine, DAPZ, and 7-hydroxyperphenazine affinities were examined in vitro by competition-binding analysis to isolated human receptors expressed in transfected cell lines. Perphenazine and metabolite effects were examined in vivo in 54 older patients who were treated with perphenazine, at a target dose of 0.1 mg/kg, for 10 to 17 days. Drug concentrations were determined by high-performance liquid chromatography with electrochemical detection. In in vitro binding studies, DAPZ demonstrated a higher affinity for serotonin-2A receptors than for dopamine-2 receptors to an extent comparable to that of some atypical neuroleptic agents. In contrast, perphenazine and 7-hydroxyperphenazine demonstrated a higher affinity for dopamine-2 receptors than for serotonin-2A receptors. The mean +/- SD concentrations in the 54 subjects were the following: perphenazine, 1.5 +/- 1.4 ng/mL; DAPZ, 2.0 +/-1.6 ng/mL; and 7-hydroxyperphenazine, 0.8 +/- 1.9 ng/mL. The mean +/- SD quotient for the DAPZ/perphenazine concentration was 1.7 +/- 1.1 and for the 7-hydroxyperphenazine/perphenazine was 0.54 +/-1.6. EPS onset was not correlated with the perphenazine concentration, the metabolite concentrations, the DAPZ/perphenazine quotient, or the 7-hydroxyperphenazine/perphenazine quotient. Despite a moderately atypical receptor-binding profile, DAPZ does not seem to moderate perphenazine effects in vivo in older patients. This outcome likely reflects the low potency of DAPZ for dopamine-2 and serotonin-2A receptors relative to the potency of perphenazine for these receptors. Further exploration of atypical properties of DAPZ should include de novo administration of this metabolite in animal models.

Response slowing on psychological tasks is found both in Alzheimer's disease and depression. However, the underlying cause for this slowing may be different in the two disorders. This research examined whether the behavioral slowing found in Alzheimer patients results from a reduction in their rate of cognitive processing, whereas the slowing in depressed geriatric patients reflects a purely motor retardation. This hypothesis was tested using a task in which subjects had simply to determine the number of dots present in an array (i.e., enumeration). In all four subject groups (Alzheimer patients, depressed geriatric patients, healthy old controls, and healthy young controls), response time increased linearly with array size. The slope of this linear function (reflecting rate of enumeration) was the same in the normal and depressed patients, but was significantly greater in the Alzheimer patients, suggesting the presence of a cognitive slowing in Alzheimer's disease, but not in depression.

Citalopram, in European studies, has shown some early promise for treatment of poststroke depression and behavioral complications of dementia. An open pilot study of citalopram was conducted in 16 patients with dementia and behavioral disturbances. Citalopram was well tolerated by 13 of the patients, and 9 had a clinically impressive response. A significant overall mean reduction in disruptive vocalizations was observed by means of a novel technique of computer-assisted real-time observation. The mean citalopram plasma level-to-dose ratio was found to be twice that previously reported in younger patients. These pilot findings should encourage future placebo concentration-controlled trials.

Neuroleptic treatment of psychotic symptoms or agitated behavior in elderly patients diagnosed with dementia is associated with reduced efficacy and increased rates of neuroleptic-induced parkinsonism in comparison to younger patients with schizophrenia. We report the first study to examine the relationship between an in vivo measure of dopaminergic function, plasma homovanillic acid (pHVA), and ratings of psychosis, agitation, and parkinsonism before and after neuroleptic treatment in dementia patients. Pretreatment pHVA was significantly correlated with parkinsonian rigidity, with a trend observed with agitation and hostility. Though mean pHVA did not change during perphenazine treatment, intraindividual change in pHVA at day 15 was correlated with improvement in hostility, with a similar trend for improvement in agitation. These preliminary findings are consistent with reports associating dopaminergic function with agitated, but not psychotic, symptoms in patients diagnosed with dementia, and with a reduced responsivity of dopaminergic systems to neuroleptic treatment in these patients.