An audit of a specialist old age psychiatry liaison service to a medium and a high secure forensic psychiatry unit

The elderly prison population is increasing and there is a significant amount of unidentified psychiatric morbidity among elderly prisoners. A sizeable number of elderly subjects are referred to regional forensic units. These units are able to provide advice but are reluctant to admit frail, physically ill and vulnerable elderly into their unit because the ward environment is considered inappropriate for them. A sizeable number of inpatients in medium and high secure units are elderly. This paper is an exploratory audit of referrals from a medium and high secure forensic psychiatry unit to a specialist consultation-only liaison old age psychiatry service, which was specifically developed to service the forensic unit. The demographic and clinical characteristics of the patients seen by this specialist service were similar to elderly inpatients in medium and high secure units. All referrals were judged to be appropriate and new management advice was provided in all cases. Main reasons for referral included diagnostic advice, placement advice and treatment advice. Establishing a diagnosis of dementia was considered important because Alzheimer's disease and Lewy body dementia can be treated with cholinesterase inhibitors. Placement advice was the most difficult to provide because of paucity of residential and nursing homes able and willing to accept patients with a forensic history. There is a need for a comprehensive model of specialist forensic old age psychiatry service at a regional or supraregional level. A consensus needs to be reached on the exact configuration of such a service.     

A controlled evaluation of assessments by doctors and nurses in a magistrates' court mental health assessment and diversion scheme

In this study, assessments of prisoners by doctors and nurses were compared in a provincial magistrates' court mental health assessment and diversion scheme, and outcomes were compared with the outcomes of those for whom no assessments were available during a control period. Substance misuse was relatively common and psychosis uncommon in the prisoners referred. Assessment by doctors enabled magistrates to reduce remands in custody of persons suspected of suffering from mental disorder and to grant bail in more cases. Only a small proportion of prisoners were admitted to hospital and although doctors and nurses recommended out-patient treatment in many cases, the attendance rate was low. Doctors were more likely than nurses to identify prisoners with medical needs that needed to be brought to the attention of the prison health care service, and to recommend out-patient psychiatric treatment and identify relevant medicolegal issues. Prisoners assessed by nurses were less likely than those assessed by doctors to attend alcohol or drug treatment services if recommended to do so. Prisoners who were admitted to hospital after a remand in custody spent longer on remand if assessed by nurses compared with those assessed by doctors.     

Psychiatric treatment in prison: a missed opportunity?

National Health Service Executive guidelines require psychiatric services to maintain links with prisoners previously subject to the Care Programme Approach (CPA) and to participate in discharge planning. We are unaware of previous studies assessing the involvement of general psychiatric services with patients in prison or prisoners' perceptions of their needs. Consecutive referrals to a prison psychiatric liaison service over a three-month period were screened for previous psychiatric contact. Half of those interviewed reported previous psychiatric contact. Two-thirds were in contact with services at the time of detention. One-third believed services knew of their imprisonment. Ninety-three per cent believed they would require psychiatric support after release. Few patients received input from general psychiatric services during imprisonment despite a high level of perceived need. Improved liaison would help facilitate both care in prison and discharge planning in the spirit of CPA and the government directive.     

Factors which influence postoperative mortality after hip fracture

BACKGROUND/AIM: One of the most significant predictors of mortality after hip fractures is cognitive impairment (dementia). The aim of this study was to report the results of a prospective study of the influence of some factors on six-month mortality in elderly patients with hip fractures. METHOD: The elderly patients with hip fracture were assessed on admission to the hospital using the measures of cognitive function, the mobility before the fracture, and physical comorbidity, the type of fracture and the place of the injury. Six months later, we checked how many of them were still alive. RESULTS: We performed univariate and multivariate analyses in 132 patients and found that the most significant predictors of six-month mortality were dementia, comorbidity, and prefacture mobility. CONCLUSIONS: A comprehensive physical and mental health assessment of an elderly patient after hip fracture could predict mortality. A good examination of cognitive functioning could be very useful in choosing the optimal treatment for this type of patients.     

Interviewing survivors of near-lethal self-harm: A novel approach for investigating suicide amongst prisoners

In most countries, rates of suicide in prison are higher than those reported in the general population, and seemingly on the increase. Previous studies of factors contributing to suicide in prisons have largely been limited to analyses of the clinical and prison records of prisoners who have died by suicide. In this paper we reflect on the limitations of this approach. Drawing on illustrative case vignettes from ongoing research, we argue that interviewing survivors of near-fatal incidents of self-harm offers a potentially fruitful method to further our theoretical understanding of this growing problem, and inform relevant policy.     

Food refusal in prison

The prevalence of mental disorder amongst prisoners refusing food was studied by examining the prison records of a remand prison and a dispersal prison. Food refusal occurred predominantly in the remand prison. Less than one per cent of the annual remand population engaged in this behaviour. The results indicate that prisoners refusing food do so as a form of protest and that the prevalence of mental disorder among such prisoners is high. The majority respond to observation and counselling. Important indicators of psychosis are: (i) the inability of the prisoner to divulge reasons for his behaviour; and (ii) the refusal by the prisoner of both food and fluids. In such cases transfer to hospital for treatment may be urgently required.     

Outcome of referral to a prison mental health team

This retrospective case note study describes the demographic, offence and diagnostic characteristics of 115 referrals made to a psychiatric service within HMP Perth between May 2003 and April 2004. Twenty per cent of referrals were diagnosed with a major mental illness with remand prisoners having a higher overall prevalence. Nearly 70% had previous contact with psychiatric services, a similar percentage had previous substance misuse. Over 8% were transferred out of prison and over a quarter continued to be followed up at the end of the study period. A wide range of index offences was seen. Over two-thirds had a previous history of offending and nearly 60% had a previous custodial sentence, reflecting a high degree of recidivism. This study supports the high degree of psychiatric morbidity in the prison population shown in other studies. The role of a prison psychiatric service is discussed in the context of services to mentally disordered offenders.     

Therapeutic effect of passive mobilization exercise on improvement of muscle regeneration and prevention of fibrosis after laceration injury of rat

BACKGROUND: Alzheimer disease and other dementing disorders are major sources of morbidity and mortality in aging societies. Proven strategies to delay onset or reduce risk for dementing disorders would be greatly beneficial. OBJECTIVE: To determine whether regular exercise is associated with a reduced risk for dementia and Alzheimer disease. DESIGN: Prospective cohort study. SETTING: Group Health Cooperative, Seattle, Washington. PARTICIPANTS: One thousand seven hundred and forty persons older than age 65 years without cognitive impairment who scored above the 25th percentile on the Cognitive Ability Screening Instrument in the Adult Changes in Thought study and who were followed biennially to identify incident dementia. MEASUREMENTS: Baseline measurements, including exercise frequency, cognitive function, physical function, depression, health conditions, lifestyle characteristics, and other potential risk factors for dementia (e.g., apolipoprotein E epsilon4); biennial assessment for dementia. RESULTS: During a mean follow‐up of 6.2 years (SD, 2.0), 158 participants developed dementia (107 developed Alzheimer disease). The incidence rate of dementia was 13.0 per 1000 person‐years for participants who exercised three or more times per week compared with 19.7 per 1000 person‐years for those who exercised fewer than three times per week. The age‐ and sex‐adjusted hazard ratio of dementia was 0.62 [95% confidence interval (CI), 0.44–0.86; P=0.004]. The interaction between exercise and performance‐based physical function was statistically significant (P=0.013). The risk reduction associated with exercise was greater in those with lower performance levels. Similar results were observed in analyses restricted to participants with incident Alzheimer disease. LIMITATIONS: Exercise was measured by self‐reported frequency. The study population had a relatively high proportion of regular exercisers at baseline. CONCLUSION: These results suggest that regular exercise is associated with a delay in onset of dementia and Alzheimer disease, further supporting its value for elderly persons.     

Dementia, quantitative neuroimaging, and apolipoprotein E genotype

BACKGROUND AND PURPOSE: Quantitative MR imaging differences in an elderly population of subjects with various clinical disorders (including dementia, particularly Alzheimer's disease and vascular dementia) and disorders of mild cognitive impairment were examined. Potential quantitative MR differences were assessed by presence or absence of the apolipoprotein E (APOE) epsilon4 allele and by level of cognitive deficit. METHODS: One hundred eighty subjects with a diagnosis of dementia or other clinical disorders were identified from an eligible population of 5,677 elderly individuals. Age, duration of disease, and head size (where appropriate) were considered as covariates. APOE genotype was determined by polymerase chain reaction using buccal material. Axial and coronal intermediate- and T2-weighted MR images were quantified using a multispectral segmentation algorithm. Cognitive status was assessed by means of a modified Mini-Mental Status Examination. RESULTS: All types of dementing illness showed significant volume reductions in the majority of structures examined, particularly in the total brain, hippocampus, and white and gray matter, and increased CSF and ventricular volumes. Subjects with mild cognitive impairment showed fewer atrophic changes but were still distinguishable from the 24 control subjects. Presence of an epsilon4 allele was associated with smaller hippocampal volume in subjects with Alzheimer's disease and vascular dementia within just 1 year of disease onset. For other analyses, atrophy related to the presence of the epsilon4 allele disappeared after controlling for age and length of disease. CONCLUSION: The effects of the epsilon4 allele on brain morphology may be subtly expressed early in the development of dementia, but do not specifically affect cerebral atrophy thereafter. Cognitive impairment is associated with atrophy irrespective of diagnosis and presence of epsilon4.     

Does insomnia in prison improve with time? Prospective study among remanded prisoners using the Pittsburgh Sleep Quality Index

Insomnia is a frequent health problem in prison, but little is known about its severity and duration. The objective was to find out whether subjective sleep quality improves during time and which factors influence improvement. Fifty-two randomly chosen prisoners complaining of insomnia at the Geneva remand prison were interviewed (T1) and followed up ten days (T2) and two months (T3) later. They received hypnotics habitually prescribed by prison physicians (benzodiazepines, chloralhydrate, zolpidem). After ten days 40 patients were still in prison and agreed to participate and after two months 16 prisoners could be re-evaluated. Total Pittsburgh Sleep Quality Index (PSQI) scores at T1 were 12.3 +/- 4.7. At T2 and T3, PSQI scores improved significantly, whereas General Health Questionnaire (GHQ) scores and conditions of imprisonment were similar. Only 12.5% of patients at T2, and 6.25% at T3, were 'good sleepers' (PSQI scores =/< 5). Cocaine users and prisoners with a healthy lifestyle reported the greatest improvement of PSQI scores. Our study shows that significant improvement of PSQI scores takes place in the first one to two weeks. However, in spite of regular drug treatment during the following weeks, PSQI scores persisted at a clinically significant level two months later. Drug treatment in prison only partially improves insomnia.     

A cross-sectional study which measures the prevalence and characteristics of prisoners who report a family history of epilepsy.

Epilepsy is often a familial disorder, although it is not known if relatives of an epileptic proband suffer from any psychological disorders, even without a clinical manifestation of epilepsy. The present study considers this concept in the setting of the largest male prison in Europe, HMP Liverpool. The study formed part of the National Prison Needs Assessment Survey, and consisted of a cross-sectional, questionnaire study. There was a high response rate, and the results indicate that prisoners have a high prevalence of a family history of epilepsy. The study also showed that prisoners who report such a history have significantly more psychological symptoms than those prisoners without such a family history. The conclusion is that the psychological health of relatives of those with epilepsy requires further investigation because the morbidity is higher than expected and may be associated with offending behaviour.     

Prescribing exercise for the elderly: Current research and recommendations

The potential for regular exercise to offset the deleterious effects of aging is well established. In fact, the pronounced health benefits attributed to regular exercise, including improvements in resting blood pressure, cholesterol profile, osteoarthritis, osteoporosis, diabetes mellitus, and cognitive functioning, can be achieved even in those individuals who start physical conditioning programs later in life. Yet, despite these impressive data, approximately 70% of elderly Americans are physically inactive. This hypokinetic state negatively affects not only the health status of the elderly but significantly influences healthcare costs as more Americans are attaining octogenarian status. As such, it is vitally important for all healthcare workers to actively encourage elderly individuals to maintain or, in the case of nonexercisers, start an exercise program. Such recommendations may help to decrease comorbid conditions associated with the aging process, increase functional independence, and attenuate skyrocketing healthcare costs associated with treating the growing elderly population.     

Autopsy in elderly psychiatric inpatients: a retrospective review of autopsy findings of deceased elderly psychiatric inpatients in north Cheshire 1980-1996

In this 17-year review of death certificates of elderly inpatients of a large psychiatric hospital in North Cheshire, the frequency, trend and value of performing autopsies were examined. Details of death certificates were compared with certificates issued after post-mortem examination to see whether an autopsy yielded any additional or relevant information about conditions that are not directly related to death but might well be of importance to public health. The rate of post-mortem examination, at 9.5% of total hospital deaths, did not show any significant trend over most of the review period. The vast majority of autopsies examined had been requested by the coroner and not by the clinicians. The review showed that an autopsy may be of some value in providing more information regarding any underlying causes of death in elderly psychiatric patients, but has no value in ensuring higher rate of the recording of conditions such as dementia, in particular Alzheimer's disease. Selective hospital autopsy in elderly psychiatric patients to verify, neuropathologically, the clinical diagnosis of Alzheimer's disease, will improve our diagnostic accuracy and provide valid statistics to be used in estimating prevalence, trends, risk factors and for use in all aspects of future research into Alzheimer's disease.     

Prescribing exercise for the elderly: Current research and recommendations

The potential for regular exercise to offset the deleterious effects of aging is well established. In fact, the pronounced health benefits attributed to regular exercise, including improvements in resting blood pressure, cholesterol profile, osteoarthritis, osteoporosis, diabetes mellitus, and cognitive functioning, can be achieved even in those individuals who start physical conditioning programs later in life. Yet, despite these impressive data, approximately 70% of elderly Americans are physically inactive. This hypokinetic state negatively affects not only the health status of the elderly but significantly influences healthcare costs as more Americans are attaining octogenarian status. As such, it is vitally important for all healthcare workers to actively encourage elderly individuals to maintain or, in the case of nonexercisers, start an exercise program. Such recommendations may help to decrease comorbid conditions associated with the aging process, increase functional independence, and attenuate skyrocketing healthcare costs associated with treating the growing elderly population.     

The National Survey of Psychiatric Morbidity among prisoners and the future of prison healthcare

It has long been known that psychiatric disorders are highly prevalent among prisoners (Coid, 1984; Gunn et al., 1991; Maden et al., 1995; Joukamaa, 1995; Bland et al., 1998; Lamb and Weinberger, 1998). However, the Survey of Psychiatric Morbidity Among Prisoners in England and Wales (Singleton et al., 1998) represents a considerable advance on earlier surveys. By using the same standardized psychiatric assessment procedures, and similar questions on medication, service use and social functioning, its findings can be compared with previous national surveys of adults living in private households (Meltzer et al., 1995), residents in institutions (Meltzer et al., 1996), homeless persons (Gill et al., 1996), and with the forthcoming household survey in England, Wales and Scotland. It should also inform the future organisation of healthcare for prisoners, following recent recommendations from a joint Home Office/Department of Health Working Party that Health Authorities must work with prisons in their catchment areas to carry out joint health needs assessments, agree prison healthcare improvement strategies and jointly plan and commission services (HM Prison Service and NHS Executive 1999). The ultimate test of the survey will be whether it provides a benchmark to evaluate the future effectiveness of the new policy changes.     

Kiel psychotherapy project for violent offenders Towards empirically based forensic psychotherapy -- disturbance profiles and risk of recidivism among incarcerated offenders in a German prison

This study reports on a psychotherapy project for violent offenders. The project was established at a German prison by the Psychiatric and Psychotherapeutic Department at the University of Kiel. The overall aim of this project is to develop a scientifically based psychotherapy programme for violent offenders. As a first step the project's systematic initial diagnostic procedures are presented. These procedures are carried out when new prisoners join the project to provide an empirical basis for the planning of therapy. Data are presented for the 60 prisoners who have so far taken part. These show high prevalences for some psychiatric disorders, namely substance related disorders (33% dependency, 55% abuse), personality disorders (58% had at least one personality disorder) and psychopathy according to Hare's criteria (13%). The data also indicate that only a basal level of self-motivation existed to take part in psychotherapy (65% precontemplative). It is apparent that violent offenders constitute a heterogeneous group as far as mental disturbances are concerned. The data suggest that a psychotherapy programme for violent offenders needs to include both targeted interventions to raise motivation and, for those with substance-related and/or personality disorders, disturbance-specific interventions.     

Late-onset dementia: structural brain damage and total cerebral blood flow

PURPOSE: To prospectively compare indicators of structural brain damage and total cerebral blood flow in patients with late-onset dementia, subjects of the same age with optimal cognitive function, and young subjects. MATERIALS AND METHODS: The institutional ethics committee approved the studies, and all participants (or their guardians) gave informed consent. The test group included 17 patients older than 75 years (four men, 13 women; median age, 83 years) and with a diagnosis of dementia according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The control group included 16 subjects (four men, 12 women; median age, 87 years) with optimal cognitive function, who were selected from among 599 elderly subjects enrolled in a population-based follow-up study, and 15 young healthy subjects (seven men, eight women; median age, 29 years). Measurements of intracranial and total brain volumes, structural brain damage, and cerebral blood flow were obtained with magnetic resonance imaging. Mean values were compared with the t test; medians, with the Mann-Whitney U test. RESULTS: Values for total brain volume were significantly smaller in elderly subjects (P < .001) but did not differ significantly between patients with dementia and subjects of the same age with optimal cognitive function (P = .69). Among the elderly, significantly higher scores for number and extent of white matter areas of signal hyperintensity (P = .028) and lower magnetization transfer ratios (P = .016) indicated greater structural brain damage in those with dementia. Cerebral blood flow was 246 mL/min lower (P < .001) in elderly subjects than in young subjects. In patients with dementia, cerebral blood flow was 108 mL/min lower than that in subjects of the same age with optimal cognitive function (551 vs 443 mL/min, P < .001). CONCLUSION: The combined observations of more structural brain damage and lower cerebral blood flow in demented elderly individuals than in subjects of the same age with optimal cognitive function support the hypothesis that vascular factors contribute to dementia in old age.     

Prevention of violence in prison – The role of health care professionals

The World Health Organization (WHO) classifies violence prevention as a public health priority. In custodial settings, where violence is problematic, administrators and custodial officials are usually tasked with the duty of addressing this complicated issue-leaving health care professionals largely out of a discussion and problem-solving process that should ideally be multidisciplinary in approach.Health care professionals who care for prisoners are in a unique position to help identify and prevent violence, given their knowledge about health and violence, and because of the impartial position they must sustain in the prison environment in upholding professional ethics. Thus, health care professionals working in prisons should be charged with leading violence prevention efforts in custodial settings.In addition to screening for violence and detecting violent events upon prison admission, health care professionals in prison must work towards uniform in-house procedures for longitudinal and systemized medical recording/documentation of violence. These efforts will benefit the future planning, implementation, and evaluation of focused strategies for violence prevention in prisoner populations.     

轻度认知障碍的功能性神经影像学研究进展

轻度认知障碍(MCI)是正常老化过程与早期阿尔茨海默病(AD)之间的一种中间过渡状态,具有进展为AD的高度危险性。功能性神经影像学手段(如PET、SPECT、fMRI脑显像)能对MCI脑代谢、血流灌注特点进行正确评价,有助于AD的早期诊断、病程监测、疗效观察及临床治疗个体的选择。