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INTRODUCTION: Depression is common in long-term care (LTC) residents and causes increased mortality and morbidity. Treatment resistance or intolerance to antidepressants is not unusual. Electroconvulsive therapy (ECT) is a safe and effective alternative for older community-dwelling residents but has not been well studied in LTC residents. METHODS: A retrospective chart review was made of all LTC residents who received ECT from a single academic 538-bed facility over a 3-year period. Demographic information, severity of medical illness as measured by the Cumulative Illness Rating Scale for Geriatrics (CIRS-G), psychiatric diagnosis, earlier psychotropic drug trials, and MMSE before and after ECT were collected. ECT therapy was reviewed for number and types of treatments and complications. Outcome after ECT was rated with the Clinical Global Impression of Change scale (CGI). RESULTS: Thirteen patients (4 men, 9 women ), mean age 81 years (range: 65-95), received ECT. All had a diagnosis of major depression, and 10 had associated psychotic features. All patients received at least two psychotropic agents before receiving ECT (range: 2-11). Patients also had significant medical comorbidity, with a mean (CIRS-G) of 19.7 (range: 14-27). On average, patients received 5.7 ECT treatments in the hospital (range: 3-10), and 9 of 13 patients received bilateral stimuli. Nine patients (69%) were rated as improved, two (15%) were clinically unchanged, and two (15%) were rated as worse. Complications included transient atrial fibrillation in one patient, posttreatment headache in one patient, and delirium in one patient. Five patients had transient cognitive decline as measured by the MMSE, but all recovered fully by 1 month. CONCLUSIONS: ECT was a safe and effective treatment modality in this population of LTC residents with a significant medical comorbidity. 69% of patients exhibited clinical improvement despite previous medication resistance. Careful monitoring for delirium in this population is essential to prevent more protracted posttreatment confusion.

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The authors (within 24 hours of the order) administered a telephone questionnaire to physicians prescribing benzodiazepines to patients over age 65 admitted to a tertiary care university hospital (N = 81 consecutive medical and surgical admissions). Data were obtained from 50 physicians. Prescriptions were most commonly written for preoperative relaxation (26%), pain (14%), nausea (12%), to aid intubation (12%), or facilitate a medical test (10%). Dosages were chosen on the basis of subjective experience (32%), lowest effective dose (28%), considerations of age/sex/weight (16%), and drug manual recommendations (8%). Ten percent of patients were prescribed a benzodiazepine before hospitalization, and their dosages were tapered (6%) or maintained (4%). There is considerable variation in physicians rationale for benzodiazepine prescriptions to hospitalized elderly patients. Benzodiazepines are used to treat symptoms rather than disorders. Age is infrequently considered in dosing judgments despite the pharmacodynamic and pharmacokinetic changes known to be associated with aging.

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Sedative-hypnotic medications are often used to treat anxiety and sleep disorders, although they may not be used appropriately. Relationships between hospital length of stay (LOS), costs, and levels of sedative-hypnotic use were examined. Charts of 856 elderly patients were reviewed for sedative hypnotic use and categorized into three groups: those whose use exceeded Health Care Financing Administration (HCFA) guidelines, those who used sedative-hypnotic medications but did not exceed HCFA guidelines, and those who did not receive any sedative-hypnotic medications. Patients whose sedative-hypnotic use exceeded guidelines had longer LOS (21.5 exceeding guidelines vs. 12.3 within guidelines vs. 6.7 no use, p < or = .001) and higher costs ($29,245 exceeding guidelines vs. $15,219 within guidelines vs. $7,516 no use, p < = or .001.) Even after controlling for severity of illness and comorbid conditions, differences in LOS and costs persisted. This study indicates that sedative-hypnotic medications are frequently prescribed to elderly patients, often in doses exceeding proposed guidelines, and are associated with longer hospital stays and higher hospital costs.

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OBJECTIVE: To assess the relationship between sedative-hypnotic (S/H) utilization, severity of illness, length of stay, and hospital costs among older patients admitted to a tertiary care university hospital. DESIGN: Retrospective review of computerized hospital and pharmacy data bases. SUBJECTS: A total of 856 older consecutive medical and surgical admissions from November 1993 to March 1994. MEASUREMENTS: Sedative/hypnotic utilization in accord with the Health Care Financing Administration (HCFA) guidelines for S/H use in nursing homes. Jefferson Disease Staging to estimate severity of illness. Hospital records to obtain demographic characteristics, length of stay, and hospital costs. RESULTS: Patients whose S/H use exceeded HCFA guide lines, compared with those within the guidelines and those receiving no drugs, had longer lengths of stay (21.5 days vs 12.3 days vs 6.7 days, P < .001), increased hospital costs ($29,245 vs $15,219 vs $7,516, P < .001). and greater severity of illness (245.8 vs 189.5 vs 148.5, P < .001). S/H use exceeding and within HCFA guidelines were associated with increased length of stay (both P < .0001) and hospital costs (both P < .0001). CONCLUSIONS: Older hospitalized patients receiving S/H have greater severity of illness, longer lengths of stay, and higher hospital costs compared with other patients. S/H use, and, in particular, S/H use exceeding the HCFA guidelines, are associated with increased hospital stay and cost.

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OBJECTIVE: The purpose of this study was to evaluate the effects of pet therapy on geriatric psychiatry inpatients. A demonstrable impact could lead to more widespread or targeted use of animal companionship programs for hospitalized older persons. METHOD: The study design was a randomized, parallel-group control treatment trial with pretreatment and posttreatment measures. Fifty-eight subjects with chronic age-related disabilities who were patients of the Wills Eye Hospital Geriatric Psychiatry Unit were assigned to a pet therapy intervention group or an exercise control group for 1 hr a day for 5 consecutive days. Every subject was blindly evaluated with the Multidimensional Observation Scale for Elderly Subjects (MOSES) before and after the intervention week. RESULTS: No significant differences in MOSES scores were found between or within groups before and after the interventions. There was a nonsignificant tendency for subjects who received the pet intervention to have less irritable behavior after treatment. However, women with dementia who received either pet therapy or exercise intervention had improved irritable behavior scores after treatment. CONCLUSION: This pilot study demonstrates the need for further research on animal-assisted interventions with hospitalized elderly persons. Differential improvement in women with dementia also requires further investigation.

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The objective of this study was to assess benzodiazepine use and the treatment of depression before admission to an inpatient geriatric psychiatry unit in a sample of elderly patients. The study design was a retrospective chart review, and the setting was a university hospital inpatient geriatric psychiatry unit. The subjects included 131 consecutively admitted patients. Preadmission benzodiazepine drug regimens were reviewed in relation to the Health Care Financing Administration (HCFA) guidelines for benzodiazepine use in nursing homes and in relation to psychiatric diagnoses. Psychiatric diagnoses were made based on DSM-III-R criteria. The preadmission benzodiazepine regimens of 38 of 59 patients receiving benzodiazepines (64.0%) were outside the HCFA guidelines. Also, 30 of 76 patients (39.5%) with depressive disorders received benzodiazepines as sole treatment of depression prior to their admission. This study suggests that benzodiazepines may be misused in the elderly and indicates the need for education and research on the appropriate use of benzodiazepines in the treatment of depression.

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OBJECTIVE: To assess benzodiazepine utilization and documentation in hospitalized medical and surgical patients in relation to demographic characteristics. METHODS: Retrospective review of computerized university hospital database and medical records. SUBJECTS: 6,020 consecutive medical and surgical admissions from January through June 1992. MEASUREMENTS: Utilization of four commonly prescribed benzodiazepines (Halcion, Ativan, Valium, Xanax) in relation to age, race, sex, length of stay, hospital service; and documentation of indications for use. RESULTS: 2,491 patients (41.4%) were prescribed a benzodiazepine during their hospital stay. Patients over 65 were as likely to receive a benzodiazepine as younger patients. Benzodiazepine utilization was associated with admission to a surgical compared to a medical service (49.0% vs. 37.3%, P < .001), race (white 45.7% vs. non-white 29.9%, P < .001) and length of stay (11.8 days vs. 6.8 days, P < .001). Review of 30 medical and 30 surgical medical records revealed no documentation of purpose for benzodiazepine use other than as a preanesthetic agent in 23 (38.3%) cases. CONCLUSIONS: Benzodiazepines are widely prescribed in the hospital setting in the absence of appropriate documentation. Older patients are as likely to receive benzodiazepines as younger patients, despite the known morbidity associated with their use in this population. Differences in prescribing practices by race, the longer length of stay among patients receiving benzodiazepines, and the appropriate use of benzodiazepines in the elderly require further study.

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