Various pharmacokinetic and pharmacodynamics features have proven to be involved in the development of drug-induced side effects in psychiatry and thus pharmacogenetic profiling should be considered during drug selection to avoid the onset of side effects.

To explore the usefulness of Neurofarmagen® testing in clinical practice by evaluating whether the genetic profile given by the tool could properly explain the onset of side effects during antipsychotic treatment.

The pharmacogenetic profile of ten patients having a history of side effect appeared during to specific a psychopharmacologic treatment was determined by Neurofarmagen® testing tool. The relationship between genetic profile and side effects was evaluated and classified.

Sixty percent of the sample showed a genomic alteration related to a increased likelihood of having any side effects, one half of which presented pharmacokinetic alteration (slow or intermediate phenotype for the implicated cytochrome) whereas the other half had a pharmacodynamic gene variant (related to dopamine or serotonin pathway).

the Neurofarmagen® testing tool may be useful in the clinical practice in order to avoid drug-induced side effects.

The authors have not supplied their declaration of competing interest.

Niemann-Pick type C disease (NPCD) is a rare metabolic illness, withautosomal recessive inheritance. NPCD has a heterogeneous presentation, withnon-specific psychiatric symptoms, mostly affective and psychotic featuresand also cognitive deficits.

We present the case reports of two brothers with an adolescent-adult onsetand discuss the evolution of their neuropsychiatric manifestations.

The patients have now 35 and 31 years old and the youngest was the first todevelop clinical manifestations of the disease. From 16 years old, hedeveloped unspecified neurological impairment with gait imbalance. In thenext years, the neurologic manifestations exacerbated, with dysarthria,ataxic gait, and his academic performance declined. With 24 years old, hepresented acute psychosis, with unstructured delusion and auditoryhallucinations. The acute psychotic symptomatology remitted with olanzapinebut he revealed social withdrawal, apathy and progressive cognitive declinethat persist until now. His brother, whose diagnosis was made in the courseof the family genetic study, developed the first signs of the NPCD with 19years old. He presented neuropsychiatric compromise, with impaired learning,social isolation and insomnia. They are receiving specific treatment withmiglustat and symptomatic treatment for the psychiatric manifestations.

NPCD is a rare metabolic disease, with neuropsychiatric compromise. Nogeneral psychopathological profile has been associated to NPCD. Sometimespsychiatric symptoms dominate the initial clinical presentation, withneuro-visceral signs appearing later. An atypical psychiatric symptomatologyshould be extensively investigated in order to exclude organic causes,including metabolic diseases like NPCD.

The authors have not supplied their declaration of competing interest.

Mitochondrial disorders of energetic metabolism (MD) represent a heterogeneous group of diseases manifesting at any age and its one of a number of mitochondria syndromes that share the common characteristics of encephalopathy and myopathy. The clinical expression of MELAS (Mitochondrial Myopathy, Encephalopathy, Lactic Acidosis and Stroke-like episodes) is highly variable and ppsychiatric symptoms are rarely reported in literature even if are more common in MELAS syndrome than in the general population.

The first aim of the study is describing the clinically observed primary psychiatric symptoms in a patient affected by MELAS syndrome admitted to the Psychiatric ward. The second aim is to go back over the diagnostic process, which led, from the uncommon psychiatric symptoms and signs to the final genetic diagnosis of MD.

We report the case of a 44-year-old male with MELAS in whom psychiatric symptoms preceded the establishment of the clinical diagnosis for several months. Diagnosis was initially based on the neuroimaging and metabolic findings and subsequently confirmed with genetic analysis.

In case of aggressive and paranoid behaviour with delusions of persecution and disorganised behaviour mmitochondrial disorders deserve consideration as part of the differential diagnosis, especially if there is suspected involvement of other organ groups or positive family history of MD. There is no specific consensus approach for treating MELAS syndrome. Management is largely symptomatic and should involve a multidisciplinary team.

The authors have not supplied their declaration of competing interest.

There is substantial evidence that hypofunction of the N-methyl-d-aspartate receptor (NMDAR) is a core pathophysiological mechanism underlying schizophrenia. d-serine and serine racemase (SR) (NMDAR co-agonist and it's producer) are thought to be involved in schizophrenia's pathophysiology as NMDAR function moderators. Our laboratory showed that excitatory neuron specific SR knock out (SRKO) mice still have just 50% reduction of SR whereas full SRKO mice had no SR. Furthermore d-serine and SR are found in inhibitory neurons not only in excitatory neurons with immunohistochemistry methods. Because NMDAR has excitatory functions, the existence of d-serine and SR in inhibitory neurons and their functions are of interest.

To elucidate the existence and roles of d-serine and SR in inhibitory neurons.

Inhibitory neuron marker, GAD65, specific conditional SRKO (GAD65 SRKO) mice were made by Cre-lox recombination method. The GAD65 SRKO mice were analyzed by HPLC for d-serine concentration, western blotting for SR expression, immunohistochemistry for SR positive cell's character identification and behavioral testing.

GAD65 SRKO had about 50% reduction of SR in striatum but no reduction in hippocampus and frontal cortex. d-serine of GAD65 SRKO mice was not different from WT mice. Immunohistochemistry works revealed SR is in medium spiny neuron of striatum and has colocalization with DARRP-32, D1 receptor, and D2 receptor.

SR is expressed in inhibitory neurons at least in striatum. It might be involved in schizophrenia's pathophysiology because it colocalizes with D1 and D2 receptors.

The authors have not supplied their declaration of competing interest.

Catatonia, described by Kahlbaum in 1874, is usually seen as a type of schizophrenia, but it can also occur in a wide range of other psychiatric/organic disturbances. There is a documented association between dementia and catatonia, in all phases of cognitive impairment.

Literature review and discussion about Catatonia, regarding a case report.

Clinical interviews and literature review in PUBMED database.

Female patient, 89 years old, without psychiatric history, was diagnosed with dementia 5 months prior to episode. On admission, she presents with prostration, mutism and refusal to eat/drink. Laboratory studies were normal and TC-CE shows signs of an old stroke in left temporo-parietal region and diffuse signs of ischemic leucoencephalopathy. At psychiatric evaluation, she was stuporous, unreactive to pain, mute, not following verbal commands, keeping her eyes closed and resisting attempts to open her eyelids. She had global rigidity, axial and limbs, and maintains the postures the examiner puts her into for long periods. She was already given chlorpromazine, without improvement. Then she takes diazepam 10 mg iv, with remission of the state.

Although catatonia usually presents with drama, clinicians often forget to consider it in differential diagnosis, probably because of its traditional association with schizophrenia. A promptly diagnostic is crucial to provide adequate treatment, avoiding drugs that can worsen/perpetuate the clinical state. Some authors even support the idea that motor features associated with end-line dementias may correspond to lorazepam-responsive catatonia, in which treatment may have a tremendous impact worldwide.

The authors have not supplied their declaration of competing interest.

Their average age at admission was 65.7. Thirty-six patients had a diagnosis of chronic psychosis, two with bipolar disorders, one with frontotemportal dementia, two with Korsakoff syndrome.

At admission, 21 (51%) patientsshowed mild cognitive deterioration (score = 18–26), 12 (29%) moderate deterioration (12–17), 6 severe deterioration (0–11), 2 had normal scores (27–30). Over the following years, 28 patients were reassessed:

– 12 (42%) were stable, 7 (25%) had a fluctuating score, 5 (18%) improved;

– 4 (14%) deteriorated over their successive MMS evaluations;

– age, socio-cultural level and psychiatric diagnosis were not associated with change in MMS scores;

– average change between initial and final assessment was +6.0 points for patients with improved score, –7.75 for those showing deterioration;

– 1.28 for those with fluctuating scores, –1.0 for stable patients.

Unstable psychiatric disorders associated with somatic pathologies influenced MMS scores for all patients, particularly for those with MMS deterioration or fluctuation even if this phenomenon could also be observed to a lesser extent in stable patients. By contrast, patients whose MMS scores improved over time were more mentally stable and had no current somatic problems. Multidisciplinary teamwork is important for patients with deteriorating MMS scores.

By illustrating the impact of somatic and psychiatric factors on dementia, the present study underlines the value of multidisciplinary professional care, the role of the family and the importance of long-stay wards.

The authors have not supplied their declaration of competing interest.

Depression is fast becoming a major public health problem with a very high prevalence rate in the 65 and over age group.

The aim of the present study was to estimate the prevalence of depression in Greeks and Cypriots older adults.

A cross-sectional study was conducted among the 445 participants, 239 members of three day care centers for older people, in the municipality of Patras, West-Greece and 206 older adults (110 in the community, 65 in outpatient clinics, 31 in nursing homes) in Cyprus, aged > 60 years. A questionnaire was administered including socio-demographic characteristics. Depression was assessed using the Greek version of Geriatric Depression Scale (GDS-15).

The overall prevalence of depression according to GDS-15 was 33% (28% moderate, 5% severe type). Depressive symptoms were more frequent in women (41,6% vs. 28,3%, P < 0,001), in not married (43,0% vs. 29,3%, P < 0,001), in elderly with chronic diseases (36,8% vs. 25,0%, P = 0,007), in older people dwellers of urban areas compared to rural (36,3% vs. 26,4%, P = 0,028) and in ages between 70 to 80 years old (38,7% vs. 31,6%, P = 0,038). Moreover, higher prevalence of depression was measured in Greeks compared to Cypriots (44,3% vs. 20,6%, P < 0,001). In a univariate analysis, the following variables were significantly associated with depression: female gender (P < 0,001), co-morbidity (P = 0,004), higher age group (P = 0,018), place of living (P = 0,022) and Greek nationality (P < 0,001).

High prevalence and several risk factors are strongly associated with depression, whereas Greeks are in higher danger of developing depressive symptoms in late life, than Cypriots.

The authors have not supplied their declaration of competing interest.

Charles Bonnet syndrome (CBS) is a disorder in older adults, and is characterized by a triad of recurrent vivid visual hallucinations, ocular pathology causing visual impairment due to lesions in central or peripheral visual pathways, and normal cognitive status. It is often misdiagnosed as a psychosis, early dementia or a drug related condition. Hypoxemia was anecdotally reported as a cause of CBS.

We present an older adult with CBS caused by severe obstructive sleep apnea syndrome.

To report a case study, describing treatment of obstructive sleep apnea syndrome as a cause of CBS.

A case study is presented and discussed.

An older male adult was admitted to hospital for persistent vivid visual hallucinations. There was no personal or family history of mental illness. Neurological examination was normal, except for visual impairment due to age related macular degeneration. The remainder of his physical examination was normal. Previous treatment with antipsychotics proved not to be effective. Severe hypoxemia (SaO2 79%) was diagnosed with overnight pulse oximetry and subsequent polysomnography revealed an obstructive sleep apnea syndrome. After three nights of nasal continuous positive airway pressure, the vivid hallucinations ceased.

Physicians need to understand the underlying causes and mechanisms of CBS. One should be aware of the importance of a full clinical examination and sleep apnea research in elderly persons with visual impairment.

The authors have not supplied their declaration of competing interest.

Insomnia is the most frequent sleep disorder in late life. Forty-two percent of elderly people in the United States often complain about difficulties to get or maintain sleep, or awakening too early. Insomnia is frequent in old people greatly due to frequency of concomitant medical illnesses and polypharmacy, rather than because of age.

The objective of our research was to revise the current state of knowledge about management of insomnia in people above 65 years of age.

For that, a bibliographical search through PubMed.gov has been made. From the obtained results, the 14 which best suited for our goals were selected, 10 of them dealing with people above 65 years and the rest with people above 75 or 80 years of age.

Based on the literature reviewed, the current options of management of late-life insomnia are based on behavioral or pharmacological therapy. The combination of behavioral therapies shows results and is currently considered as an option, especially given the possibility of medicine interaction and the secondary effects hypnotic and sedative medicines might produce. There is a paucity of long-term safety and efficacy data for the use of non-benzodiazepine sedative-hypnotics. There are no criteria for the use of antidepressant sedatives in elderly people without diagnosed depression, although they are still used in practice.

Possibility of using behavioral therapy as first option. In case of polymedicated or multi-pathological patients, pay special attention when starting a pharmacological treatment, choose the most suitable one and supervise it closely.

The authors have not supplied their declaration of competing interest.

A substantial body of evidence linking late-life depression and dementia is now available. However, precise estimates of the relative risk attributable to late-life depression assessed with specific screening instruments at specified thresholds have not been previously produced.

Summarise dementia risks associated with depression.

Conduct a systematic review of the literature to produce precise and specific risk estimates for all cause dementia, Alzheimer's disease (AD), and vascular dementia (VaD).

The PubMed, PsycInfo, and Cochrane databases were systematically searched. Studies assessing incident dementia using validated measures of clinical depression or depressive symptomatology from prospective population studies were selected. The most specific analyses were conducted using both continuous symptomatology ratings and categorical measures of clinical depression based on single instruments with defined cut-offs.

The literature search yielded 121,301 articles, of which 36 were eligible. Included studies provided a combined sample size of 66,532 individuals including 6593 dementia, 2797 AD, and 585 VaD cases. Random-effects summary estimates showed that the risk associated with depression did not differ by type of dementia. The most widely used instrument was the CES-D. A clinical threshold of 20 produced similar estimates for all-cause dementia (HR 1.83, 95% CI 0.95–3.52) and for AD (HR 1.97, 95% CI 0.96–4.04). Estimates based on other thresholds and continuous measures produced consistent results.

Reliable dementia risk estimates associated with late-life depression can be produced and do not differ between dementia types. Such estimates should be used in evidence-based medicine practice to assess individual risk and to inform policy on interventions to decrease risk in the population.

The authors have not supplied their declaration of competing interest.

Desvenlafaxine is a prescription medication approved for the treatment of major depressive disorder in adults. Hyponatremia secondary to inappropriate secretion of antidiuretic hormone (SIADH) is a possible side effect in patients receiving serotonin-norepinephrine reuptake inhibitors (SNRIS)

To report a case of SIADH associated with desvenlafaxine.

We present a 80-year-old female patient who required hospitalization due to an episode of psychotic depression. During the hospitalization, the patient developed hyponatremia after commencing treatment with desvenlafaxine. The serum sodium at this time was 117 mmol/L, serum osmolality was 249 mosmol/kg, urine osmolality 395 mosmol/kg and urine sodium 160 mmol/L, consistent with a diagnosis of SIADH. Desvenlafaxine was ceased and fluid restriction implemented. The mental status improved, and electrolyte studies 6 days later revealed serum sodium and osmolality values of 135 mEq/L during treatment with duoxetine.

SIADH has been reported with a range of antidepressants in elderly patients. This case report suggests that desvenlafaxine might cause clinically significant hyponatremia. Close monitoring is recommended in patients starting therapy with antidepressant treatment to study and prevent possible adverse effects.

The authors have not supplied their declaration of competing interest.

Although cognitive impairment occurs early in the course of dementia with Lewy bodies, little is known about DLB and its impact on more complex civil capacities, such as financial capacity.

Three patients (mild DLB, severe DLB and MCI in DLB) were examined. Their total scores and (sub)scores on a financial capacity test revealed below normal (more than 1.5–2 SDs below) performance in contrast to cognitive intact elders (see Table 1).

This is in contrast with their personal beliefs of financial capacity, which reflect a tendency to overestimate their level of financial capacity as recorded on a Likert-scale questionnaire.

The findings prompt a need for further research for an emerging problem in forensic psychiatry, that takes the form of the question: do all DLB patients – even in the stage of MCI – have the capacity for financial transactions?

The authors have not supplied their declaration of competing interest.

Lithium has been widely used as mood stabilizer in bipolar disease, despite its narrow therapeutic range and its side effects. Sodium levels and water consumption could affect lithium renal elimination.

Describe a lithium intoxication without risk factors and normal kidney function.

A 71-year-old female, diagnosed with bipolar disorder, current episode euthymic. On treatment with lithium 800 mg/day, 6 months ago she started with hematuria and urologist found a multifocal oncocytoma in left kidney. She was operated with double lumpectomy and partial nephrectomy without complications. Normal preoperative and postoperative renal function. Two months ago, she started with dysarthria, dystonia and coarse tremor, and T wave inversion on the electrocardiogram. In the blood test, lythemia was 1.67 mEQ/L. Creatinine was 0.65 mg/dL. She was admitted to Internal Medicine Unit. She was treated with rehydration by serum. All psychoactive drugs were removed. Twenty days later, lithemia was undetectable in the blood analysis.

Two weeks ago, the patient was transferred to the mental health unit due to worsening her mood. Lithium was reintroduced 3 days ago, at doses of 200 mg per day. Today, the patient starts again with symptoms of poisoning by lithium. Lithemia was 1.78.

On this occasion, partial nephrectomy due to oncocytoma is the most likely cause two consecutive lithium poisonings. Although creatinine and glomerular filtration are in normal range, patients after partial nephrectomy may have a reduced sodium reabsorption in proximal convoluted tubule, which may cause lithium compensatory resorption. This could cause rising in blood lithium levels.

The authors have not supplied their declaration of competing interest.

Delusional of parasitosis or Ekbom's syndrome (ES) is a psychiatric disorder in which the patient has a fixed and false belief that small organisms infest the body. The belief is often accompanied by hallucinations. It is an uncommon condition that was initially studied by dermatologists, more prevalent in the elderly and typically observed in women older than 50 years although isolated cases among men have been reported.

To review current knowledge about delusional of parasitosis in elderly patients through literature systematic review and the analysis of a case report.

We performed a literature search using electronic manuscripts available in PubMed database published during the last five years, following the description and discussion of a clinical case. We report a case of an 85-year-old man who presented a delusional parasitosis as a primary disorder.

The literature on ES consists mostly of case reports and limited series. In this paper, we analyze the etiology, demographic characteristics, clinical features and treatment in geriatric patients with delusional parasitosis.

International classifications have included this syndrome in non-schizophrenic delusions. However, it has also been reported in schizophrenia, affective disorders, and organic or induced psychosis. Treatment is based on antipsychotic agents, psychotherapy and cooperation between dermatologists and psychiatrists.

The authors have not supplied their declaration of competing interest.

Citicoline is a choline donor involved in the biosynthesis of brain phospholipids and acetylcholine, used for treating neurodegenerative disorders. Several studies have shown its beneficial effects both in degenerative and vascular cognitive decline. Due to its effects on the adrenergic and dopaminergic CNS activity, citicoline can also be used as an adjuvant in depression treatment.

Comparative evaluation of efficacy and safety of a multimodal antidepressive therapy with ceraxone (citicoline) plus one of the antidepressants (venlafaxine, agomelatine, or fluvoxamine) and monotherapy with the same antidepressant for the treatment of depression in the elderly. Two groups of patients were included in the study (21 patients in each group) aged from 60 to 79 years old, comparable to the main clinical characteristics.

First group patients were treated with a single antidepressant, patients of the second group – with the same antidepressant and intravenous infusions of ceraxone: 10 infusions (500 mg in 100 mL isotonic sodium chloride solution) during 2 weeks, followed by transfer to the drug in solution at 3 mL per os two times a day for six weeks.

A multimodal therapy with ceraxone leads to more rapid and significant therapeutic response along with the reduction of adverse events compared to antidepressant monotherapy.

Obtained data allows to recommend a multimodal antidepressive therapy with ceraxone (citicoline) for the treatment of elderly depressive patients to reduce the risk of adverse effects of antidepressants and to shorten hospitalization period.

The authors have not supplied their declaration of competing interest.

The Charles Bonnet syndrome refers to symptoms of visual hallucinations that occur in patients with visual acuity or visual field loss. These are often called release hallucinations, reflecting the most widely accepted theory about their pathogenesis. The syndrome is most found in elderly patients, 70–85 years, and this probably reflect the mean age at which the most common underlying conditions are seen. It is probably more common than is thought and because either it is misdiagnosed as psychosis and/or dementia or it is not reported by patients because they fear that the hallucinations represent psychiatric disease.

The authors present the clinical case of a 89-year-old woman, with no previous psychiatric disease, admitted to hospital because of visual hallucinations in form of children and animals. She experienced them during months until she told someone. No psychiatric symptoms were found. The lady had a serious cataract on the left eye with total loss of the visual acuity, as documented by ophthalmologic examination.

The patient initiated quetiapine 300 mg and will have period appointments with a neurologist. Further future information will be presented.

A correct diagnosis is essential to treat these patients and explaining them the meaning of the hallucinations is generally relieving. Many author disagree with antipsychotic agents, while others report benefit.

The authors have not supplied their declaration of competing interest.

Schizophrenia has traditionally been considered to strictly be an early-onset disorder. Current nosologies, including DSMV, are not restrictive with age of onset in schizophrenia and all patients that satisfy diagnostic criteria fall into the same category. Since 1998, International Late-Onset Schizophrenia Group consensus, patients after 60 are classified as very-late onset schizophrenia-like psychosis. Female overrepresentation, low prevalence of formal thought disorder, and a higher prevalence of visual hallucinations are associated with later age at onset. Atypical antipsychotics represent the election treatment because of the reduced likelihood of EPS and tardive dyskinesias, and should be started at very low doses, with slow increases.

To review the current knowledge about very late-onset schizophrenia through systematic review of the literature and the analysis of a case.

Case Report. Review. Literature sources were obtained through electronic search in PubMed database of last fifteen years.

We present a case of a 86-year-old woman suffering from delusions and hallucinations, diagnosed with very late-onset schizophrenia-like psychosis, after differential diagnosis with other disorders. We analyze ethiology, epidemiology, clinical features and treatment in geriatric patients with schizophrenia.

Reluctance to diagnose schizophrenia in old people is still present today, probably in relation with the inconsistency in diagnostic systems and nomenclature, and consideration of medical conditions in the diagnosis. Identification of these patients is really important in order to start an appropriate treatment, which can lead to patient clinical stability.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

The ageing process is characterized by a high level of complexity, due to theco-occurrence of multiple chronic diseases (comorbidity) that often resultsin the concomitant use of multiple drug therapies (polypharmacy) fortreatment and prophylaxis. Institutionalized elderly may be regarded as theparadigm of this complexity because of their multiple chronic diseases anddecreased functional and cognitive functions.

To explore and characterize the prevalence of comorbidity and polypharmacy ina sample of institutionalized elderly.

A cross-sectional study was conducted with an elderly sample recruited fromthree Portuguese nursing homes. Clinical information was obtained throughinterview and by review of residents’ medical records. The AnatomicalTherapeutic Chemical/ATC classification was used to indicate the main groupof medicines used, and polypharmacy was categorized into minor (2–4medicines) or major (≥ 5). Comorbidities were coded using theindividual body systems of Cumulative Illness Rating Scale forGeriatrics/CIRS-G.

The sample included 175 elderly with a mean age of 81 (sd = 10) years andinstitutionalized for an average of 7 (sd = 11) years. Residents presented amean of 9 (sd = 4) co-morbid medical conditions, mostly psychiatric (80.8%),vascular (76.7%) and endocrine/metabolic (70.3%). Major polypharmacy wasverified for 73.9% of residents. The mean number of medicines was 7 (sd =3), most commonly for cardiovascular (86.0%) and nervous system (79.1%) andfor blood and blood-forming organs (69.2%).

As in other studies in similar settings, polypharmacy was fairly common.These results convey an important message considering that polypharmacy hasbeen associated with negative clinical outcomes that could otherwise bepreventable by reducing the number of prescribed medicines.

The authors have not supplied their declaration of competing interest.

Capgras syndrome is the most frequent delusional misidentification syndrome (DMS) which was first described in 1923 by Capgras and Reboul-Lachaux as ‘L’illusion des sosies’. Consists of believe that close relatives have been replaced by nearly identical impostors. It can occur in the context of psychiatric disorders (schizophrenia, major depression) such organic, in which onset of delirium is usually later coinciding with neurological damage or neurodegenerative disease.

Woman 73-year-old diagnosed of schizophrenia since more than thirty years ago. Her family talk about general impairment of the patient in the last two years. She needed a couple of psychiatric hospitalizations because of her psychiatric disease, and probably onset of cognitive impairment. In this context, we objectified the presence of a Capgras syndrome.

To review the literature available about Capgras syndrome in elderly and illustrate it with a clinical case.

Review of literature about Capgras syndrome in elderly by searching of articles in the PubMed database of the last five years to illustrate the exposure of a single case report.

The etiology of this syndrome is not yet well understood. Advanced age is frequently found Capgras syndrome with or without the concomitant presence of an obvious cognitive impairment.

Since it is a complex process an etiological model that combines cognitive and perceptual deficits, organic impairment and psychodynamic factors should be proposed. And it is important to make a correct differential diagnosis that allows us to carry out the best possible treatment.

The authors have not supplied their declaration of competing interest.