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.

Although the prevalence of malnutrition is relatively low among elderly people, the risk increases significantly among inpatients and even more in those with mental deterioration.

To evaluate the possible association between the severity of depressive symptoms, the nutritional status and the cognitive decline in a sample of geriatric inpatients.

Fifty-one geriatric inpatients completed the following tests:

– Hamilton Depression Rating Scale (HAM-D), to assess the severity of depressive symptoms;

– Mini Nutritional Assessment (MNA), as a nutrition screening and assessment tool;

– Mini Mental State Examination (MMSE), to assess the cognitive impairment.

There is a negative proportional relationship between HAM-D and MMSE scores (P = 0.001) and between HAM-D and MNA scores (P = 0.023). Depressed patients found to have a greater cognitive impairment and a worse nutritional status. Considering a HAM-D cut-off point of 14, distinguishing mild than moderate depression, it shows a significant correlation with the MNA scores (P = 0.008). Patients with HAM-D scores ≥ 14 have an average MNA score of 19.8, while patients with HAM-D scores < 14 have an MNA average score of 23.6. Euthymic or mildly depressed patients are not at risk of malnutrition, while those with moderate or severe depression have an increased risk of malnutrition.

Our study shows significant correlations between the severity of depressive symptoms and the risk of malnutrition or cognitive impairment. A mild depression state does not seem to be associated with an increased risk of malnutrition.

The authors have not supplied their declaration of competing interest.

The diagnostics of cognitive disorders (CD) in patients with essential arterial hypertension (EAH) is often necessary for the choice of treatment strategy.

To assess the role of neuropsychological and motivational factors in cognitive efficiency of elderly EAH patients.

Twenty-five patients with EAH took part in the study, stage 1–2, mean age was 67.6 ± 6.1. The assessment of cognitive functions embraced a quantitative measurement of intelligence quotient (IQ) with the Wechsler Adult Intelligence Scale (Wechsler, 1955), and investigation into qualitative features of cognitive processes with Luria's neuropsychological assessment scheme (Luria, 1980) and Zeigarnik's procedure of pathopsychological study (Zeigarnik, 1972).

Within the psychological syndrome structure of CD in EAH patients the leading part is played by the neuro-dynamic factor, manifested in general lability, slowing down, and sudden exhaustion caused by reduction in energy of mental activity. The conclusion is supported by the high frequency of described symptoms among EAH patients and low dynamics of their reduction against the antihypertensive therapy (Pervichko et al., 2014, 2015). However, performance of experimental tasks makes 30% of EAH patients reveal reduced motivation. They would achieve poor results in general scoring, if compared with the group of highly motivated participants. Correlation analysis data show the interconnection between frequency disturbances in motivation and frequency in occurrence of various signs of cognitive decline, such as low efficiency in memorization and delayed recall, as well as low IQ indices.

The data provide a strong argument to support the hypothesis of particular importance of motivational factor of cognitive efficiency in elderly EAH patients.

The authors have not supplied their declaration of competing interest.

Selective serotonin reuptake inhibitors (SSRIs) are the most widely prescribed antidepressants with generally fewer side effects than most other types of antidepressants. However, in frail elderly, the use of SSRIs was anecdotally reported as a potential cause of a delirium.

To present a case of citalopram-induced delirium in an older adult diagnosed with late-life depression.

To review available literature on SSRI-induced delirium.

A case report is presented and discussed, followed by a literature review.

Seven published cases of SSRI-induced delirium in older adults (> 60 years) were found while searching through Pubmed and Embase. Our case of a 75-year-old female is also included in this report. This patient was ambulatory treated with citalopram 20 mg per os against depressive symptoms and she developed a delirium four days after the initiation of the therapy. Blood tests were normal and CT scan showed no significant findings. No other medical evidence was found that could explain her delirium. Her symptoms finally resolved after discontinuation of citalopram.

The on- and off-treatment side-effect correlation by a segregate oral use of citalopram strongly suggests that SSRIs may have the potential to cause a delirium, especially in frail elderly. Further research on this topic is needed.

The authors have not supplied their declaration of competing interest.

Following a case presented in our inpatient unit as well as various interdepartmental from internal medicine and other emergencies, we decided to conduct a literature review on the different organic causes that can trigger the onset of psychotic symptoms in elderly.

A correct differential diagnosis of psychiatric symptoms in elderly.

Literature review of the literature on the presentation of psychotic symptoms in the elderly.

Description of a clinical case and development of diagnostic hypotheses.

For several decades are experiencing a gradual aging of the population, which means that we are at the onset of clinical symptoms not described by classical authors. Furthermore, scientific advances make infectious causes (such as neurosyphilis was our first diagnostic hypothesis) are increasingly rare. The elderly usually has multiple comorbidities, which are receiving various treatments that must be ruled out possible adverse effects.

The author has not supplied his/her declaration of competing interest.

The author has not supplied his/her declaration of competing interest.

Alzheimer's disease (AD) patients are often treated with inadequate doses of AD's medications, which can lead to harms and additional costs.

In most European countries, there is no data on inappropriate prescribing (IP) in patients with AD in terms of inadequate doses. In Slovenia, the interest for a collaborative care between clinical pharmacists and physicians is increasing, mainly because of payer's interest to reduce several additional costs.

The main aim of this paper was to present the benefits of clinical pharmacist interventions in AD patients in community health centres in Eastern Slovenia.

All included outpatients with AD in 2013 were included, where clinical pharmacists’ interventions were ordered by the general practitioners (GPs). All study data from the patients’ records were obtained from the clinical pharmacists’ reports and patients’ charts. Main outcome measures were obtained from the summary of the patients’ treatments and the questionnaires.

Six hundred and twenty-nine patients were included. Before the clinical pharmacist medications review, 39 patients were treated with AD medications (10 without established AD). In 51.0% of these cases, the suggestions to GPs were provided (mainly dose adjustment). In 70.0% of all cases, the recommendations were accepted by GPs, which led to a total reduction in the number of patients with IP (before 20 and after 6).

A clinical pharmacist could help GPs in recognizing IP in patients with AD. These data will guide health system directors and clinical coordinators in allocating resources to establish this cooperation in more European countries.

The authors have not supplied their declaration of competing interest.

The prevalence of dementia rises with the rapidly increasing elderly population in developed world. In Singapore, 10% of the elderly population is estimated to have dementia. Other than physical and psychological needs, social welfare should also be addressed with the support of specialised geriatric care sources to improve their quality of life.

To study a case of an elderly with dementia, who was identified and managed through a multi-agency approach and to describe different services involved for dementia care.

To highlight the various elderly care organizations available in Singapore to address healthcare and social needs in dementia.

Through a case report of an elderly who presented to hospital for medical issues with dementia, the social needs were identified and multiple agencies were involved to provide holistic care in dementia.

A 77-year-old gentleman was brought by a community social worker to hospital as he was found ill during home visit. During admission, the concern for poor self-care and cognition decline was raised by his family. Mini-mental state examination was 16/30. He was diagnosed with vascular dementia with clinical and MRI Brain finding. With active multidisciplinary intervention, his medical issues were addressed, and family and social needs were attended by several voluntary welfare organizations. Access to memory clinic service was also arranged for. This intervention also provided opportunity for his long-term care and welfare.

Multi-agency approach is crucial in dementia care to identify their unmet needs and plan for long-term care in Singapore.

The authors have not supplied their declaration of competing interest.

In DSM-V, catatonia is individualized as a disease of its own. The priority is to look first for organic causes like intoxication. We present a clinical case diagnosed with intellectual disability (ID) and catatonia.

To study a case of catatonia which underwent testing using Bush-Francis Catatonia rating scale (BFCRS) prior/after clinical intervention. We therefore study catatonia's etiology in ID population.

To study the etiology of catatonia (and its clinical complications) in ID.

Our patient is 48-year-old female with DI. Considering her clinical features of catatonia (using BFCRS) and clinical examination (fever and hypoxia), the case orientated towards a secondary diagnosis. Work-up tests revealed pneumonia in the lower lobe of the right lung (chest radiography showed opacities and blood tests showed Leuokocytosis with a left shift). The case further received a course oral levofloxacin (500 mg/day) and haloperidol was stopped. Valproic acid was also added to a dose of 600 mg/day, which led to clinical improvement. Remaining psychotropic treatment (duloxetine 60 mg/day, lorazepam 15 mg/day, diazepam 35 mg/day) was not modified.

After 1 month, the patient improved according to BFCSR score.

We presented a case of presence of catatonia in other psychiatric conditions and undiagnosed general medical conditions. Haloperidol is contraindicated those circumstances and it may have worsened her clinical state (it should be used cautiously in DI). Other medications (gabaergic drugs) should be considered in such settings and rare causes related to hypoxia cannot be ruled out (Table 1).

The authors have not supplied their declaration of competing interest.

People with intellectual disabilities (ID) present with behaviours that challenge community services. Community models of care as alternatives to hospital care exist but are often vary in their function. Certain strategies have been developed to manage challenging behaviour in people with ID. Data from a three-year period on a community-based service for people with ID and challenging behaviour that uses an objective, multi-disciplinary approach is presented.

A case note survey of adults with ID under the care of the Assessment and Intervention Team (AIT), a challenging behaviour service in the London Borough of Haringey.

Over the three-year period, 65 adults were managed by AIT. Forty-four were male and 21 were female. The age range was 21–64 years of age. The level of ID was mild ID 61%, moderate 39%. Diagnoses included psychotic disorder (25%); mood disorder (20%); developmental disorder (40%); dementia (10%); challenging behaviour (45%). Six people (11%) were admitted to hospital during their time with AIT. The length of care under AIT ranged from four to fourteen months.

AIT managed effectively people with ID living in the community who presented with complex problems putting their placement at risk. The rate of hospital admission was reduced in this period compared with the previous three years. The length of stay in in-patient services was reduced. The most common reasons for the behaviours included mental illness and ‘challenging behaviour’. People with developmental disorders were a large proportion. Community alternatives are effective with positive benefits to the person.

The authors have not supplied their declaration of competing interest.

In contrast to psychopharmacological treatment, the current evidence base in psychotherapy for people with IDD is limited. But psychotherapeutic approaches offer an alternative treatment modality in people with IDD.

Orientated on the “Dialectic-Behaviour-Therapy” concept, we developed an adapted manual for people with IDD and impulsive behaviour.

This study presents the first results of an evaluation our adapted DBT manual.

Three closed groups with 11 patients in total were prospectively included in a six-week in-patient psychotherapeutic DBT-programme. There was no randomisation or control group. Typical borderline symptoms (BS) were recorded using the “Borderline Symptom List” (BSL) and a short screening version for personality disorders (PSS-K). Impulsivity and behaviour in general were observed with the scale for impulsiveness and emotional deregulation (IES) and the German Developmental Behavioural Checklist (VFE). Special tendencies to self-harm were assessed using the scale for self-harm behaviour (IEFAS). From these scales, the means were observed during the course of our hospital therapy program over 6 weeks.

There were 19 patients in total in 3 different groups. Eight dropped out for a variety of reasons. The mean scores for the remaining 11 patients in the BSL and PSS-K reduced significantly. The scores for impulsivity and self-harm improved. Overall, there was no significant change in behaviour.

This study presents the results of a trial of a DBT manual for people with IDD and BS. In general the BS declined, the impulsivity improved. The study is limited by the small numbers in the patient sample and the absence of a control group.

The author has not supplied his/her declaration of competing interest.

Psychopharmacology and psychotherapy in children with ADHD is still well established and has been studied for many years. There has been a growing interest in treatment of ADHD in adults for some years. Whereas meanwhile the psychopharmacological treatment is well studied, the psychotherapeutic interventions are still to optimize.

Since the acceptance of the diagnosis of “ADHD” in adults, there has been a growing interest in using medication as the first-line therapy. There is an established evidence base for psychopharmacological treatment in ADHD. The current therapeutic recommendations for the general population apply to people with ADHD and IDD. The study is a review of psychotherapeutic interventions in the treatment of ADHD in adults with and without IDD supported by a case study.

A literature search was conducted in “Pubmed” and “PsycInfo” using the keywords “Psychotherapy”, “ADHD”, “Adults” and further “Psychotherapy”, “ADHD”, “Adults”, “intellectual”, “disabilities”. Exclusion criterion was ADHD as a sub-syndrome in the presence of other syndromes.

Only 2–3 publications on psychotherapy in adults with ADHD were found. Very little was found on people with IDD, and these were especially combined with the Fragile X Syndrome.

Psychotherapy in adults with ADHD is not yet well elaborated in the scientific literature. There are some common used intervention strategies like psycho-education, cognitive behavioural therapy, and attention focusing interventions such as mindfulness-strategies. Using the principles of Easy-to-Read language and modifying the general therapeutic settings as recommended by NICE, an adaptation of these interventions in the treatment of adults with ADHD and IDD has potential.

The author has not supplied his/her declaration of competing interest.

Rapidly progressive dementias (RPD) are conditions that develop over days, weeks or months, which could be treatable if diagnosed in the acute phase.

A 62-year-old man with personal history of type 2 diabetes, started complaining of fronto-temporal headache, nausea and sub-febrile temperature. He went to his family doctor who prescribed ciprofloxacin 500 mg bid. Later on, he had difficulty to sleep and referred complex visual hallucinations. His family noted involuntary movements of the left upper limb and that he became more clumsy needing help for daily life activities. He went to our hospital one week later. He was apyretic and hemodynamically stable. On neurological examination, he had executive and visuospecial dysfunction, left limbs bradykinesia and ipsilateral limb ataxia. Involuntary movements of his left upper limb resembled alien limb phenomena. Complete blood count, complete metabolic panel, iron, folic acid, vitamin B12, anti-neuronal antibodies were normal. HIV, hepatitis B and C serologies were negative. Cerebrospinal fluid study showed 4 cells (100% mononuclear), normal glucose and protein levels, negative bacteriological exam but positive Herpes Simplex-1 Virus (HSV) DNA. Brain CT and MRI showed signs of ischemic microangiopathic leukoencephalopathy. He started treatment with acyclovir 30 mg/kg/d IV and quetiapine 100 mg id. His symptoms improved but he remained with a mild mnesic cognitive deficit and bradykinesia that stayed stable 3 years later.

This case exemplifies atypical HSV-1 encephalitis, one cause of RPD, that an early recognition is essential to reduce its associated morbidity.

The authors have not supplied their declaration of competing interest.

Down syndrome was clinically described the first time in France by Esquirol (1838) followed by Down (England, 1866), to the identification of a chromosomal abnormality in 1959 (trisomy 21), which is the most common abnormality in neurodevelopmental disorders. Life expectancy increased from 9 years in 1929 to 55 currently. This is a common cause of mental retardation, and few tools are suitable for the care of these patients, including patients with Alzheimer's disease (prevalence of 55% between 50 and 59) or depression (prevalence 30%). No study evaluates the effectiveness of cognitive and behavioral therapy (CBT) in patients with Down syndrome but it is known to be effective in Alzheimer's patients. Some cases have been reported on the efficacy of CBT on phobias in patients with intellectual disability.

To evaluate the efficacy of CBT in the treatment of a specific phobia in a patient with Down syndrome and early Alzheimer's disease.

Literature review and clinical case of a 51-year-old patient, hospitalized under constraints for behavioral disorders (agitation, body treatments refusals).

By adapting CBT techniques to the problem of intellectual disability, treatment against the phobia was effective with clinical improvement, which allowed a return home.

The tools provided by CBT are suitable for the treatment of anxiety disorders in patients with intellectual disability, especially in patients with Down syndrome. Psychiatric disorders are under-diagnosed in these patients and under-treated. CBT is an aid to the treatment. It may allow the dismantling of symptoms and reduce behavioral problems.

The authors have not supplied their declaration of competing interest.