Rob M. Kok

Introduction: Postictal agitation (PIA) is an impactful confusional state occasionally occurring after electroconvulsive therapy (ECT). PIA creates dangerous situations for caregivers and patients, prolongs lead times, and sometimes leads to the premature discontinuation of ECT. Despite the impact PIA can have on patients and caregivers, little is known about its incidence and the factors associated with its occurrence. This study aims to investigate putative prognostic factors for PIA. Methods: We utilized data from the “Rivastigmine for ECT‐induced Cognitive Adverse effects in Late‐Life depression” (RECALL) prospective cohort study; a study on older adults ( ≥ 55 years) with a major depressive episode receiving ECT. We investigated several putative prognostic factors based on previous research, biological plausibility, and availability. PIA was defined by either a Richmond Agitation‐Sedation score ≥ 2 or the administration of emergency medication specifically for PIA. Mixed‐effects logistic regression was used to analyze univariate and adjusted odds ratios for the prognostic factors. Results: We included 142 patients who received 1838 ECT sessions. The incidence of PIA was 34.5% at the patient‐level and 9.2% at the session‐level. A small subset of older adults (19.7%) accounted for 87.5% of all PIA occurrences. We found that male sex, flumazenil use, and a longer seizure duration were associated with higher odds of developing PIA. Multi‐seizure sessions and a higher level of education were associated with lower occurrence of PIA. Conclusion: This study identified sex, flumazenil use, seizure duration, the amount of seizures during a session, and education level as prognostic factors for PIA. The pronounced clustering of PIA events within a small subset of patients suggests meaningful interindividual vulnerability, but should be replicated in future studies. If confirmed, these findings could provide actionable insights for preventive treatment strategies. In particular, the use of flumazenil should be critically reconsidered in persons experiencing PIA. Trial Registration: EudraCT 2014‐003385‐24.

When medication and other interventions for challenging behaviour in people with dementia are insufficient, safety net enclosures are frequently used. It is a restrictive intervention with a limited number of available research studies. This article presents some data from an observational study that we have published recently. Finally, we discuss for which patient groups, in which settings, and under what conditions the use of safety net enclosures could be considered.

Background/Objective: To examine whether patients with late-onset schizophrenia (LOS) and very-late-onset schizophrenia-like psychosis (VLOS) are at a higher risk of developing dementia than patients with early-onset schizophrenia (EOS). Methods: A random sample of incident cases of patients with schizophrenia with an age of onset after age 40 (LOS) and age 60 (VLOS) was selected from a psychiatric case register covering all psychiatric services within the city of The Hague, The Netherlands, between 1997 and 2012. Schizophrenia diagnosis and age of onset were audited by systematic review of all case notes up to 2019. Patients who were initially misclassified as LOS/VLOS in the registry but, after this audit, had an age of onset before age 40, were classified as EOS. The risk of developing dementia was compared between the groups using a logistic regression model with correction for age, gender, and stroke as possible confounders. Results: Our study groups consisted of 74 patients with EOS, 81 with LOS, and 25 with VLOS. Dementia was present in 10 patients at follow-up, 7 out of 106 (6.6%) patients in the combined LOS and VLOS groups, and 3 out of 74 (4.1%) patients in the EOS group. However, after correction for confounders, logistic regression showed no statistically significant higher change in the development of dementia in LOS nor VLOS patients compared to EOS patients, nor with age of onset as a continuous variable. Conclusions: Patients with LOS and VLOS are not at a higher risk of developing dementia compared to patients with EOS. These results do not support the hypothesis that LOS and especially VLOS, are precursors of dementia.

Objectives: Behavioural and Psychological Symptoms of Dementia (BPSD) are usually managed with a combination of pharmacological and nonpharmacological interventions, but efficacy is often moderate, and many patients are treatment‐resistant. We aimed to evaluate the indication for treatment with clozapine, response, side effects, frequency of clozapine discontinuation, reasons for discontinuation and time to discontinue clozapine in patients with a neurocognitive disorder.Methods: A retrospective cohort study including all patients with a neurocognitive disorder who started with clozapine between 2011 and 2020, admitted to old age departments of a psychiatric hospital in The Netherlands. The Clinical Global Impression of Improvement‐scale (CGI‐I) was used to evaluate treatment response, based on clinical notes in the electronical patients' files. Side effects and variables concerning discontinuation of clozapine treatment were also extracted from patients' files.Results: We included 81 inpatients who started with clozapine and had a major neurocognitive disorder. A clinically relevant positive treatment response (CGI‐I score 1‐2) was found in 27 patients. Patients without a delirium have a statistically significantly better outcome compared to patients with a delirium superposed on a neurocognitive disorder (Chi² = 14.47, df = 2, p < 0.0001). Only 79 side effects were reported in these 81 patients, and severe side effects in only 2 patients. Side effects were the primary reason to discontinue clozapine in 11 patients, lack of efficacy in 7 patients and side effects combined with lack of efficacy in 5 patients. The median clozapine dose was only 50 mg/day, and a higher dose was a significant predictor of a shorter treatment duration.Conclusion: Clozapine may be an effective and safe intervention for patients with a neurocognitive disorder and BPSD without a superposed delirium. Clozapine at a low dose may be a treatment option for severe, treatment resistant BPSD.

This study aimed to identify trajectories of core depressive symptoms and insomnia symptoms in depressed older adults, their prevalence and association, and predictors of unfavorable trajectories. We examined 6-year follow-up data of 329 depressed older adults from the Netherlands Study of Depression in Older persons. Core depressive symptoms and insomnia symptoms were assessed with the Inventory of Depressive Symptomatology. We applied growth mixture modeling to identify classes of participants with similar trajectories of core depressive symptoms and insomnia symptoms. The association between core depressive and insomnia symptom trajectories and predictors of these trajectories were examined. We identified three core depressive symptom trajectories: low and declining (40.4%), moderate and declining (37.4%), and high and stable (22.2%); and four insomnia symptom trajectories: moderate and declining (13.7%), low and increasing (7.6%), moderate and stable (55.6%), and high and stable (23.1%). Participants with favorable core depressive symptom trajectories often had unfavorable insomnia symptom trajectories. Older age, chronic diseases, and functional limitations predicted unfavorable core depressive symptom trajectories. Functional limitations predicted unfavorable insomnia symptom trajectories. Trajectories of core depressive and insomnia symptoms in depressed older adults were partly associated, but insomnia symptoms often persisted despite improving core depressive symptoms, highlighting the importance of different targeted interventions.

Aim/Objectives: To investigate whether frailty predicts adherence to psychotropic drug treatment or adverse drug reactions, within 6 months after treatment initiation. Methods: A prospective cohort study including 77 patients over the age of 65, treated in one large psychiatric institute in the Netherlands. Patients were assessed at baseline for their frailty status, using different operationalizations of the Fried frailty criteria. Data on duration of psychotropic drug treatment and number of reported adverse drug reactions were retrieved from electronic patient files. Regression analyses were adjusted for age, sex, patient setting, and polypharmacy as potential confounders. Results: Frail patients were not significantly more likely to discontinue psychotropic treatment than non-frail patients (OR = 1.4; 95% CI 0.6–3.7, p = 0.468). Time to treatment discontinuation was also not statistically different between both study groups (HR = 0.8; 95% CI 0.4–1.6, p = 0.498), and neither was the number of adverse drug reactions (OR = 1.6, 95% CI 0.6–4.1, p = 0.345). Conclusions: We could not demonstrate a statistically significant effect of frailty as predictor of discontinuing psychotropic treatment or adverse drug reactions, but a lack of power may also explain our results. A more comprehensive frailty assessment may be needed to predict treatment adherence or adverse drug reactions in psychiatric patients.

Introduction: Cognitive side effects, such as memory loss, associated with electroconvulsive therapy (ECT) have been extensively studied. However, knowledge about (sub)acute confusional states during ECT is limited, particularly in older adults with depression. Their incidence, recurrence, and co‐occurrence remain unclear. This study aimed to describe the incidence, recurrence, co‐occurrence, and clinical course of various subtypes of confusional states during ECT.Methods: Data were derived from the ‘Rivastigmine for ECT‐induced Cognitive Adverse effects in Late‐Life depression’ (RECALL) prospective cohort study, involving 145 older adults (≥ 55 years) with a major depressive episode receiving ECT. We assessed different subtypes of confusional states: postictal and interictal delirium (PID and IID), postictal agitation (PIA), prolonged time to reorientation (TRO), and subacute general cognitive decline (Mini Mental State Examination decline ≥ 4 points) throughout the ECT course.Results: Over half of the older adults (55.9%) experienced at least one subtype of confusional state during their ECT course. The most prevalent subtypes were PIA (29.5%) and prolonged TRO (28.3%), while postictal (5.9%) and interictal delirium (4.2%) were less common. Recurrence rates varied, with interictal delirium (66.7%) and prolonged TRO (50.0%) showing the highest rates compared to postictal delirium (12.5%). Notably, 18.0% of older adults experienced more than one subtype of confusional state during their ECT course, and these states could emerge at any time during the ECT course.Conclusion: This is the first study to comprehensively examine the clinical course of various subtypes of confusional states during ECT in older adults with depression Our findings reveal that confusional states are highly prevalent, heterogeneous, and may emerge at any time during the ECT course. Notably, since the instruments used were not designed to measure (subtypes of) confusional states during ECT, further research into the differentiation of (sub)acute confusional states is warranted.Trial Registration: EudraCT 2014‐003385‐24

Objective: Safety net enclosures are used in addition to (non-) pharmacological interventions in patients suffering from neuropsychiatric symptoms in dementia. However, no data on effectiveness are available. Methods: In a prospective observational cohort study of 81 patients diagnosed with dementia, and admitted to a geriatric ward of a psychiatric hospital, available behavioral assessment scores were used to compare 45 patients who used safety net enclosures with 36 patients who never used safety net enclosures. Behavior was evaluated weekly using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory Questionnaire (NPI-Q) at admission, start of the enclosure, and before discharge. Results: At baseline, the intervention group had a significantly higher CMAI and NPI-Q-score. At follow-up, the intervention group showed a greater improvement in CMAI [median −13.0 (interquartile range: −27.3 to 0.05) vs 0.0 (interquartile range: −6.0 to 2.5); Mann-Whitney U = 338.5 (P = 0.005)] compared with the comparison group. Only some NPI-Q subscales showed significantly greater improvement during the intervention than in the comparison group. Conclusions: Our observational study is the first to present effectiveness data on Neuropsychiatric symptoms in persons suffering from dementia and suggests significantly greater improvement in CMAI scores when using safety net enclosures. However, almost no significant differences were found in other outcomes.