Request for euthanasia by a psychiatric patient with undetected intellectual disability

In the Netherlands, euthanasia or assisted suicide (EAS) in psychiatric disorders is legal in certain circumstances. Guidelines recommend a second opinion to independently check diagnosis and treatment resistance. A 68-year-old patient, diagnosed with bipolar I disorder, with a request for euthanasia because of tiredness, repeated falls and racing thoughts was seen for such a second opinion. Persisting in her wish, her reluctant family and psychiatrist became convinced of euthanasia. Our disagreement with the diagnosis of bipolar I disorder upset her, but she agreed with discontinuation of psychotropic drugs. Her mobility and tiredness improved, whereafter her request for euthanasia evolved into a death wish due to completed life. Intellectual disability and an attention deficit hyperactivity disorder could explain her struggle in life. This case report shows that extending the procedure regarding EAS with an independent psychiatric evaluation is important. For our patient, this second opinion supported her to find meaning in life

Research into the cause of brackish marsh recession in the Fraser River estuary

At least 160 ha (30%) of the brackish marsh on Sturgeon Bank in the Fraser River estuary have disappeared since 1989. A collaborative effort between the provincial and federal governments and industry aims to determine the cause(s) of the recession to inform future restoration efforts. Three adjacent low-elevation brackish marshes along the delta front have also receded to varying degrees. River training structures and regular dredging of the Fraser River divert sediments and fresh water, and thus alter sediment and salinity patterns along the delta front. Lesser snow geese (Anser c. caerulescens) preferentially grub bulrush, and the Fraser-Skagit population has increased 2-3 fold over the last three decades. Investigation of the marsh recession to date includes (1) describing historical rates and patterns of recession, (2) assessing the present environment (e.g., sediment accretion rates and salinity regimes), and (3) conducting inferential experiments to identify factors that contribute to marsh loss and prevent recovery. No single recession hypothesis we tested singularly explains the recession. The anticipated effects of climate change, especially sea-level rise, pose additional threats to all tidal marshes in the Fraser River estuary

Strengths and Weaknesses of the Vascular Apathy Hypothesis:A Narrative Review

The vascular apathy hypothesis states that cerebral small vessel disease (CSVD) can cause apathy, even when no other symptoms of CSVD are present. In order to examine this hypothesis, the objectives of this narrative review are to evaluate the evidence for a pathophysiological mechanism linking CSVD to apathy and to examine whether CSVD can be a sole cause of apathy. The nature of the CSVD-apathy relationship was evaluated using the Bradford Hill criteria as a method for research on the distinction between association and causation. Pathological, neuroimaging, and behavioral studies show that CSVD can cause lesions in the reward network, which causes an apathy syndrome. Studies in healthy older individuals, stroke patients and cognitively impaired persons consistently show an association between CSVD markers and apathy, although studies in older persons suffering from depression are inconclusive. A biological gradient is confirmed, as well as a temporal relationship, although the evidence for the latter is still weak. The specificity of this causal relationship is low given there often are other contributing factors in CSVD patients with apathy, particularly depression and cognitive deterioration. Differentiating between vascular apathy and other apathy syndromes on the basis of clinical features is not yet possible, while in-depth knowledge about differences in the prognosis and efficacy of treatment options for apathy caused by CSVD and other apathy syndromes is lacking. Since we cannot differentiate between etiologically different apathy syndromes as yet, it is premature to use the term vascular apathy which would suggest a distinct clinical apathy syndrome

Advance request in euthanasia and assisted suicide of patients with severe dementia.

Background - To permit euthanasia or assisted suicide (EAS( the medical ‘due care criteria’ of the Termination of Life on Request and Assisted Suicide Act (TLRASA) should be met, i.e., the request should be (1) voluntary and well considered and (2) expressed after informed consent about diagnosis and prognosis. (3) Suffering should be unbearable, with no prospect of improvement and (4) no reasonable alternatives should be available. Aim - To explore key elements influencing the RTE’s judgement on whether the due care criteria have been met of EAS cases in severe dementia based on written advance euthanasia requests. Methods - Qualitative study of reports of the RTE published online (n=21) in which a written euthanasia directive was mentioned and considered incompetent to make a decision regarding EAS. Two independent researchers (AvdB, GM) extracted factual data independently of one another (see appendix) and judged the due care criterion 'competence to make a decision regarding EAS'. Results & conclusion - Examination of the RTE’s judgment underlines the need for a clear euthanasia directive in advance request cases, as in 2 cases the criteria voluntary and well considered were not met because of this. Additionally, it becomes apparent that it is essential that the patient confirms their request after writing the directive. The RTE did not consider consulting an independent expert to establish the patient’s decision-making capacity essential for the due care criteria to be met. However, this solely applied when physicians acted diligently. Recommendations – We would recommend updating a written directive at least every year

Frailty measures in immuno-metabolic subtypes of late-life depression; A two-year prospective study:A two-year prospective study

Background/Objectives - Frailty is highly prevalent with increasing age. Based on the concept of depression as a disorder of accelerated aging and its association with inflammation and metabolic dysregulation, we examined whether frailty measures at baseline and over time differed between immuno-metabolic subtypes of late-life depression. Methods - Clinical cohort study in primary and secondary mental health care with two-year follow-up. In total 359 depressed older patients (≥ 60 years) classified in four immuno-metabolic subgroups by latent profile analysis. We compared frailty measures at baseline and two-year follow-up adjusted for confounders between immuno-metabolic based depressed subgroups. Frailty measures included the frailty index, physical frailty phenotype, and two proxies (handgrip strength, gait speed). Results - At baseline, the relatively healthy depressed subgroup (n = 181) performed best on all frailty markers. While frailty markers worsened over time, the two-year course did not differ between the subgroups for any of these markers. Conclusion - The more severe immuno-metabolic dysregulation present in late-life depression, the more frail. Nonetheless, as trajectories over time did not differ between subgroups, the difference probably emerged at midlife. Future studies should examine whether geriatric assessment might become relevant at earlier ages in specialized mental health care

Adverse health outcomes in vitamin D supplementation trials for depression:A systematic review

BACKGROUND: Vitamin D deficiency is a universal risk factor for adverse health outcomes. Since depression is consistently associated with low vitamin D levels as well as several adverse health outcomes, vitamin D supplementation may be especially relevant for depressed persons. This review examines the potential benefits of vitamin D for (somatic) health outcomes in randomised controlled supplementation trials for depression. METHOD: Systematic literature search to assess whether adverse health outcomes, such as frailty, falls, or cognitive functioning, were included in vitamin D supplementation trials for depression, and whether these outcomes were affected by supplementation. The revised Cochrane tool for assessing risk of bias in randomised trials was used. RESULTS: Thirty-one trials were included. Adverse health outcomes were considered in five studies. Two studies reported some beneficial effect on an adverse health outcome. CONCLUSIONS AND IMPLICATIONS: While depressed persons are at increased risk of vitamin D deficiency, supplementation trials hardly addressed the common negative health consequences of low vitamin D levels as secondary outcome measures. Well-designed trials of the effects of vitamin D supplementation in late-life depression should explore whether adverse health outcomes can be prevented or stabilised, and whether depression benefits from this improvement