1046

LETTERS TO THE EDITOR

readmission by a physician and research nurse. Medication non-compliance was considered to be a direct contributory cause to readmission only if iflagrant errors in compliance occurred (eg, patient ran out of medication and did not refill prescription). Similarly, dietary sodium intake was not quantified, but only major excesses in sodium ingestion (eg, regular use of canned soups or eating ai bag of potato chips just prior to readmission) were classified as contributing to readmission. These assessments are admittedly subjective, but it should be noted that the intent of our study was not to measure compliance, which is fraught with difficulties, but to determine to what extent major and easily identifiable lapses in compliance contributed directly to readmission. To this end, quantification of compliance may not have been helpful, since there is no objective method for determining what degree of non-compliance may lead to readmission. Moreover, a patient may take all prescribed medication for 2 months, then discontinue therapy and be rehospitalized shortly thereafter. Calculated as a percentage, compliance would be high, yet non-compliance clearly contributed to rehospitalization. Thus, we believe our methods were appropriate given the goals of our study, and we are confident that the percentages provided in Table 3 are an accurate reflection of the degree to which these factors clearly contributed to readmission in our population.’ Nonetheless, we agree with Dr. Kruse that the effect of non-compliance on hospitalization in the elderly requires further study, and in our ongoing research in this area we are assessing medication and dietary compliance objectively (by pill counts and food logs, respectively) as well as subjectively. Several other points in Dr. Kruse’s letter are worthy of comment. First, we agree that readmissions for dehydration were most likely due to overprescribing of diuretics by physicians rather than excessive diuretic use by the patient as originally implied. Second, we concur that in order to optimize compliance, physicians must simplify medication regimens as much as possible, not only with regard to the number of medications prescribed but also the number of dosing intervals throughout the day. Finally, changes in medications following initial discharge were evaluated in our study but did not contribute directly to readmission in our patients.

IAGS-OCTOBER 1991-VOL. 39, NO. 10

space.”These sevencases were part of 150 successivereferrals to a psychogeriatrician in the city of Cambridge. They found no significant association between this sign and sex, age, underlying pathology, impending death, or score on the Blessed Information-Memory-Concentrationtest. No specific diagnoses were given for these seven patients, although over half the sample had a dementia. It has also been observed that 8% of a group of 110 research subjects with SDAT were unable to recognize that people on television were not physically p r e ~ e n tOne . ~ such subject refused to dress in a room with a television, and another feared they were being shot at by characters on the television. While these latter cases were not reacting to printed pictures per se, they are clearly included in the broader perceptual disorder described by Bemos. The phenomenology of dementia is complex, and identification of unique perceptual disorders is important as it may allow a better understanding of the underlying pathophysiology of these symptoms in a wide range of disorders. Drs. Neitch and Zarraga are to be applauded for bringing this interesting symptom to broader attention.

WILLIAM J. BURKE,MD UNIVERSITY OF NEBRASKA MEDICAL CENTER OMAHA, NE 68198-5575 REFERENCES 1 . Neitch SM, Zarraga A. A misidentification delusion in two Alzheimer’s patients. J Am Geriatr SOC1991; 39:513-515. 2. Berrios GE, Brook P. Visual hallucinationsand sensory delusions in the elderly. Br J Psychiatry 1984; 144:662-664. 3. Rubin EH, Drevets WC, Burke WJ. The nature of psychotic symptoms in senile dementia of the Alzheimer type. J Geriatr Psychiatry Neurol 1988; 1:16-20.

The above letter was referred to the authors of the original paper, and their reply follows.

In reply:-We appreciate Dr. Burke’s bringing to our attention the report of Drs. Berrios and Brook. In spite of an extensive literature search we had not encountered their paper. Having subsequently reviewed their article, we agree that MICHAEL W. RICH, MD they are describing the same delusion we reported. It is not Jewish Hospital at Washington University Medical Center clear, however, whether all seven of their patients misidenSt. Louis, MO tified TV and printed images or if some only misperceived the TV images. It has been our experience that misperception of television pictures is relatively common, but identifying a REFERENCE printed picture as “existing in three dimensional space” is 1 . Vinson JM, Rich MW, Sperry JC et al. Early readmission of elderly patients with congestive heart failure. J Am Geriatr SOC quite unusual. Unfortunately, Drs. Berrios and Brook did not indicate 1990;38:1290-1295. whether the seven patients showing the “picture sign” were among the 72 persons diagnosed as having Alzheimer’s out of their series of 150 successive referrals. We hope that our report and this interchange will stimulate others to inquire The Picture Sign in Dementia about this delusion in their Alzheimer’s patients, ascertaining To the Editor:-Drs. Neitch and Zarraga describe a “misiden- whether it is peculiar to the Alzheimer’s brain, and ultimately tification delusion”’which they claim has not previously been determining its true pathophysiologic significance. described. Not only has this phenomenon, the ”delusional SHIRLEY M. NEITCH, MD belief that pictures are real,” previously been described, but ANTONIO ZARRAGA, MD it has also been given a name, “the picture sign.”’ DEPARTMENT OF INTERNAL MEDICINE Berrios and Brook described seven patients “who treated MARSHALL UNIVERSITY TV images and newspaper photographs (eg a nude calendar HUNTINGTON, WV girl) as if they were real and existed in the three-dimensional

The picture sign in dementia.

1046 LETTERS TO THE EDITOR readmission by a physician and research nurse. Medication non-compliance was considered to be a direct contributory cause...
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