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While most older people are mentally healthy, persons over age 65 are vulnerable to the same spectrum of psychiatric disorders as are younger people. The heart of the psychiatric evaluation is the mental status examination, the here-and-now data-gathering equivalent of the physical examination, that allows a systematic examination of the major aspects of the patient’s mental state. Mood disorders, such as depression, are the most frequently clinically diagnosed and the most treatable psychiatric disorders in older people. Depression can commonly co-occur with anxiety, and clinicians must become comfortable asking their older patients about suicidal ideation, as rates of suicide are consistently higher among the elderly than for other age groups. The psychopharmacologic treatment of mood disorders and anxiety has advanced considerably, and many effective antidepressant and anxiolytic medications are available. Whichever medication the clinician chooses, one should start at a low dose and titrate up to a therapeutic dose gradually and slowly to prevent adverse effects. Psychotherapy is also an important part of treatment. No one approach is best; rather, a pluralistic approach that emphasizes life review and focuses on specific issues of concern is most effective for older people.
Psychiatric disorders in older patients can be lifelong or begin in later life. Those beginning in later life are sometimes associated with dementia, delirium, and stroke/brain vascular disease but are often idiopathic. In general, the same psychological and pharmacologic treatments that are effective in younger individuals have similarly efficacy in the elderly, but the presence of structural brain disease and comorbid physical illness are risk factors for poorer response. Antidepressants are effective therapies for major depression and often require the same doses as in the young. Antipsychotics should be used sparingly and at as low a dose as possible. Benzodiazepines should be avoided if possible.
Placebo responses raise significant challenges for the design of clinical trials. We report changes in agitation outcomes in the placebo arm of a recent trial of citalopram for agitation in Alzheimer's disease (CitAD).
In the CitAD study, all participants and caregivers received a psychosocial intervention and 92 were assigned to placebo for nine weeks. Outcomes included Neurobehavioral Rating Scale agitation subscale (NBRS-A), modified AD Cooperative Study-Clinical Global Impression of Change (CGIC), Cohen-Mansfield Agitation Inventory (CMAI), the Neuropsychiatric Inventory (NPI) Agitation/Aggression domain (NPI A/A) and Total (NPI-Total) and ADLs. Continuous outcomes were analyzed with mixed-effects modeling and dichotomous outcomes with logistic regression.
Agitation outcomes improved over nine weeks: NBRS-A mean (SD) decreased from 7.8 (3.0) at baseline to 5.4 (3.2), CMAI from 28.7 (6.7) to 26.7 (7.4), NPI A/A from 8.0 (2.4) to 4.9 (3.8), and NPI-Total from 37.3 (17.7) to 28.4 (22.1). The proportion of CGI-C agitation responders ranged from 21 to 29% and was significantly different from zero. MMSE improved from 14.4 (6.9) to 15.7 (7.2) and ADLs similarly improved. Most of the improvement was observed by three weeks and was sustained through nine weeks. The major predictor of improvement in each agitation measure was a higher baseline score in that measure.
We observed significant placebo response which may be due to regression to the mean, response to a psychosocial intervention, natural course of symptoms, or nonspecific benefits of participation in a trial.
Involuntary emotional expression disorder (IEED), a distressing and potentially debilitating condition characterized by uncontrollable episodes of laughing and/or crying, causes extensive social and occupational dysfunction amongst patients. However, despite affecting more than one million people worldwide, IEED is often overlooked or misdiagnosed, and current treatments are compromised by uncertain efficacy. In this supplement we review the epidemiology and pathophysiology of IEED, and discuss new pharmacologic interventions which may afford opportunities for symptom control amongst IEED sufferers.
Although the uncontrollable episodes of emotion which characterize IEED were first described more than a century ago, a bewildering profusion of terminology has since confused and hampered the efforts of physicians to recognize and treat this condition. In the first article, John E. Duda, MD, examines the history of IEED in the medical literature, and evaluates the prevalence of the condition amongst patients in whom emotional or affective motor control has become dysregulated, either as a result of brain damage from neurological disease or as a result of brain injury.
Extensive clinical experience and research suggest that a cortico-limbic-subcortico-thalamic-ponto-cerebellar network plays a significant role in the expression of human emotions. This network includes specific cerebral, cerebellar, and brainstem areas and their multiple projections/pathways, with activity modulated through serotonergic, dopaminergic, glutamatergic, and possibly sigma receptor neurotransmitter systems. Disruptions of regulatory and inhibitory mechanisms in the structure and function of this network likely constitute a pathophysiological basis for the crying and laughing episodes characteristic of involuntary emotional expression disorder. Pharmacologic interventions targeting the neurochemical modulators of the emotional expression systems may afford opportunities for symptom control among persons affected by this disorder.
Study partners for dementia research participants are vital to the research process, but little is known about their role, responsibilities, and experiences. Study partners are usually family members or friends – often the patient's informal caregiver – who are knowledgeable about and usually accompany the participant to study visits. This study examines researchers’ perspectives on the role of study partners in dementia research.
Qualitative data collection and analytic methods were used. Semi-structured individual interviews with principal investigators, study coordinators, and research nurses (i.e. researchers; n = 17) at two academic research sites were recorded, transcribed, and content analyzed to identify themes in the data.
According to researchers, study partners either make or help make research enrollment and post-enrollment decisions, serve as knowledgeable informants for the participants, manage the logistics that enable participants to comply with a study's protocol, and provide comfort and encouragement for the patient to engage in and complete a study. Researchers describe ideal qualities of study partners as being able to provide reliable information, being dependable and adherent to the protocol, and not expecting a benefit. They also report that study partners may face both practical and emotional challenges during research participation. However, researchers believe that study partners derive dementia-related education, caregiver support, and satisfaction from their involvement in research.
Investigators, potential study partners, and institutional review boards should be aware of study partners’ research responsibilities, challenges, and their interests as caregivers.
Most trainees, whether social workers, physicians, psychologists or nurses, are attracted to their career choice by the desire and hope that they will “cure” people and restore them to full health. Cures do occur in all of these fields, of course, but it is a surprise to most people to learn that cures are the exception and that chronicity is the basis of the care needs for a majority of individuals in most settings.
Environmental influences on the rate of Alzheimer's disease (AD) progression have received little attention. Our objective was to test hypotheses concerning associations between caregiver personality traits and the rate of AD progression.
Care receivers (CR) were 161 persons with AD from a population-based dementia progression study; 55 of their caregivers were spouses and 106 were adult children. Cognitive status of the CR was measured with the Mini-Mental State Examination every six months, over an average of 5.6 (range: 1–14) years. Linear mixed models tested rate of cognitive decline as a function of caregiver personality traits from the NEO Five-Factor Inventory.
Significantly faster cognitive decline was observed with higher caregiver Neuroticism overall; however, in stratified models, effects were significant for adult child but not spouse caregivers. Neuroticism facets of depression, anxiety, and vulnerability to stress were significantly associated with faster decline. Higher caregiver Extraversion was associated with slower decline in the CR when caregivers were adult children but not spouses.
For adult child caregivers, caregiver personality traits are associated with rate of cognitive decline in CRs with AD regardless of co-residency. Results suggest that dementia caregiver interventions promoting positive care management strategies and ways to react to caregiving challenges may eventually become an important complement to pharmacologic and other approaches aimed at slower rate of decline in dementia.
Recent manmade and natural disasters highlight weaknesses in the public health systems designed to protect populations from harm and minimize disruption of the social and built environments. Emergency planning and response efforts have, as a result, focused largely on ensuring populations' physical well-being during and after a disaster. Many public health authorities, including the World Health Organization, have recognized the importance of addressing both mental and physical health concerns in emergency plans. Individuals with mental disorders represent a notable proportion of the overall population, and anticipating their needs is critical to comprehensive emergency planning and response efforts. Because people with serious mental disorders historically have been stigmatized, and many individuals with mental disorders may be unable to care for themselves, ethical guidance may be of assistance to those engaged in emergency planning and response. This article considers several broad categories of ethical issues that arise during emergencies for people with serious mental disorders and offers recommendations for ways in which emergency planners and other stakeholders can begin to address these ethical challenges.
(Disaster Med Public Health Preparedness. 2012;6:72–78)
Background: To estimate the 12-month incidence, prevalence, and persistence of mental disorders among recently admitted assisted living (AL) residents and to describe the recognition and treatment of these disorders.
Methods: Two hundred recently admitted AL residents in 21 randomly selected AL facilities in Maryland received comprehensive physician-based cognitive and neuropsychiatric evaluations at baseline and 12 months later. An expert consensus panel adjudicated psychiatric diagnoses (using DSM-IV-TR criteria) and completeness of workup and treatment. Incidence, prevalence, and persistence were derived from the panel's assessment. Family and direct care staff recognition of mental disorders was also assessed.
Results: At baseline, three-quarters suffered from a cognitive disorder (56% dementia, 19% Cognitive Disorders Not Otherwise Specified) and 15% from an active non-cognitive mental disorder. Twelve-month incidence rates for dementia and non-cognitive psychiatric disorders were 17% and 3% respectively, and persistence rates were 89% and 41% respectively. Staff recognition rates for persistent dementias increased over the 12-month period but 25% of cases were still unrecognized at 12 months. Treatment was complete at 12 months for 71% of persistent dementia cases and 43% of persistent non-cognitive psychiatric disorder cases.
Conclusions: Individuals recently admitted to AL are at high risk for having or developing mental disorders and a high proportion of cases, both persistent and incident, go unrecognized or untreated. Routine dementia and psychiatric screening and reassessment should be considered a standard care practice. Further study is needed to determine the longitudinal impact of psychiatric care on resident outcomes and use of facility resources.
Background: Quality of life (QOL) is frequently assessed in persons with dementia (PWD) through self- and/or proxy-report. Determinants of QOL ratings are multidimensional and may differ between patients and caregiver proxies. This study compared self- and proxy-reported QOL ratings in a population-based study of PWD and their caregivers, and examined the extent to which discrepancies in reports were associated with characteristics of the PWD.
Methods: The sample consisted of 246 patient/caregiver dyads from the initial visit of the Cache County Dementia Progression Study, with both members of the dyad rating PWD QOL. PWD age, gender, cognitive impairment (Mini-Mental State Examination), neuropsychiatric symptoms (Neuropsychiatric Inventory; NPI), dementia severity (Clinical Dementia Rating), medical comorbidities (General Medical Health Rating), and functional impairment (Dementia Severity Rating Scale) were examined as correlates of self- and proxy-reported QOL ratings and the differences between the QOL reports.
Results: Self- and proxy-reported PWD QOL ratings were only modestly correlated. Medical comorbidity was associated with self-report whereas NPI was associated with proxy-report. Dementia severity was associated with discrepancies in self- and proxy-report, with worse patient cognition associated with poorer proxy-reported QOL ratings.
Conclusions: PWD self- and proxy-reported QOL ratings are associated with different variables. Discrepancies between PWD and caregiver perceptions of PWD QOL should be recognized, particularly in cases of more severe dementia.
Background: Approximately 25% of individuals with dementia live alone, yet little is known about the cognitive and functional factors that impact detection of impairment.
Methods: Subjects with dementia (n = 349) from a community study of dementia management were administered the Mini-mental State Examination (MMSE) and were asked to rate their cognitive status. Each participant's knowledgeable informant (KI) was interviewed to provide information about the subject's mental health and levels of cognitive and functional impairment. Subjects with dementia living alone (n = 97, 27.8%) were compared to subjects living with others (n = 252, 72.2%) regarding functional impairment, psychiatric symptoms, cognitive functioning, and dementia recognition.
Results: While subjects with dementia living alone had significantly fewer ADL impairments (p < 0.0001) and less cognitive impairment (p < 0.0001) than subjects with dementia who were living with others, nearly half of subjects living alone had two or more IADL impairments. Both knowledgeable informants (p < 0.001) and primary care physicians (p < 0.009) were less likely to detect dementia in subjects living alone, while 77.3% of subjects with dementia living alone rated their cognitive abilities as “good” or “a little worse”. Subjects with dementia living alone and those living with others had similar rates of psychosis (p = 0.2792) and depressive symptoms (p = 0.2076).
Conclusions: Lack of awareness of cognitive impairment by individuals with dementia living alone as well as their knowledgeable informants and physicians, combined with frequent functional impairment and psychiatric symptoms, heightens risk for adverse outcomes. These findings underscore the need for increased targeted screening for dementia and functional impairment among older persons living alone.
Background: Advanced dementia is characterized by severe cognitive and functional impairments that lead to almost total dependency in self-care. Neuropsychiatric symptoms (NPS) are common in advanced dementia, diminishing quality of life and increasing the care burden. The challenge for health care providers is to find safe and effective treatments. Non-pharmacological interventions offer the potential for safer alternatives to pharmacotherapy, but little is known about their efficacy. This review evaluates the published literature on non-pharmacological interventions for treating NPS in advanced dementia.
Methods: A literature search was undertaken to find non-pharmacological intervention studies published between 1998 and 2008 that measured NPS outcomes in individuals diagnosed with advanced dementia. Strict inclusion criteria initially required that all study participants have severe or very severe dementia, but this range was later broadened to include moderately severe to very severe stages.
Results: Out of 215 intervention studies, 21 (9.8%) specifically focused on treatments for individuals with moderately severe to very severe dementia. The studies provide limited moderate to high quality evidence for the use of sensory-focused strategies, including aroma, preferred or live music, and multi-sensory stimulation. Emotion-oriented approaches, such as simulated presence may be more effective for individuals with preserved verbal interactive capacity.
Conclusions: Most studies of interventions for dementia-related NPS have focused on individuals with mild to moderate cognitive impairment. Individuals with severe cognitive impairment do not necessarily respond to NPS treatments in the same manner. Future studies should be specifically designed to further explore the stage-specific efficacy of non-pharmacological therapies for patients with advanced dementia. Areas of particular need for further research include movement-based therapies, hands-on (touch) therapies, and interventions that can be provided during personal care routines. Interventions appear to work best when they are tailored to balance individual arousal patterns.
The importance of the neurotransmitter serotonin (5-HT) in the pathophysiology of anxiety is well known. A key role for postsynaptic 5-HT1A receptors has recently been suggested in studies of genetic knockout mice.
To measure 5-HT1A receptor binding in patients with panic disorder in the untreated state and after recovery on treatment with selective serotonin reuptake inhibitors (SSRIs).
Nine symptomatic untreated patients with panic disorder, seven patients recovered on SSRI medication and nineteen healthy volunteers underwent a single positron emission tomography (PET) scan using the 5-HT1A tracer [11C]WAY-100635.
In comparison with controls, both presynaptic and postsynaptic 5-HT1A receptor binding was reduced in untreated patients, with the most significant reductions being in the raphe, orbitofrontal cortex, temporal cortex and amygdala. In recovered patients presynaptic binding was reduced, but there was no significant reduction in postsynaptic binding.
Panic disorder is associated with reduced 5-HT1A receptor availability, which is also known to have a key role in depression.
Background: Dementia differs from other terminal illnesses both in its slow progression and the fact that patients and family members often do not perceive it as a cause of death. Furthermore, because decisional incapacity is almost universal in patients with advanced dementia, decisions must be made by surrogates. However, little is known about the factors that influence how surrogates make decisions for persons with late-stage dementia.
Methods: The setting was the first wave of a study of patients with advanced dementia in three Maryland nursing homes (The Care of Nursing Home Residents with Advanced Dementia Study). Of 125 consented participants, 123 residents and their surrogates provided adequate information and agreed to interviews and medical record reviews. Bivariate analysis and logistic regression models were used to explore whether variables related to demographics, illness, communication and surrogate background were associated with surrogate decisions to not provide aggressive treatments (i.e. hospitalization or surgery).
Results: Treatment decisions regarding aggressive medical care had been made by 81% of surrogates over the preceding 6 months. In bivariate analysis the following factors were significantly associated with not providing aggressive care: resident and surrogate of white race, older surrogate age, worse resident medical illness, worse surrogate perception of resident quality of life, presence of a ‘do not hospitalize’ order (DNH), and more contact with nurses. In the multivariate analysis, resident white race and presence of a DNH were significant predictors of surrogate decisions to not provide aggressive treatments. Treatment decisions were not associated with surrogate relationship or religiosity.
Conclusions: Treatment decisions for individuals with advanced dementia are mostly strongly associated with the patient's race and presence of DNH and less so with changeable features of illness or environment.
The choice of outcomes in clinical research should be influenced by a linkage between the targeted symptom or disorder and the outcome being measured, the clinical meaningfulness of the outcome, and the ability to measure the outcome accurately. Dementia, defined as a syndrome consisting of disorders that impair two or more distinct cognitive capacities, occur in clear consciousness, and begin in adulthood, presents unique challenges in the choice of appropriate outcomes for treatment trials.
Over the past twenty years, qualitative research has gained recognition as a useful approach to scientific inquiry on issues related to health and health care, including those of particular interest to psychogeriatrics. This is evidenced not only by the inclusion of health-related qualitative reports in exclusively qualitative publications but also by their acceptance in venues that have traditionally favored quantitative methods of investigation (Sandelowski, 2004). The increased number of these reports has also led in recent years to systematic reviews of qualitative studies and qualitative metasyntheses, metaethnography or meta-analyses (Nygard, 2004;Smith et al., 2005; Steeman et al., 2006).