FOCUS Current Issue

From the Guest Editors

Lavretsky H, Jeste D. — Fri, 01 Feb 2013 00:00:00 GMT

The current issue of FOCUS is dedicated to the field of Geriatric Psychiatry. Geriatric mental health research topics covered in this issue encompass the latest clinically relevant studies on successful aging (1) and the use of natural products and supplements for prevention of geriatric mood and cognitive disorders (2), as well as articles on novel preventive strategies for late-life depression (3) and suicide (4), and the topics of end-of-life care including dementia (5) and palliative care (6). The breadth of the topics is reflective of the breadth and depth of the field of geriatric mental health, which is charged with developing strategies for maintaining optimal mental and physical health and functioning in older adults.

Ask the Expert: Cognitive Decline

Walaszek A. — Fri, 01 Feb 2013 00:00:00 GMT

“What treatment options are available to address cognitive decline in a patient with Alzheimer’s disease?”

Ask the Expert: Inflammation and Aging

Lavretsky H. — Fri, 01 Feb 2013 00:00:00 GMT

An older woman with severe treatment-resistant depression has not responded to multiple antidepressant and augmentation trials or to ECT. She functions poorly on a daily basis and complains of insomnia, poor appetite, and a “brain fog,” or unclear thinking. In addition, she has had a history of breast cancer, currently in remission after chemotherapy, with subsequent development of fibromyalgia, rheumatoid arthritis, chronic fatigue, and chronic pain. Would the use of anti-inflammatory drugs be indicated for augmentation of her antidepressant treatment given a large number of comorbid inflammatory conditions?

Communication Commentary: Enhancing Communication With Aging Patients

Stubbe DE. — Fri, 01 Feb 2013 00:00:00 GMT

Depression in Late-Life: A Focus on Prevention

Okereke OI, Lyness JM, Lotrich FE, et al. — Fri, 01 Feb 2013 00:00:00 GMT

Depression is a leading cause of disease burden, disability, and distress for millions of older adults. Thus, prevention of late-life depression is a priority research area. This article addresses the science of late-life depression prevention with the following: 1) an introduction to the Institute of Medicine framework of universal, selective, and indicated prevention as it pertains to late-life depression, with particular attention to successes of indicated and selective prevention in primary care; 2) a discussion of how biomarkers can be integrated into prevention research, using interferon-alpha-induced depression as a model; 3) an outline for expansion of prevention to nonspecialist care delivery systems in low- and middle-income countries, thus extending the reach of current successful approaches; and 4) a description of a novel approach to simultaneous testing of universal, selective, and indicated prevention in late-life depression, with emphasis on study design features required to achieve practical, scalable tests of health impact.

Ethics Commentary: Ethical Issues in Geriatric Psychiatry

Dunn LB, Hauptman A. — Fri, 01 Feb 2013 00:00:00 GMT

By 2030, due to the aging of the baby boomers, the U.S. Census Bureau predicts that nearly one in five people will be 65 or older—a substantial increase from the 13% of the population that was 65 or older in 2010. This population of older adults is projected to have increased needs for mental health care, which the current workforce is inadequate to meet (1, 2). For example, by the year 2050, an estimated 13 million adults will suffer from Alzheimer’s disease (AD) (3). Many of these individuals will develop behavioral and psychological symptoms as their disease progresses. Depressive disorders remain underdetected in older adults, and despite years of attention to the issue of undertreatment of depression in the older adult population, this continues to be a problem (1, 4). Ongoing stigma about mental health treatment on the part of patients, as well as misconceptions and inadequate training regarding depression on the part of health care providers, likely contribute to the lack of identification and treatment of depressive disorders in older adults (5).

Palliative Care

Irwin SA. — Fri, 01 Feb 2013 00:00:00 GMT

Patient Management Exercise: Late-Life Psychiatry

Cook IA. — Fri, 01 Feb 2013 00:00:00 GMT

This exercise is designed to test your comprehension of material presented in this issue of FOCUS as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below, to the best of your ability, on the information provided, making your decisions as you would with a real-life patient.Questions are presented at “consideration points” that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections. You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. At the end of the exercise, you will add up your points to obtain a total score.

Successful Aging: Implications for Psychiatry

Depp CA, Martin A, Jeste DV. — Fri, 01 Feb 2013 00:00:00 GMT

Aging may be the number one public health issue facing the world today. With the growth in the aging population, there has been an expansion in initiatives and interventions to promote successful aging and to reduce disparities in attaining maximum healthy life expectancy. There will be a corresponding increase in absolute number of older adults who have mental illness, and there are a number of points of intersection between psychiatry and successful aging. We review recent research in defining successful aging in people with and without mental illnesses. We also highlight current literature on genetic, molecular, neurobiological, psychosocial, and social determinants of successful aging. Finally, we summarize the evidence for interventions that may increase the likelihood of successful aging, particularly physical activity and exercise, nutrition and diet, cognition and memory, and social and psychological interventions.

Suicide and Suicide Prevention in Later Life

Conwell Y. — Fri, 01 Feb 2013 00:00:00 GMT

In 2010, almost 6,000 adults over age 65 died by suicide in the United States, and perhaps 200,000 worldwide. Because older adults are the most rapidly growing segment of the population, the number of suicides in this age group is expected to rise dramatically in coming decades. Development of effective approaches to late-life suicide prevention is a major public health priority. However, older adults pose particular challenges to prevention because self-injurious acts in later life tend to be more immediately lethal and with fewer warning signs than at earlier points in the life course. Research has delineated risk and protective factors in five domains: psychiatric illness (primarily mood disorders), personality and coping style, physical illnesses, social stressors and supports, and functional impairments. Research findings also indicate that primary care and other community-based health and human service settings are best suited to intervention implementation. Late-life suicide preventive interventions can be categorized as indicated (targeting high-risk individuals), selective (for individuals or groups with more distal risk factors), or universal (targeting a population) prevention approaches. Relatively few studies of preventive interventions that specifically target suicidal ideation, attempts, or completed suicide have been conducted in this age group. Available findings suggest that rates of suicidal ideation and behavior may be reduced by a variety of approaches. However, older women have been more responsive overall to preventive interventions than elderly men, the group at highest risk. Challenges remain to reducing suicide-related morbidity and mortality in later life.

The Role of Antipsychotic Drugs in the Treatment of Neuropsychiatric Symptoms of Dementia

Keenmon C, Sultzer D. — Fri, 01 Feb 2013 00:00:00 GMT

Patients with dementia frequently experience comorbid behavioral and psychiatric symptoms, also known as neuropsychiatric symptoms of dementia. Neuropsychiatric symptoms are harmful to both patients and their caregivers, and contribute to the high healthcare costs associated with Alzheimer’s dementia. Since the discovery of neuroleptic medications in the 1950s, antipsychotic medications have been the preferred drug option for the treatment of behavioral and psychiatric symptoms of dementia. Despite their frequent use in the past, there is limited evidence to support the efficacy of first-generation antipsychotics in this population. Second-generation antipsychotics may be modestly helpful for reducing global neuropsychiatric symptoms, psychosis, and agitation/aggression in demented older adults. However, second-generation antipsychotics are associated with potentially serious adverse reactions in elderly adults, which may undermine the potential benefits. In clinical practice, second-generation antipsychotics are prescribed for demented patients with distressing or dangerous behavioral disturbances that fail to respond adequately to nonpharmacological approaches. The decision to utilize an antipsychotic requires thoughtful consideration of the potential risks and benefits for the individual patient.

The Use of Natural Products and Supplements in Late-Life Mood and Cognitive Disorders

Varteresian TC, Merrill DA, Lavretsky H. — Fri, 01 Feb 2013 00:00:00 GMT

Natural products and supplements are widely and increasingly used by the aging population for mood and cognitive symptoms. Evidence suggests that some supplements may be effective at treating a range of mood and cognitive symptoms. There is growing use of complementary and alternative medicine in the treatment of mental disorders because they may be seen as “safer” than traditional drugs, and because patients with mental disorders frequently use complementary and alternative medicine. We review the existing limited evidence of the efficacy and safety of natural products and supplements that are being used for treatment of mental disorders. More rigorous studies in the area of holistic and integrative treatment and preventive approaches for late-life mood and cognitive disorders are urgently needed.

A Systematic Review of Treatments for Refractory Depression in Older People

Cooper C, Katona C, Lyketsos K, et al. — Fri, 01 Feb 2013 00:00:00 GMT

Objective

The authors systematically reviewed the management of treatment-refractory depression in older people (defined as age 55 or older).

Method

The authors conducted an electronic database search and reviewed the 14 articles that fit predetermined criteria. Refractory depression was defined as failure to respond to at least one course of treatment for depression during the current illness episode. The authors rated the validity of studies using a standard checklist and calculated the pooled proportion of response to any treatment reported by at least three studies.

Results

All the studies that met inclusion criteria investigated pharmacological treatment. Most were open-label studies, and the authors found no double-blind randomized placebo-controlled trials. The overall response rate for all active treatments investigated was 52% (95% CI=42–62; N=381). Only lithium augmentation was assessed in more than two trials, and the response rate was 42% (95% CI=21–65; N=57). Only two studies included comparison groups receiving no additional treatment, and none of the participants in these groups responded. In single randomized studies, extended-release venlafaxine was more efficacious than paroxetine, lithium augmentation more than phenelzine, and selegiline more than placebo.

Conclusions

Half of the participants responded to pharmacological treatments, indicating the importance of managing treatment-refractory depression actively in older people. The only treatment for which there was replicated evidence was lithium augmentation. Double-blind randomized controlled trials for management of treatment-refractory depression in older people, encompassing pharmacological and nonpharmacological therapies and populations that reflect the levels of physical and cognitive impairment present in the general older population with depression, are needed.(Reprinted with permission from The American Journal of Psychiatry 2011; 168:681–688)

Abstracts: Geriatric Psychiatry

Fri, 01 Feb 2013 00:00:00 GMT

Bibliography: Geriatric Psychiatry

Fri, 01 Feb 2013 00:00:00 GMT

This section contains a compilation of recent publications that have shaped the thinking in the field as well as classic works that remain important to the subject reviewed in this issue. This bibliography has been compiled by experts in the field and members of the editorial and advisory boards. Entries are listed chronologically and within years by first author. Articles from the bibliography that are reprinted in this issue are in bold type.

Meta-Analysis of Nonpharmacological Interventions for Neuropsychiatric Symptoms of Dementia

Brodaty H, Arasaratnam C. — Fri, 01 Feb 2013 00:00:00 GMT

Objective

Behavioral and psychological symptoms are common in dementia, and they are especially stressful for family caregivers. Nonpharmacological (or psychosocial) interventions have been shown to be effective in managing behavioral and psychological symptoms, but mainly in institutional settings. The authors reviewed the effectiveness of community-based nonpharmacological interventions delivered through family caregivers.

Method

Of 1,665 articles identified in a literature search, 23 included unique randomized or pseudorandomized nonpharmacological interventions with family caregivers and outcomes related to the frequency or severity of behavioral and psychological symptoms of dementia, caregiver reactions to these symptoms, or caregiver distress attributed to these symptoms. Studies were rated according to an evidence hierarchy for intervention research.

Results

Nonpharmacological interventions were effective in reducing behavioral and psychological symptoms, with an overall effect size of 0.34 (95% CI= 0.20–0.48; z=4.87; p<0.01), as well as in ameliorating caregiver reactions to these behaviors, with an overall effect size of 0.15 (95% CI=0.04–0.26; z=2.76; p=0.006).

Conclusions

Nonpharmacological interventions delivered by family caregivers have the potential to reduce the frequency and severity of behavioral and psychological symptoms of dementia, with effect sizes at least equaling those of pharmacotherapy, as well as to reduce caregivers’ adverse reactions. The successful interventions identified included approximately nine to 12 sessions tailored to the needs of the person with dementia and the caregiver and were delivered individually in the home using multiple components over 3–6 months with periodic follow-up.(Reprinted with permission from The American Journal of Psychiatry 2012;169:946–953)

Research Advances in Geriatric Depression

Alexopoulos GS, Kelly RE, Jr.. — Fri, 01 Feb 2013 00:00:00 GMT

Technical advances have facilitated the exploration of factors related to geriatric depression and have helped generate novel biological and psychosocial treatment approaches. This review summarizes the main advancements in epidemiology, clinical presentation and course, genetics, and other areas of biological research. Treatment interventions outlined in this paper include electroconvulsive therapy, repetitive transcranial magnetic stimulation, magnetic seizure therapy, vagus nerve stimulation, deep brain stimulation, depression prophylaxis, multidisciplinary approaches to depression treatment, and psychotherapy. Forms of psychotherapy for geriatric depression summarized include interpersonal psychotherapy, supportive psychotherapy, cognitive-behavioral therapy, problem-solving therapy, and ecosystem-focused therapy. Neuroimaging techniques based on magnetic resonance imaging are discussed briefly, including volumetric brain studies, diffusion tensor imaging, fractional anisotropy, fiber tractography, magnetization transfer imaging, and blood-oxygenation-level-dependent functional magnetic resonance imaging. Finally, treatment effectiveness is addressed in a discussion of new models to improve access to and quality of care offered in the community.(Reprinted with permission from World Psychiatry, 2009; 8:140–149)

The Diagnosis of Mild Cognitive Impairment due to Alzheimer’s Disease: Recommendations from the National Institute on Aging-Alzheimer’s Association Workgroups on Diagnostic Guidelines for Alzheimer’s Disease

Albert MS, DeKosky ST, Dickson D, et al. — Fri, 01 Feb 2013 00:00:00 GMT

The National Institute on Aging and the Alzheimer’s Association charged a workgroup with the task of developing criteria for the symptomatic predementia phase of Alzheimer’s disease (AD), referred to in this article as mild cognitive impairment due to AD. The workgroup developed the following two sets of criteria: (1) core clinical criteria that could be used by healthcare providers without access to advanced imaging techniques or cerebrospinal fluid analysis, and (2) research criteria that could be used in clinical research settings, including clinical trials. The second set of criteria incorporate the use of biomarkers based on imaging and cerebrospinal fluid measures. The final set of criteria for mild cognitive impairment due to AD has four levels of certainty, depending on the presence and nature of the biomarker findings. Considerable work is needed to validate the criteria that use biomarkers and to standardize biomarker analysis for use in community settings.(Reprinted with permission from Alzheimers Dement 2011;7(3):270–279)

Erratum

Fri, 01 Feb 2013 00:00:00 GMT

In the quiz for the Depression and Dysthymia issue (Fall 2012), the correct response to question 1 should have been “D. All of the above.” This has been corrected in the online edition of the issue.