As care for individuals needing long-term services and supports has shifted from institutional se... more As care for individuals needing long-term services and supports has shifted from institutional settings to home- and community-based services (HCBS), caring for people with serious mental illness has become a significant challenge. Oregon has a long history of using community-based care (CBC) to serve all populations needing supports. This article outlines Oregon\u27s use of CBC and how those services apply to individuals with serious mental illness; it also addresses the financial and health related issues facing family caregivers, who themselves often are of advanced age
Dementia, now known as major neurocognitive disorder (MNCD), is conceptualized as a cognitive dis... more Dementia, now known as major neurocognitive disorder (MNCD), is conceptualized as a cognitive disorder with concomitant functional impairment. Behavioral disturbance is briefly mentioned in the 2013 update to the American Psychiatric Association Diagnostic and Statistical Manual. Neuropsychiatric symptoms (NPS) should be considered essential to the diagnosis, assessment, and clinical management of those with MNCD. It is the NPS that most impair quality of life for those with dementia as well as their families and caregivers. NPS are one of the main reasons people with dementia must leave their homes and enter institutional settings. This chapter reviews the syndrome of dementia, its nature as a cognitive, behavioral, and functional disorder, and its impact on individuals. Communication can be challenging for those with dementia, and often language abilities are impaired. Some of what is referred to as behaviors related to dementia is a form of nonverbal communication. Understanding behavior as communication is required to care for those with these life-limiting diseases such as dementia.
Major neurocognitive disorders cause complex challenges for the people diagnosed with them as wel... more Major neurocognitive disorders cause complex challenges for the people diagnosed with them as well as those who care for them and about them. To fully support a person as they move through the trajectory of their disease, comprehensive care requires the most interdisciplinary integration possible. Evidence supports the use of an interdisciplinary team where possible especially for those with the most complex needs. This chapter explores advantages and disadvantages of different models of team care in the context of caring for someone with significant multimorbid disease which affects many different areas of brain functioning including neuropsychiatric symptoms. Specific communication tools that may be helpful to the interdisciplinary team are also reviewed.
translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microf... more translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.
The American Journal of Geriatric Psychiatry, 2015
A 2012 update of the Beers criteria categorizes selective serotonin reuptake inhibitors (SSRIs) a... more A 2012 update of the Beers criteria categorizes selective serotonin reuptake inhibitors (SSRIs) as potentially inappropriate medications in all older adults based on fall risk. The application of these recommendations, not only to frail nursing home residents, but also to all older adults, may lead to changes in health policy or clinical practice with harmful consequences. A systematic review of studies on the association between SSRIs and falls in older adults was conducted to examine the evidence for causation. Twenty-six studies met the inclusion criteria. The majority of studies were observational and suggest an association between SSRIs and falls. The direction of the relationship-causation or effect-cannot be discerned from this type of study. Standardized techniques for determining likely causation were then used to see if there was support for the hypothesis that SSRI's lead to falls. This analysis did not suggest causation was likely. There is no Level 1 evidence that SSRIs cause falls. Therefore, changes in the current treatment guidelines or policies on the use of SSRIs in older adults based on fall risk may not be justified at this time given the lack of an established evidence base. Given its significance to public health, welldesigned experimental studies are required to address this question definitively.
Assisting professionals to care for those with major neurocognitive disorders (MNCD), including t... more Assisting professionals to care for those with major neurocognitive disorders (MNCD), including the inevitable neuropsychiatric symptoms, using the person-centered philosophy is the goal of this text. After a review of the history of person-centered care planning, a model to assess/evaluate a person’s behavioral communications is presented. The viewpoint for all care starts with a strength-based assessment of the person living with dementia. The framework makes use of the supported decision-making paradigm. After assessment, there is a review about choosing and applying person-centered interventions using regular monitoring of outcomes.
successes?What problems have we faced?How have they impacted our work and our directions?To what ... more successes?What problems have we faced?How have they impacted our work and our directions?To what extent have we overcome them? A futuristic view of geriatric psychiatry:We are now a middle-aged organization.We have gone through significant growth spurts, & also have endured setbacks.Newer organizations have assumed roles that once were exclusively ours. We must ask ourselves:Is AAGP still relevant?If so, we are what are our unique contributions, organization's future projects & goals? How can we best integrate our training, knowledge and experience into the evolving directions of society?What will clinical, research and teaching in geriatric psychiatry look like in forty years?How can we best prepare for the future?I will conclude with hypotheses on the activities of geriatric psychiatrists at the time of AAGP's 80th birthday. Bio: Dr. Finkel is currently a Clinical Profeesor of Psychiatry at the University of Chicago Medical School. Previously, he was a Professor of Psychiatry at Northwestern University Medical School with Secondary Professorial appointments in the Departments of Neurology and Internal Medicine. As the Founder of AAGP, co-Founder of the American Psychiatric Association's Council on Aging as well as the International Psychogeriatric Association.I have been privileged to witness and contribute to the birth, growth and development of our field. Our members have shared many successes, experienced many problems, and, nevertheless, are poised to participate in an exciting and worthwhile future. A praciticing clinician and teacher of geriatric psychiatry for fifty years, he continues to be active in his field, innovating in a range of areas, including Behavior and Psychological Symptoms of Dementia, the use of telephone technology for caregivers, testmanetary capacity and undue influence issues, the use of computers for memory training, agitation in nursing homes, and capitation for dually eligibel elderly.
Introduction -- Background of Dementia as a leading health concern -- History of treatment and as... more Introduction -- Background of Dementia as a leading health concern -- History of treatment and assessment -- Defining roles and scope of practice -- Recommendation for communication, documentation -- Diagnostic criteria for NCD -- Review DSM 5 Cognitive Domains -- Review Assessments -- Review functional cognition and task performance -- Delirium -- Frontotemporal Dementia Variants -- Alzheimer’s Disease -- Strokes and other Vascular injuries -- Parkinson’s/ Parkinson’s Plus -- Huntington’s.
Journal of the American Medical Directors Association, 2020
We appreciate the attention Drs Kale, Gitlin, and Lyketsos bring to CMS's singular focus on antip... more We appreciate the attention Drs Kale, Gitlin, and Lyketsos bring to CMS's singular focus on antipsychotic use in those long-term care (LTC) residents with dementia and behavior disturbance. As the authors point out, these universal behaviors are themselves associated with poor health outcomes including mortality, injury to peers and staff, and other undesirable outcomes. We agree with their premise: the focus on this 1 class of medication without assessing the resident and the entire situation is both misguided and leads to the use of less effective, more risky, and less evidencebased interventions. The focus on antipsychotic rates distracts from the imperative to implement comprehensive person-centered care for this group of disabled older adults. 1 All behavior contains communication. For those with dementia, behavior may be the only way they have to communicate. However, there is 1 crucial factor that was not considered. Alzheimer's disease (AD) is a progressive, life-limiting, fatal illness. The vignette to start the article is notable for describing an 88-year-old man with advanced AD residing in LTC who has a history of falls and new agitated behaviors. Without knowing any more, we can predict he is likely nearing the end of his life. 2,3 There is no mention of considering palliative care nor looking at the behavior disturbance through that lens. 1,4,5 The behavior disturbance could be the person communicating the beginning of terminal delirium as well as many other things. We realize that this is not the goal of the article, but a significant gap exists in discussing and interpreting behavioral disturbance in those with dementia when one does not place this in the context of treating those with a terminal life-limiting disease. The entire discussion around risks and benefits of treatment as well as the overall goals of care of the person is incomplete without the palliative lens. The most likely reason that comprehensive training of caregivers has the highest efficacy of all behavioral interventions in those with dementia and behavior disturbance is likely due to the nature of dementia itself. As the disease progresses, people with dementia lose cognitive and functional abilities, including the ability to learn and adapt their behavior. Those with dementia also lose the ability to use language to communicate and understand language from others. Caregivers do not have these limitations and retain the ability to assess, intervene and monitor interventions. 1
The American Journal of Geriatric Psychiatry, 2018
The practice of geriatric psychiatrists during this period of rapid changes in requirement, regul... more The practice of geriatric psychiatrists during this period of rapid changes in requirement, regulation and reimbursement in our United States health care system have become more challenging. With the low reimbursement from Medicare and Medicaid systems make it difficult for geriatric psychiatrist to have financially viable practice in this setting. During this session, we will review the different models of geriatric psychiatry practice in Long-term care setting including traditional consultation by geriatric psychiatrist with and without the collaboration of the nurse practitioners with the focus on the logistic and reimbursement to maintain a thriving practice. We will discuss the current trend in moving toward the integration of population health practice in Long-Term Care setting including discussion of programs such as All Inclusive Care for the Elderly (PACE) program and Project ECHO, which is a model of consultation to a collective of organizations caring for similar populations. We will explore the use of Collaborative Care model in this setting. We will also discuss the use of Telemedicine in providing the care to this population.
The prevalence of persistent pain is high in older adults, and undertreated pain is disproportion... more The prevalence of persistent pain is high in older adults, and undertreated pain is disproportionately elevated in older adults with neurocognitive disorders (NCDs). This chapter will explore the concept of pain and how it may be expressed differently in an individual suffering from an NCD.
The American Journal of Geriatric Psychiatry, 2019
When an adult is thought to be making poor decisions or is unable to care for him or herself, man... more When an adult is thought to be making poor decisions or is unable to care for him or herself, many people assume that a guardianship is necessary to secure that person's well being. An older adult may require a guardian because of a new inability to care for themselves in the contest of a neurocognitive disorder, or after a lifetime of chronic mental illness, and self-neglect. The appointment of a guardian by the court can be lifesaving, provide much needed financial protection from exploitation, and guarantee stable housing and access to health care. However, a guardianship may also leave older adults vulnerable to abuse and financial exploitation. In many cases, the needs of older adults are layered and complex, and guardianship is not necessarily the best remedy, especially when the court-appointed guardians may be responsible for hundreds of clients.
The American Journal of Geriatric Psychiatry, 2019
Opportunities for professional development and mentorship are vital for junior and mid-level facu... more Opportunities for professional development and mentorship are vital for junior and mid-level faculty members to succeed in academic medicine. Too often, those opportunities are of short supply at institutions. In this special 2-hour, interactive workshop affiliated with the Teaching and Training Committee, learners will be exposed to several areas of professional development. Dr. Brandon Yarns and Dr. Alessandra Scalmati will build on their presentations from last year and discuss implementation and evaluation of a freshly developed curricula, focusing on choosing appropriate educational strategies and describing various designs for assessment and evaluation. Finally, barriers to introducing new curricula and tips about dissemination of the curricula will be discussed. Learners will also have a chance to practice what they learned. Dr. Dennis Popeo and Dr. Elizabeth (EJ) Santos will discuss helpful hints for junior faculty members. Dr. Popeo will specifically discuss things that he "wished he knew way back when" about career planning, negotiation and work-life balance. Dr. Santos will discuss networking − something that unnerves many people − and graceful self-promotion. Faculty Disclosures Alessandra Scalmati Nothing to disclose Brandon Yarns Nothing to disclose
The American Journal of Geriatric Psychiatry, 2013
CMS and the state surveyors who implement federal regulations on a state by state level have been... more CMS and the state surveyors who implement federal regulations on a state by state level have been shaping clinician behavior in the use of psychotropic medications in those people living in Nursing Homes and other supervised settings (for example OBRA regulations and GDR gradual dose reduction madates. Recently, the use of antipsychotic medications in older adults with dementia has come under increasing pressure due to concerns for risks, and possibly, underappreciation of benefits. This session will cover the history and rationale for these regulations followed by a debate on the merits of using psychotropic medications in this vulnerable population. The debators are 2 experienced clinicians who have both been practicing geriatric psychiatry for more than 20 years. All data used for the debate will be shared and agreed upon by both presentors prior to the debate so that they may cite the same evidence in support of their positions. Faculty Disclosures: David Greenspan, MD Nothing to disclose Maureen C. Nash, MD, MS Nothing to disclose Larry E. Tune, MD Nothing to disclose COGNITION AND MOOD DISORDER: IS THERE A CONNECTION TO NEURODEGENERATION AND COGNITIVE DECLINE? Jovier D. Evans, PhD; Helen Lavretsky, MD; Ruth O’Hara, PhD; Ariel Gildengers, MD NIMH, Bethesda, MD University of California, Los Angeles, Los Angeles, CA Stanford University, Palo Alto, CA University of Pittsburgh, Pittsburgh, PA Abstract: The examination of cognitive trajectories in older adults with mental disorder is a primary target of examination for the National Institute of Mental Health (NIMH). The focus on cognition and its consequences in late life will be the focus of this symposium. Experts in the field of cognitive psychology and geriatric psychiatry will examine the role of cognitive impairments in relationship to late life affective disorder. Speakers will highlight current work in the following areas: 1) The interaction of sleep disturbances, APOE, and cognitive dysfunction in late life depression. 2) The results of a randomized clinical trial examining the effectiveness of methylphenidate augmentation of citalopram on both cognitive and affective symptoms among older adults with depression. And 3) Long term effects of lithium treatment on amyloid deposition in older adults with bipolar disorder. This will be followed by a discussion of NIMH efforts to foster and develop this area of research. The examination of cognitive trajectories in older adults with mental disorder is a primary target of examination for the National Institute of Mental Health (NIMH). The focus on cognition and its consequences in late life will be the focus of this symposium. Experts in the field of cognitive psychology and geriatric psychiatry will examine the role of cognitive impairments in relationship to late life affective disorder. Speakers will highlight current work in the following areas: 1) The interaction of sleep disturbances, APOE, and cognitive dysfunction in late life depression. 2) The results of a randomized clinical trial examining the effectiveness of methylphenidate augmentation of citalopram on both cognitive and affective symptoms among older adults with depression. And 3) Long term effects of lithium treatment on amyloid deposition in older adults with bipolar disorder. This will be followed by a discussion of NIMH efforts to foster and develop this area of research. S8 Am J Geriatr Psychiatry 21:3, Supplement 1 2013 AAGP Annual Meeting Faculty Disclosures: Jovier D. Evans, PhD Nothing to disclose Ariel Gildengers, MD Nothing to disclose Helen Lavretsky, MD Research Support: Forest Research Insitute Research grants Consultant: Lilly Consultant fee Consultant: Dey Pharma Consultant fee Ruth O’Hara, PhD Nothing to disclose CULTURAL PERSPECTIVES ON UNDERSTANDING DEMENTIA AND ASSOCIATED CAREGIVING Helen H. Kyomen, MD; Rika Suzuki, MD; Maria Llorente, MD; Rita Hargrave, MD Kaiser Permanante, Honolulu, HI Washington D.C. VA Medical Center, Washington, DC Martinez VA Outpatient Mental Health Clinic, Martinez, CA Harvard Medical School, Boston, MA North Shore Medical Center, Partners Healthcare, Salem, MA Abstract: There are compelling reasons to examine cultural issues in dementia, including the understanding of dementia and impact on caregivers. Cultural beliefs may affect the explanations given by different groups as to the etiology of dementia, recognition of symptoms, and help seeking behaviors. For example folk beliefs about dementi, as compared to biomedical beliefs, may lead to the beliefs such as dementia is a normal part of aging, or a punishment from god, and therefore not amenable to any medical intervention. Further culture may affect concepts of caregiving obligations to elders suffering from dementia, and how burdensome the demands of caregiving may be experienced by spouses and children of people suffering from dementia. Culture and minority status may affect seeking of help from family and professional resources, and…
The American Journal of Geriatric Psychiatry, 2014
Family caregivers face many challenges in caring for an older relative with cognitive, physical o... more Family caregivers face many challenges in caring for an older relative with cognitive, physical or emotional challenges. In this session three experienced geriatric psychiatrists will describe what they've learned from observing and assessing older relatives, trying to get them to agree to help, arranging that help, and monitoring the situation with adjustments to the plan as needed.
The American Journal of Geriatric Psychiatry, 2015
Schizophrenia is a lifelong illness that typically requires maintenance antipsychotic treatment o... more Schizophrenia is a lifelong illness that typically requires maintenance antipsychotic treatment over a patient's life span. Older age, however, is a risk factor for antipsychotic-induced side effects, including parkinsonism, tardive dyskinesia, falls, and metabolic syndrome to which patients with schizophrenia become more vulnerable with age. Additionally, antipsychotics may have a deleterious effect on cognition that is already compromised in patient with schizophrenia in late-life. Consensus guideline recommends the use of lower doses of antipsychotics in patients with schizophrenia in late-life. However, empirical data, combining neuroimaging, clinical and cognitive outcomes on age-specific antipsychotic dosing are limited, leaving clinicians with no clear guidance to adjust the dose of antipsychotics as patients get older. We will present data from one study funded by the US National Institute of Mental Health and the Canadian Institute of Health Research. This study was aimed to determine the therapeutic threshold of the dopamine D2 receptors occupancy by antipsychotics in clinically stable older patients with early-onset schizophrenia chronically maintained on risperidone or olanzapine for at least 12 months. The patients had gradual dose-reduction of up to 40% of the baseline dose. Dopamine D2 receptors occupancy by antipsychotics, measured by [11C]-Raclopride Positron Emission Tomography, was determined at baseline and after completion of dose-reduction. Clinical and cognitive assessments were performed before and after dose-reduction and were related to the dopamine D2 receptors occupancy data. The study is unique in comparing clinical and cognitive outcomes, before and after antipsychotic's dose-reduction, to determine the impact of the dopamine D2 receptors occupancy in treatment response. We will (1) review the rationale and design of our antipsychotic dose-reduction study in schizophrenia in late-life; (2) present the dopamine D2 receptors occupancy (neuroimaging) and clinical data of older patients with schizophrenia before and after antipsychotic dose-reduction; (3) present the cognition data and the relationship with neuroimaging data; and (4) will discuss the practical translation of the neuroimaging, clinical and cognitive data to the bedside care of older patients with schizophrenia.
As care for individuals needing long-term services and supports has shifted from institutional se... more As care for individuals needing long-term services and supports has shifted from institutional settings to home- and community-based services (HCBS), caring for people with serious mental illness has become a significant challenge. Oregon has a long history of using community-based care (CBC) to serve all populations needing supports. This article outlines Oregon\u27s use of CBC and how those services apply to individuals with serious mental illness; it also addresses the financial and health related issues facing family caregivers, who themselves often are of advanced age
Dementia, now known as major neurocognitive disorder (MNCD), is conceptualized as a cognitive dis... more Dementia, now known as major neurocognitive disorder (MNCD), is conceptualized as a cognitive disorder with concomitant functional impairment. Behavioral disturbance is briefly mentioned in the 2013 update to the American Psychiatric Association Diagnostic and Statistical Manual. Neuropsychiatric symptoms (NPS) should be considered essential to the diagnosis, assessment, and clinical management of those with MNCD. It is the NPS that most impair quality of life for those with dementia as well as their families and caregivers. NPS are one of the main reasons people with dementia must leave their homes and enter institutional settings. This chapter reviews the syndrome of dementia, its nature as a cognitive, behavioral, and functional disorder, and its impact on individuals. Communication can be challenging for those with dementia, and often language abilities are impaired. Some of what is referred to as behaviors related to dementia is a form of nonverbal communication. Understanding behavior as communication is required to care for those with these life-limiting diseases such as dementia.
Major neurocognitive disorders cause complex challenges for the people diagnosed with them as wel... more Major neurocognitive disorders cause complex challenges for the people diagnosed with them as well as those who care for them and about them. To fully support a person as they move through the trajectory of their disease, comprehensive care requires the most interdisciplinary integration possible. Evidence supports the use of an interdisciplinary team where possible especially for those with the most complex needs. This chapter explores advantages and disadvantages of different models of team care in the context of caring for someone with significant multimorbid disease which affects many different areas of brain functioning including neuropsychiatric symptoms. Specific communication tools that may be helpful to the interdisciplinary team are also reviewed.
translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microf... more translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.
The American Journal of Geriatric Psychiatry, 2015
A 2012 update of the Beers criteria categorizes selective serotonin reuptake inhibitors (SSRIs) a... more A 2012 update of the Beers criteria categorizes selective serotonin reuptake inhibitors (SSRIs) as potentially inappropriate medications in all older adults based on fall risk. The application of these recommendations, not only to frail nursing home residents, but also to all older adults, may lead to changes in health policy or clinical practice with harmful consequences. A systematic review of studies on the association between SSRIs and falls in older adults was conducted to examine the evidence for causation. Twenty-six studies met the inclusion criteria. The majority of studies were observational and suggest an association between SSRIs and falls. The direction of the relationship-causation or effect-cannot be discerned from this type of study. Standardized techniques for determining likely causation were then used to see if there was support for the hypothesis that SSRI's lead to falls. This analysis did not suggest causation was likely. There is no Level 1 evidence that SSRIs cause falls. Therefore, changes in the current treatment guidelines or policies on the use of SSRIs in older adults based on fall risk may not be justified at this time given the lack of an established evidence base. Given its significance to public health, welldesigned experimental studies are required to address this question definitively.
Assisting professionals to care for those with major neurocognitive disorders (MNCD), including t... more Assisting professionals to care for those with major neurocognitive disorders (MNCD), including the inevitable neuropsychiatric symptoms, using the person-centered philosophy is the goal of this text. After a review of the history of person-centered care planning, a model to assess/evaluate a person’s behavioral communications is presented. The viewpoint for all care starts with a strength-based assessment of the person living with dementia. The framework makes use of the supported decision-making paradigm. After assessment, there is a review about choosing and applying person-centered interventions using regular monitoring of outcomes.
successes?What problems have we faced?How have they impacted our work and our directions?To what ... more successes?What problems have we faced?How have they impacted our work and our directions?To what extent have we overcome them? A futuristic view of geriatric psychiatry:We are now a middle-aged organization.We have gone through significant growth spurts, & also have endured setbacks.Newer organizations have assumed roles that once were exclusively ours. We must ask ourselves:Is AAGP still relevant?If so, we are what are our unique contributions, organization's future projects & goals? How can we best integrate our training, knowledge and experience into the evolving directions of society?What will clinical, research and teaching in geriatric psychiatry look like in forty years?How can we best prepare for the future?I will conclude with hypotheses on the activities of geriatric psychiatrists at the time of AAGP's 80th birthday. Bio: Dr. Finkel is currently a Clinical Profeesor of Psychiatry at the University of Chicago Medical School. Previously, he was a Professor of Psychiatry at Northwestern University Medical School with Secondary Professorial appointments in the Departments of Neurology and Internal Medicine. As the Founder of AAGP, co-Founder of the American Psychiatric Association's Council on Aging as well as the International Psychogeriatric Association.I have been privileged to witness and contribute to the birth, growth and development of our field. Our members have shared many successes, experienced many problems, and, nevertheless, are poised to participate in an exciting and worthwhile future. A praciticing clinician and teacher of geriatric psychiatry for fifty years, he continues to be active in his field, innovating in a range of areas, including Behavior and Psychological Symptoms of Dementia, the use of telephone technology for caregivers, testmanetary capacity and undue influence issues, the use of computers for memory training, agitation in nursing homes, and capitation for dually eligibel elderly.
Introduction -- Background of Dementia as a leading health concern -- History of treatment and as... more Introduction -- Background of Dementia as a leading health concern -- History of treatment and assessment -- Defining roles and scope of practice -- Recommendation for communication, documentation -- Diagnostic criteria for NCD -- Review DSM 5 Cognitive Domains -- Review Assessments -- Review functional cognition and task performance -- Delirium -- Frontotemporal Dementia Variants -- Alzheimer’s Disease -- Strokes and other Vascular injuries -- Parkinson’s/ Parkinson’s Plus -- Huntington’s.
Journal of the American Medical Directors Association, 2020
We appreciate the attention Drs Kale, Gitlin, and Lyketsos bring to CMS's singular focus on antip... more We appreciate the attention Drs Kale, Gitlin, and Lyketsos bring to CMS's singular focus on antipsychotic use in those long-term care (LTC) residents with dementia and behavior disturbance. As the authors point out, these universal behaviors are themselves associated with poor health outcomes including mortality, injury to peers and staff, and other undesirable outcomes. We agree with their premise: the focus on this 1 class of medication without assessing the resident and the entire situation is both misguided and leads to the use of less effective, more risky, and less evidencebased interventions. The focus on antipsychotic rates distracts from the imperative to implement comprehensive person-centered care for this group of disabled older adults. 1 All behavior contains communication. For those with dementia, behavior may be the only way they have to communicate. However, there is 1 crucial factor that was not considered. Alzheimer's disease (AD) is a progressive, life-limiting, fatal illness. The vignette to start the article is notable for describing an 88-year-old man with advanced AD residing in LTC who has a history of falls and new agitated behaviors. Without knowing any more, we can predict he is likely nearing the end of his life. 2,3 There is no mention of considering palliative care nor looking at the behavior disturbance through that lens. 1,4,5 The behavior disturbance could be the person communicating the beginning of terminal delirium as well as many other things. We realize that this is not the goal of the article, but a significant gap exists in discussing and interpreting behavioral disturbance in those with dementia when one does not place this in the context of treating those with a terminal life-limiting disease. The entire discussion around risks and benefits of treatment as well as the overall goals of care of the person is incomplete without the palliative lens. The most likely reason that comprehensive training of caregivers has the highest efficacy of all behavioral interventions in those with dementia and behavior disturbance is likely due to the nature of dementia itself. As the disease progresses, people with dementia lose cognitive and functional abilities, including the ability to learn and adapt their behavior. Those with dementia also lose the ability to use language to communicate and understand language from others. Caregivers do not have these limitations and retain the ability to assess, intervene and monitor interventions. 1
The American Journal of Geriatric Psychiatry, 2018
The practice of geriatric psychiatrists during this period of rapid changes in requirement, regul... more The practice of geriatric psychiatrists during this period of rapid changes in requirement, regulation and reimbursement in our United States health care system have become more challenging. With the low reimbursement from Medicare and Medicaid systems make it difficult for geriatric psychiatrist to have financially viable practice in this setting. During this session, we will review the different models of geriatric psychiatry practice in Long-term care setting including traditional consultation by geriatric psychiatrist with and without the collaboration of the nurse practitioners with the focus on the logistic and reimbursement to maintain a thriving practice. We will discuss the current trend in moving toward the integration of population health practice in Long-Term Care setting including discussion of programs such as All Inclusive Care for the Elderly (PACE) program and Project ECHO, which is a model of consultation to a collective of organizations caring for similar populations. We will explore the use of Collaborative Care model in this setting. We will also discuss the use of Telemedicine in providing the care to this population.
The prevalence of persistent pain is high in older adults, and undertreated pain is disproportion... more The prevalence of persistent pain is high in older adults, and undertreated pain is disproportionately elevated in older adults with neurocognitive disorders (NCDs). This chapter will explore the concept of pain and how it may be expressed differently in an individual suffering from an NCD.
The American Journal of Geriatric Psychiatry, 2019
When an adult is thought to be making poor decisions or is unable to care for him or herself, man... more When an adult is thought to be making poor decisions or is unable to care for him or herself, many people assume that a guardianship is necessary to secure that person's well being. An older adult may require a guardian because of a new inability to care for themselves in the contest of a neurocognitive disorder, or after a lifetime of chronic mental illness, and self-neglect. The appointment of a guardian by the court can be lifesaving, provide much needed financial protection from exploitation, and guarantee stable housing and access to health care. However, a guardianship may also leave older adults vulnerable to abuse and financial exploitation. In many cases, the needs of older adults are layered and complex, and guardianship is not necessarily the best remedy, especially when the court-appointed guardians may be responsible for hundreds of clients.
The American Journal of Geriatric Psychiatry, 2019
Opportunities for professional development and mentorship are vital for junior and mid-level facu... more Opportunities for professional development and mentorship are vital for junior and mid-level faculty members to succeed in academic medicine. Too often, those opportunities are of short supply at institutions. In this special 2-hour, interactive workshop affiliated with the Teaching and Training Committee, learners will be exposed to several areas of professional development. Dr. Brandon Yarns and Dr. Alessandra Scalmati will build on their presentations from last year and discuss implementation and evaluation of a freshly developed curricula, focusing on choosing appropriate educational strategies and describing various designs for assessment and evaluation. Finally, barriers to introducing new curricula and tips about dissemination of the curricula will be discussed. Learners will also have a chance to practice what they learned. Dr. Dennis Popeo and Dr. Elizabeth (EJ) Santos will discuss helpful hints for junior faculty members. Dr. Popeo will specifically discuss things that he "wished he knew way back when" about career planning, negotiation and work-life balance. Dr. Santos will discuss networking − something that unnerves many people − and graceful self-promotion. Faculty Disclosures Alessandra Scalmati Nothing to disclose Brandon Yarns Nothing to disclose
The American Journal of Geriatric Psychiatry, 2013
CMS and the state surveyors who implement federal regulations on a state by state level have been... more CMS and the state surveyors who implement federal regulations on a state by state level have been shaping clinician behavior in the use of psychotropic medications in those people living in Nursing Homes and other supervised settings (for example OBRA regulations and GDR gradual dose reduction madates. Recently, the use of antipsychotic medications in older adults with dementia has come under increasing pressure due to concerns for risks, and possibly, underappreciation of benefits. This session will cover the history and rationale for these regulations followed by a debate on the merits of using psychotropic medications in this vulnerable population. The debators are 2 experienced clinicians who have both been practicing geriatric psychiatry for more than 20 years. All data used for the debate will be shared and agreed upon by both presentors prior to the debate so that they may cite the same evidence in support of their positions. Faculty Disclosures: David Greenspan, MD Nothing to disclose Maureen C. Nash, MD, MS Nothing to disclose Larry E. Tune, MD Nothing to disclose COGNITION AND MOOD DISORDER: IS THERE A CONNECTION TO NEURODEGENERATION AND COGNITIVE DECLINE? Jovier D. Evans, PhD; Helen Lavretsky, MD; Ruth O’Hara, PhD; Ariel Gildengers, MD NIMH, Bethesda, MD University of California, Los Angeles, Los Angeles, CA Stanford University, Palo Alto, CA University of Pittsburgh, Pittsburgh, PA Abstract: The examination of cognitive trajectories in older adults with mental disorder is a primary target of examination for the National Institute of Mental Health (NIMH). The focus on cognition and its consequences in late life will be the focus of this symposium. Experts in the field of cognitive psychology and geriatric psychiatry will examine the role of cognitive impairments in relationship to late life affective disorder. Speakers will highlight current work in the following areas: 1) The interaction of sleep disturbances, APOE, and cognitive dysfunction in late life depression. 2) The results of a randomized clinical trial examining the effectiveness of methylphenidate augmentation of citalopram on both cognitive and affective symptoms among older adults with depression. And 3) Long term effects of lithium treatment on amyloid deposition in older adults with bipolar disorder. This will be followed by a discussion of NIMH efforts to foster and develop this area of research. The examination of cognitive trajectories in older adults with mental disorder is a primary target of examination for the National Institute of Mental Health (NIMH). The focus on cognition and its consequences in late life will be the focus of this symposium. Experts in the field of cognitive psychology and geriatric psychiatry will examine the role of cognitive impairments in relationship to late life affective disorder. Speakers will highlight current work in the following areas: 1) The interaction of sleep disturbances, APOE, and cognitive dysfunction in late life depression. 2) The results of a randomized clinical trial examining the effectiveness of methylphenidate augmentation of citalopram on both cognitive and affective symptoms among older adults with depression. And 3) Long term effects of lithium treatment on amyloid deposition in older adults with bipolar disorder. This will be followed by a discussion of NIMH efforts to foster and develop this area of research. S8 Am J Geriatr Psychiatry 21:3, Supplement 1 2013 AAGP Annual Meeting Faculty Disclosures: Jovier D. Evans, PhD Nothing to disclose Ariel Gildengers, MD Nothing to disclose Helen Lavretsky, MD Research Support: Forest Research Insitute Research grants Consultant: Lilly Consultant fee Consultant: Dey Pharma Consultant fee Ruth O’Hara, PhD Nothing to disclose CULTURAL PERSPECTIVES ON UNDERSTANDING DEMENTIA AND ASSOCIATED CAREGIVING Helen H. Kyomen, MD; Rika Suzuki, MD; Maria Llorente, MD; Rita Hargrave, MD Kaiser Permanante, Honolulu, HI Washington D.C. VA Medical Center, Washington, DC Martinez VA Outpatient Mental Health Clinic, Martinez, CA Harvard Medical School, Boston, MA North Shore Medical Center, Partners Healthcare, Salem, MA Abstract: There are compelling reasons to examine cultural issues in dementia, including the understanding of dementia and impact on caregivers. Cultural beliefs may affect the explanations given by different groups as to the etiology of dementia, recognition of symptoms, and help seeking behaviors. For example folk beliefs about dementi, as compared to biomedical beliefs, may lead to the beliefs such as dementia is a normal part of aging, or a punishment from god, and therefore not amenable to any medical intervention. Further culture may affect concepts of caregiving obligations to elders suffering from dementia, and how burdensome the demands of caregiving may be experienced by spouses and children of people suffering from dementia. Culture and minority status may affect seeking of help from family and professional resources, and…
The American Journal of Geriatric Psychiatry, 2014
Family caregivers face many challenges in caring for an older relative with cognitive, physical o... more Family caregivers face many challenges in caring for an older relative with cognitive, physical or emotional challenges. In this session three experienced geriatric psychiatrists will describe what they've learned from observing and assessing older relatives, trying to get them to agree to help, arranging that help, and monitoring the situation with adjustments to the plan as needed.
The American Journal of Geriatric Psychiatry, 2015
Schizophrenia is a lifelong illness that typically requires maintenance antipsychotic treatment o... more Schizophrenia is a lifelong illness that typically requires maintenance antipsychotic treatment over a patient's life span. Older age, however, is a risk factor for antipsychotic-induced side effects, including parkinsonism, tardive dyskinesia, falls, and metabolic syndrome to which patients with schizophrenia become more vulnerable with age. Additionally, antipsychotics may have a deleterious effect on cognition that is already compromised in patient with schizophrenia in late-life. Consensus guideline recommends the use of lower doses of antipsychotics in patients with schizophrenia in late-life. However, empirical data, combining neuroimaging, clinical and cognitive outcomes on age-specific antipsychotic dosing are limited, leaving clinicians with no clear guidance to adjust the dose of antipsychotics as patients get older. We will present data from one study funded by the US National Institute of Mental Health and the Canadian Institute of Health Research. This study was aimed to determine the therapeutic threshold of the dopamine D2 receptors occupancy by antipsychotics in clinically stable older patients with early-onset schizophrenia chronically maintained on risperidone or olanzapine for at least 12 months. The patients had gradual dose-reduction of up to 40% of the baseline dose. Dopamine D2 receptors occupancy by antipsychotics, measured by [11C]-Raclopride Positron Emission Tomography, was determined at baseline and after completion of dose-reduction. Clinical and cognitive assessments were performed before and after dose-reduction and were related to the dopamine D2 receptors occupancy data. The study is unique in comparing clinical and cognitive outcomes, before and after antipsychotic's dose-reduction, to determine the impact of the dopamine D2 receptors occupancy in treatment response. We will (1) review the rationale and design of our antipsychotic dose-reduction study in schizophrenia in late-life; (2) present the dopamine D2 receptors occupancy (neuroimaging) and clinical data of older patients with schizophrenia before and after antipsychotic dose-reduction; (3) present the cognition data and the relationship with neuroimaging data; and (4) will discuss the practical translation of the neuroimaging, clinical and cognitive data to the bedside care of older patients with schizophrenia.
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