Review of Management Considerations for Excoriation Disorder in Older Adults.

Excoriation disorder (ED) is defined as compulsive skin picking that results in skin damage and emotional distress. Optimal management of ED includes individualized treatment plans consisting of psychotherapies, behavioral and pharmacologic interventions. Compared with younger populations, older adults are at increased risk for poor outcomes, such as infection and hospitalization, and require unique management considerations. Risk factors that contribute to disease burden include age-related changes to the skin and underlying medical and psychiatric comorbidities. A literature review was conducted on ED yielding limited evidence exclusive to older adults. The authors suggest a therapeutic approach to ED in older adults based on available evidence and experience from inpatient and outpatient psychiatric settings. Finally, opportunities for future research are highlighted.

Returning Individual Research Results from Digital Phenotyping in Psychiatry.

Psychiatry is rapidly adopting digital phenotyping and artificial intelligence/machine learning tools to study mental illness based on tracking participants' locations, online activity, phone and text message usage, heart rate, sleep, physical activity, and more. Existing ethical frameworks for return of individual research results (IRRs) are inadequate to guide researchers for when, if, and how to return this unprecedented number of potentially sensitive results about each participant's real-world behavior. To address this gap, we convened an interdisciplinary expert working group, supported by a National Institute of Mental Health grant. Building on established guidelines and the emerging norm of returning results in participant-centered research, we present a novel framework specific to the ethical, legal, and social implications of returning IRRs in digital phenotyping research. Our framework offers researchers, clinicians, and Institutional Review Boards (IRBs) urgently needed guidance, and the principles developed here in the context of psychiatry will be readily adaptable to other therapeutic areas.

Deep Learning and Geriatric Mental Health.

The goal of this overview is to help clinicians develop basic proficiency with the terminology of deep learning and understand its fundamentals and early applications. We describe what machine learning and deep learning represent and explain the underlying data science principles. We also review current promising applications and identify ethical issues that bear consideration. Deep Learning is a new type of machine learning that is remarkably good at finding patterns in data, and in some cases generating realistic new data. We provide insights into how deep learning works and discuss its relevance to geriatric psychiatry.

Digital Collateral Information Through Electronic and Social Media in Psychotherapy: Comparing Clinician-reported Trends Before and During the COVID-19 Pandemic.

BACKGROUND: Patient clinical collateral information is critical for providing psychiatric and psychotherapeutic care. With the shift to primarily virtual care triggered by the COVID-19 pandemic, psychotherapists may have received less clinical information than they did when they were providing in-person care. This study assesses whether the shift to virtual care had an impact on therapists' use of patients' electronic and social media to augment clinical information that may inform psychotherapy. METHODS: In 2018, we conducted a survey of a cohort of psychotherapists affiliated with McLean Hospital. We then reapproached the same cohort of providers for the current study, gathering survey responses from August 10, 2020, to September 1, 2020, for this analysis. We asked clinicians whether they viewed patients' electronic and social media in the context of their psychotherapeutic relationship, what they viewed, how much they viewed it, and their attitudes about doing so. RESULTS: Of the 99 respondents, 64 (64.6%) had viewed at least 1 patient's social media and 8 (8.1%) had viewed a patient's electronic media. Of those who reported viewing patients' media, 70 (97.2%) indicated they believed this information helped them provide more effective treatment. Compared with the 2018 prepandemic data, there were significantly more clinicians with>10 years of experience reporting media use in therapy. There was also a significant increase during the pandemic in the viewing of media of adult patients and a trend toward an increase in viewing of media of older adult patients. CONCLUSIONS: Review of patients' electronic and social media in therapy became more common among clinicians at a large psychiatric teaching hospital during the COVID-19 pandemic. These findings support continuing research about how reviewing patients' media can inform and improve clinical care.

Effects of lithium on serum Brain-Derived Neurotrophic Factor in Alzheimer's patients with agitation.

BACKGROUND: There is ample evidence in animal models that lithium increases Brain-Derived Neurotrophic Factor (BDNF) with supporting evidence in human studies. Little is known, however, about the effects of lithium on BDNF in Alzheimer's Dementia (AD). In one study of patients with Mild Cognitive Impairment, serum BDNF increased after treatment with lithium. These patients also showed mild improvement in cognitive function. OBJECTIVES: To evaluate low-dose lithium treatment of agitation in Alzheimer's disease (AD). METHOD: We measured levels of BDNF in patients treated with lithium prior to and after a 12-week randomized placebo-controlled trial. RESULTS: BDNF levels did not change significantly and were not associated with improvement in overall neuropsychiatric symptoms or in cognitive function. CONCLUSIONS: More research is needed to understand the potential effects of lithium on BDNF in AD including whether its use might be dependent on the stage of cognitive decline and dementia.

Effects of virtual reality guided meditation in older adults: the protocol of a pilot randomized controlled trial.

Background: Virtual reality (VR) based meditation has been shown to help increase relaxation and decrease anxiety and depression in younger adults. However, this has not been studied in Randomized Controlled Trials (RCT) in the older adult population. The aim of this RCT is to assess the feasibility and acceptability of a VR-guided meditation intervention for community-dwelling older adults and its effect on stress and mental health. Methods: We will recruit 30 participants aged ≥ 60 years, whose perceived stress score (PSS) is > 14 (moderate stress), and randomize them 1:1 to the intervention or control waitlist group. The intervention will involve exposure to eight 15-min VR-guided meditation sessions distributed twice weekly for 4-weeks. Two modalities will be offered: in-home and at the hospital. Data analysis: Baseline and post-intervention assessments will evaluate perceived stress, anxiety, depression, sleep quality, quality of life, and mindfulness skills. Analyses will employ mixed methods repeated ANOVA tests. Qualitative analyses through semi-structured interviews and participant observation will be used to assess participants' experiences. Study outcomes include: (A) feasibility and acceptability compared to a waitlist control (B) stress, using the Perceived Stress Scale (PSS); (C) anxiety, and depression, using the Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9); (D) insomnia, quality of life and mindfulness skills, using the Athens Insomnia Scale (AIS), Quality of Life Questionnaire (EQ-5D-5L) and Five Facets Mindfulness Questionnaire Short Forms (FFMQ-SF), respectively. We will also measure immersive tendencies, sickness and sense of presence using the Simulator Sickness Questionnaire (SSQ) and the Presence Questionnaire (PQ). Discussion: Virtual reality-guided meditation could be an acceptable, feasible, safe, and cost-effective novel alternative health intervention for improving older adults' mental health.Clinical trial registration: NCT05315609 at https://clinicaltrials.gov.

Technology-guided assessment of vocalisations and their diagnostic value as pain indicators for people living with dementia.

BACKGROUND: during pain assessment in persons unable to self-report, such as people living with dementia, vocalisations are commonly used as pain indicators. However, there is a lack of evidence from clinical practice regarding their diagnostic value and relationship with pain. We aimed to explore vocalisations and pain in people with dementia undergoing pain assessments in clinical practice settings. METHODS: a total of 22,194 pain assessments were reviewed in people with dementia (n = 3,144) from 34 different Australian aged care homes and two dementia specific programs. Pain assessments were conducted by 389 purposely trained health care professionals and cares using PainChek pain assessment tool. Vocalised expressions were determined based on nine vocalisation features included in the tool. Linear mixed models were used to examine the relationship of pain scores with vocalisation features. Using a single pain assessment for each of the 3,144 people with dementia, additional data analysis was conducted via Receiver Operator Characteristic (ROC) analysis and Principal Component Analysis. RESULTS: vocalisation scores increased with increasing pain intensity. High pain scores were more likely with the presence of sighing and screaming (8 times). The presence of vocalisation features varied depending on the intensity of pain. The ROC optimal criterion for the voice domain yielded a cut-off score of ≥2.0 with a Youden index of 0.637. The corresponding sensitivity and specificity were 79.7% [confidence interval (CI): 76.8-82.4%] and 84.0% (CI: 82.5-85.5%), respectively. CONCLUSION: we describe vocalisation features during presence of different levels of pain in people with dementia unable to self-report, therefore providing evidence in regard to their diagnostic value in clinical practice.

Isolating together during COVID-19: Results from the Telehealth Intervention Program for older adults.

Background: A pressing challenge during the COVID-19 pandemic and beyond is to provide accessible and scalable mental health support to isolated older adults in the community. The Telehealth Intervention Program for Older Adults (TIP-OA) is a large-scale, volunteer-based, friendly telephone support program designed to address this unmet need. Methods: A prospective cohort study of 112 TIP-OA participants aged ≥60 years old was conducted in Quebec, Canada (October 2020-June 2021). The intervention consisted of weekly friendly phone calls from trained volunteers. The primary outcome measures included changes in scores of stress, depression, anxiety, and fear surrounding COVID-19, assessed at baseline, 4 and 8-weeks. Additional subgroup analyses were performed with participants with higher baseline scores. Results: The subgroup of participants with higher baseline depression scores (PHQ9 ≥10) had significant improvements in depression scores over the 8-week period measured [mean change score = -2.27 (±4.76), 95%CI (-3.719, -0.827), p = 0.003]. Similarly, participants with higher baseline anxiety scores (GAD7 ≥10) had an improvement over the same period, which, approached significance (p = 0.06). Moreover, despite peaks in the pandemic and related stressors, our study found no significant (p ≥ 0.09) increase in stress, depression, anxiety or fear of COVID-19 scores. Discussion: This scalable, volunteer-based, friendly telephone intervention program was associated with decreased scores of depression and anxiety in older adults who reported higher scores at baseline (PHQ 9 ≥10 and GAD7 ≥10).

Impact of COVID-19 restrictions on behavioural and psychological symptoms in home-dwelling people with dementia: a prospective cohort study (PAN.DEM).

OBJECTIVES: To investigate the impact of the COVID-19 restrictions on behavioural and psychological symptoms of dementia (BPSD). DESIGN: Prospective cohort study (PAN.DEM) nested within the halted parent trial (LIVE@Home.Path). SETTING: Households in Norway immediate before and 6-9 weeks into the COVID-19 restrictions. PARTICIPANTS: 104 dyads (persons with mild to moderate dementia aged ≥65 and their informal carers) completed both prepandemic and pandemic assessments, among 237 in the parent trial. Mini-Mental Status Examination score 15-26 or Functional Assessment Staging score 3-7 covered dementia severity. MAIN OUTCOME MEASURES: Neuropsychiatric Inventory (NPI-12) total (range 0-144), psychosis (range 0-24), hyperactive behaviour (range 0-60) and mood subsyndrome (range 0-48) scores; Cornell Scale for Depression in Dementia (CSDD) total score (range 0-38). RESULTS: We found an overall increase in BPSD by NPI-12 total score comparing prepandemic to pandemic levels (median 16 IQR (4.5-29) to 20 (7-32.5), p=0.03) over a mean of 86 days (SD 19). NPI-12 total score worsened in 57 (55%) of people with dementia and was associated with postponed or averted contacts with healthcare professionals (logistic regression, OR 3.96, 95% CI 1.05 to 14.95). Psychosis subsyndrome levels increased (0 (0-3) to 0.5 (0-6), p=0.01) in 37 (36%) persons; this worsening was associated with partial insight (9.57, 1.14 to 80.71) and reduced informal carer contact (4.45, 1.01 to 19.71). Moreover, depressive symptoms increased as assessed by CSDD total score (5 (3-9) to 7 (4-12), p=0.01) and worsened for 56 (54%), which was inversely associated with psychotropic drugs on-demand (0.16, 0.03 to 0.75). CONCLUSIONS: BPSD worsened during the first months of the COVID-19 restrictions, most pronounced for psychosis and depression. These BPSD exacerbations have implications for pandemic policies, emphasising that restrictions must balance COVID-19 morbidity and mortality against dementia deterioration. TRIAL REGISTRATION NUMBER: NCT04043364; Results.

Monitoring Behaviors of Patients With Late-Stage Dementia Using Passive Environmental Sensing Approaches: A Case Series.

OBJECTIVE: To show the feasibility of using different unobtrusive activity-sensing technologies to provide objective behavioral markers of persons with dementia (PwD). DESIGN: Monitored the behaviors of two PwD living in memory care unit using the Oregon Center for Aging & Technology (ORCATECH) platform, and the behaviors of two PwD living in assisted living facility using the Emerald device. SETTING: A memory care unit in Portland, Oregon and an assisted living facility in Framingham, Massachusetts. PARTICIPANTS: A 63-year-old male with Alzheimer's disease (AD), and an 80-year-old female with frontotemporal dementia, both lived in a memory care unit in Portland, Oregon. An 89-year-old woman with a diagnosis of AD, and an 85-year-old woman with a diagnosis of major neurocognitive disorder, Alzheimer's type with behavioral symptoms, both resided at an assisted living facility in Framingham, Massachusetts. MEASUREMENTS: These include: sleep quality measured by the bed pressure mat; number of transitions between spaces and dwell times in different spaces measured by the motion sensors; activity levels measured by the wearable actigraphy device; and couch usage and limb movements measured by the Emerald device. RESULTS: Number of transitions between spaces can identify the patient's episodes of agitation; activity levels correlate well with the patient's excessive level of agitation and lack of movement when the patient received potentially inappropriate medication and neared the end of life; couch usage can detect the patient's increased level of apathy; and periodic limb movements can help detect risperidone-induced side effects. This is the first demonstration that the ORCATECH platform and the Emerald device can measure such activities. CONCLUSION: The use of technologies for monitoring behaviors of PwD can provide more objective and intensive measurements of PwD behaviors.