[Intensive exposure treatment for obsessive compulsive disorder in old age.] / Intensieve exposure bij obsessieve-compulsieve stoornis op oudere leeftijd.

The absence of treatment studies for obsessive compulsive disorder (OCD) in older adults and the fact that OCD typically starts at a young age and often follows a chronic, fluctuating course quickly leads to therapeutic nihilism for older adults with OCD. In this case report, we present a 72-year-old man with OCD symptoms from the age of 35, who has only been treated with medication and psychotherapy for a recurrent depressive disorder. After a short, intensive exposure and response prevention treatment (four days in two weeks), the OCD symptoms and the depressive symptoms were fully in remission and all medications (venlafaxine, olanzapine, depakine) were discontinued. Treatment gains were maintained with persistent remission until 18 months follow up. This case report shows that a comorbid depressive disorder may lead to undertreatment of OCD. It also shows that long standing OCD can be successfully treated in older adults.

Subtyping late-life depression according to inflammatory and metabolic dysregulation: a prospective study.

BACKGROUND: Inflammation and metabolic dysregulation are age-related physiological changes and are associated with depressive disorder. We tried to identify subgroups of depressed older patients based on their metabolic-inflammatory profile and examined the course of depression for these subgroups. METHODS: This clinical cohort study was conducted in a sample of 364 depressed older (⩾60 years) patients according to DSM-IV criteria. Severity of depressive symptoms was monitored every 6 months and a formal diagnostic interview repeated at 2-year follow-up. Latent class analyses based on baseline metabolic and inflammatory biomarkers were performed. Adjusted for confounders, we compared remission of depression at 2-year follow-up between the metabolic-inflammatory subgroups with logistic regression and the course of depression severity over 2-years by linear mixed models. RESULTS: We identified a 'healthy' subgroup (n = 181, 49.7%) and five subgroups characterized by different profiles of metabolic-inflammatory dysregulation. Compared to the healthy subgroup, patients in the subgroup with mild 'metabolic and inflammatory dysregulation' (n = 137, 37.6%) had higher depressive symptom scores, a lower rate of improvement in the first year, and were less likely to be remitted after 2-years [OR 0.49 (95% CI 0.26-0.91)]. The four smaller subgroups characterized by a more specific immune-inflammatory dysregulation profile did not differ from the two main subgroups regarding the course of depression. CONCLUSIONS: Nearly half of the patients with late-life depressions suffer from metabolic-inflammatory dysregulation, which is also associated with more severe depression and a worse prognosis. Future studies should examine whether these depressed older patients benefit from a metabolic-inflammatory targeted treatment.

The impact of a history of child abuse on cognitive performance: a cross-sectional study in older patients with a depressive, anxiety, or somatic symptom disorder.

BACKGROUND: Child abuse is a major global burden with an enduring negative impact on mental and physical health. A history of child abuse is consistently associated with worse cognitive performance among adults; data in older age groups are inconclusive. Since affective symptoms and cognitive functioning are interrelated among older persons, a synergistic effect can be assumed in patients with affective symptoms who also have suffered from child abuse. This study examines the association between a history of child abuse and cognitive performance in such patients. METHODS: Cross-sectional data were collected from the 'Routine Outcome Monitoring for Geriatric Psychiatry & Science' project, including 179 older adults (age 60-88 years) with either a unipolar depressive, any anxiety, or somatic symptom disorder referred to specialized geriatric mental health care. A history of physical, sexual, and psychological abuse, and emotional neglect was assessed with a structured interview. Cognitive functioning was measured with three paper and pencils tests (10-words verbal memory test, Stroop Colour-Word test, Digit Span) and four tests from the computerized Cogstate Test Battery (Detection Test, Identification Test, One Card Learning Test, One Back Test). The association between a history of child abuse and cognitive performance was examined by multiple linear regression analyses adjusted for covariates. RESULTS: Principal component analyses of nine cognitive parameters revealed four cognitive domains, i.e., visual-verbal memory, psychomotor speed, working memory and interference control. A history of child abuse was not associated with any of these cognitive domains. However, when looking at the specific types of child abuse separately, a history of physical abuse and emotional neglect were associated with poorer interference control. A history of physical abuse was additionally associated with better visual-verbal memory. CONCLUSIONS: The association between a history of child abuse and cognitive performance differs between the different types of abuse. A history of physical abuse might particularly be a key determinant of cognitive performance in older adults with a depressive, anxiety, or somatic symptom disorder. Future studies on the impact of these disorders on the onset of dementia should take child abuse into account. TRIAL REGISTRATION: ROM-GPS is registered at the Dutch Trial Register ( NL6704 at www.trialregister.nl ).

[Geriatric syndromes, multimorbidity and geriatric psychiatry; an integrated perspective]. / Geriatrische syndromen, multimorbiditeit en ouderenpsychiatrie; een geïntegreerd perspectief.

BACKGROUND: The prevalence of geriatric syndromes, frailty and multimorbidity increases in older age, with a negative impact on health outcomes. Little is known on these problems in older adults with psychiatric disorders. AIM: To evaluate the prevalence of geriatric syndromes and multimorbidity in older adults with psychiatric disorders and their impact on treatment outcomes. METHOD: We conducted a pilot study and a case-control study on older adults with medically insufficiently explained symptoms, a prospective cohort study in older adults, acutely admitted to psychiatric wards and a systematic review to evaluate whether geriatric syndromes were considered in RCTs on depression treatment. RESULTS: Unexplained symptoms were often accompanied by frailty, multimorbidity and psychiatric disorders. Older adults who were acutely admitted to psychiatric wards had a high level of multimorbidity, about half of them were frail, and a third undernourished. Frailty and multimorbidity were independent predictors for not being discharged to their own home. Frailty also strongly predicted the 5-year mortality rate. Geriatric syndromes were hardly considered in study design or as secondary outcome in treatment studies on depression in older adults. CONCLUSION: Overall, geriatric problems are highly prevalent among older adults with psychiatric disorders and have a relevant prognostic impact. The complexity of older psychiatric patients is probably best addressed by interdisciplinary, integrated diagnostic and treatment trajectories.

Course of frailty stratified by physical and mental multimorbidity patterns: a 5-year follow-up of 92,640 participants of the LifeLines cohort study.

BACKGROUND: The frailty index (FI) is a well-recognized measurement for risk stratification in older people. Among middle-aged and older people, we examined the prospective association between the FI and mortality as well as its course over time in relation to multimorbidity and specific disease clusters. METHODS: A frailty index (FI) was constructed based on either 64 (baseline only) or 35 health deficits (baseline and follow-up) among people aged ≥ 40 years who participated in LifeLines, a prospective population-based cohort living in the Northern Netherlands. Among 92,640 participants, multivariable Cox proportional hazard models were fitted to study the hazard ratio (HR) of the FI at baseline, as well as for 10 chronic disease clusters for all-cause mortality over a 10-year follow-up. Among 55,426 participants, linear regression analyses were applied to study the impact of multimorbidity and of specific chronic disease clusters (independent variables) on the change of frailty over a 5-year follow-up, adjusted for demographic and lifestyle characteristics. RESULTS: The FI predicted mortality independent of multimorbidity and specific disease clusters, with the highest impact in people with either endocrine, lung, or heart diseases. Adjusted for demographic and lifestyle characteristics, all chronic disease clusters remained independently associated with an accelerated increase of frailty over time. CONCLUSIONS: Frailty may be seen as a final common pathway for premature death due to chronic diseases. Our results suggest that initiating frailty prevention at middle age, when the first chronic diseases emerge, might be relevant from a public health perspective.

COVID-19: Clinical Challenges in Dutch Geriatric Psychiatry.

The COVID-19 pandemic has changed everyday life tremendously in a short period of time. After a brief timeline of the Dutch situation and our management strategy to adapt geriatric mental health care, we present a case-series to illustrate the specific challenges for geriatric psychiatrists.

Group schema-focused therapy enriched with psychomotor therapy versus treatment as usual for older adults with cluster B and/or C personality disorders: a randomized trial.

BACKGROUND: Several types of psychotherapy have been proven successful in the treatment of personality disorders in younger age groups, however studies among older patients are lacking. We developed a group schema-focused therapy (SFT) enriched with psychomotor therapy (PMT) for older adults with cluster B and/or C personality disorders. This paper describes the design of a randomized controlled trial (RCT). We will evaluate the (cost-)effectiveness of this therapy protocol in specialized mental health care. We hypothesize that our treatment program is cost-effective and superior to treatment as usual (TAU) in reducing psychological distress and improving quality of life in older adults treated to specialized mental healthcare. METHODS: A multicenter RCT with a one-year follow-up comparing group schema-focused therapy enriched with psychomotor therapy (group SFT + PMT) and TAU for adults aged 60 years and older who suffer from either a cluster B and/or C personality disorder. The primary outcome is general psychological distress measured with the 53-item Brief Symptom Inventory. Secondary outcomes are the Schema Mode Inventory (118-item version) and the Young Schema Questionnaire. Cost-effectiveness analysis will be performed from a societal perspective with the EuroQol five dimensions questionnaire and structured cost-interviews. DISCUSSION: This study will add to the knowledge of psychotherapy in later life. The study specifically contributes to the evidence on (cost-) effectiveness of group SFT enriched with PMT adapted to the needs of for older adults with cluster b and/or c personality. TRIAL REGISTRATION: Netherlands Trial Register NTR 6621 . Registered on 20 August 2017.

Outcome of day treatment for older adults with affective disorders: An observational pre-post design of two transdiagnostic approaches.

OBJECTIVE: First, to evaluate the outcome of 2 transdiagnostic day treatment programs. A 20-week psychotherapeutic day treatment (PDT) and an activating day treatment (ADT) program delivered in blocks of 4 weeks with a maximum of 24 weeks with respect to depression, anxiety, and hypochondriasis. Second, to explore the impact of cognitive impairment and personality pathology on treatment outcome. METHODS: The course of depression (Inventory of Depressive Symptoms), anxiety (Geriatric Anxiety Inventory), and hypochondriasis (Whitley Index) were evaluated by linear mixed models adjusted for age, sex, level of education, and alcohol usage among 49 patients (mean age 65 years, 67% females) receiving PDT and among 61 patients (mean age 67.1, 61% females) receiving ADT. Pre-post effect-sizes were expressed as Cohen's d. Subsequently, cognitive impairment (no, suspected, established) and personality pathology (DSM-IV criteria as well as the Big Five personality traits) were examined as potential moderators of treatment outcome. RESULTS: Among patients receiving PDT, large improvements were found for depression (d = 1.1) and anxiety (d = 1.2) but not for hypochondriasis (d = 0.0). Patients receiving ADT showed moderate treatment effects for depression (d = 0.6), anxiety (d = 0.6), as well as hypochondriasis (d = 0.6). Personality pathology moderates treatment outcome of neither PDT nor ADT. Cognitive impairment negatively interfered with the course of depressive symptoms among patients receiving PDT. CONCLUSIONS: Transdiagnostic day treatment is promising for older adults with affective disorders with high feasibility.

Metabolic dysregulation and late-life depression: a prospective study.

BACKGROUND: Depression is associated with the metabolic syndrome (MS). We examined whether metabolic dysregulation predicted the 2-year course of clinical depression. METHOD: A total of 285 older persons (⩾60 years) suffering from depressive disorder according to DSM-IV-TR criteria was followed up for 2 years. Severity of depression was assessed with the Inventory of Depressive Symptomatology (IDS) at 6-month intervals. Metabolic syndrome was defined according the National Cholesterol Education Programme (NCEP-ATP III). We applied logistic regression and linear mixed models adjusted for age, sex, years of education, smoking, alcohol use, physical activity, somatic co-morbidity, cognitive functioning and drug use (antidepressants, anti-inflammatory drugs) and severity of depression at baseline. RESULTS: MS predicted non-remission at 2 years (odds ratioper component = 1.26, 95% confidence interval 1.00-1.58), p = 0.047), which was driven by the waist circumference and HDL cholesterol. MS was not associated with IDS sum score. Subsequent analyses on its subscales, however, identified an association with the somatic symptom subscale score over time (interaction time × somatic subscale, p = 0.005), driven by higher waist circumference and elevated fasting glucose level. CONCLUSIONS: Metabolic dysregulation predicts a poor course of late-life depression. This finding supports the concept of 'metabolic depression', recently proposed on population-based findings of a protracted course of depressive symptoms in the presence of metabolic dysregulation. Our findings seem to be driven by abdominal obesity (as indicated by the waist circumference) and HDL cholesterol dysregulation.

[DSM-5 classification of personality disorders in older persons]. / DSM-5-classificatie van persoonlijkheidsstoornissen bij ouderen.

BACKGROUND: Although it is generally agreed that personality disorders are an important topic in old-age psychiatry, DSM-5 has paid relatively little attention to older persons affected with this severe mental disorder. AIM: To look closely and carefully at several aspects of the way in which DSM-5 defines personality disorders relating to older persons. METHOD: We make a critical evaluation of the description of personality disorders given in DSM-5. RESULTS: First of all, we question whether the phrase 'personality change due to another medical condition' should really be included in the dsm-5 chapter of personality disorders because a personality change actually has the features of a persistent conduct disorder. Secondly, we argue that in a future revised version of dsm-5 personality disorders affecting older persons should be referred to specifically as 'late-onset' personality disorders. Thirdly, we stress that the research programme relating to the dimensional dsm-5 model of personality disorders should involve a larger number of older persons. In addition, more research is needed with regard to the use, wording and validity of the phrase 'personality change due to a medical condition'. Those responsible for the revision of the DSM-5 should ensure that the concept 'late-onset personality disorders' is incorporated in the text. CONCLUSION: The description of personality disorders in DSM-5 is confusing. This is probably due to the transitional period between the old categorical (dsm-iv) system and the newly proposed dimensional approach to personality disorders in DSM-5, an approach that needs further investigation. However, this intervening period could be a good opportunity for doing further research into personality disorders in older adults.

A brief cognitive-behavioral intervention for treating depression and panic disorder in patients with noncardiac chest pain: a 24-week randomized controlled trial.

BACKGROUND: Most patients with noncardiac chest pain experience anxiety and depressive symptoms. Commonly they are reassured and referred back to primary care, leaving them undiagnosed and untreated. Some small studies have suggested efficacy of 12 cognitive behavioral therapy (CBT) sessions. Our aim was to examine efficacy of brief CBT in reducing anxiety and depressive symptoms in patients with noncardiac chest pain and comorbid panic and/or depressive disorders. METHODS: In this 24-week randomized controlled trial comparing CBT (n = 60) versus treatment as usual (TAU, n = 53), we included all adults who presented at the cardiac emergency unit of a university hospital with noncardiac chest pain, scored ≥8 on the hospital anxiety and depression scale (HADS) and were diagnosed with a comorbid panic and/or depressive disorder with the Mini International Neuropsychiatric Interview. CBT consisted of six individual sessions. Main outcome was disease severity assessed with the clinical global inventory (CGI) by a blinded independent rater. RESULTS: ANCOVA in the intention-to-treat and completer sample showed that CBT was superior to TAU after 24 weeks in reducing disease severity assessed with CGI (P < .001). Secondary outcomes on anxiety (HADS-anxiety, state trait anxiety inventory (STAI)-trait) and depressive symptoms (Hamilton depression rating scale) were in line with these results except for HADS-depression (P = .10), fear questionnaire (P = .13), and STAI-state (P = .11). CONCLUSIONS: Brief CBT significantly reduces anxiety and depressive symptoms in patients with noncardiac chest pain who are diagnosed with panic and/or depressive disorders. Patients presenting with noncardiac chest pain should be screened for psychopathology and if positive, CBT should be considered.

[Resident old-age psychiatrists need training in the interpretation of cerebral imaging: a pituitary incidentaloma]. / Interpretatie van cerebraal beeldvormend onderzoek in de opleiding tot ouderenpsychiater: een hypofyse-incidentaloom.

Due to the increased use of cerebral imaging with higher sensitivity, the old-age psychiatrist is more likely to find unexpected lesions. We report on a 73-year-old man with schizoaffective disorder and increasing cognitive deterioration. When given a diagnostic MRI cerebrum a pituitary incidentaloma was found. An overview of the literature shows a high prevalence of pituitary incidentalomas. Complications are generally rare, but one should be alert. The old-age psychiatrist should take the lead in the assessment and interpretation of such imaging results. The relevant skills for this task should be developed in the field of old-age psychiatry during the residency training in psychiatry.

Risk of Four Geriatric Syndromes: A Comparison of Mental Health Care and General Hospital Inpatients.

An observational, cross-sectional study is conducted to compare elevated risk scores of four geriatric syndromes (falls, malnutrition, physical impairment, delirium) in older hospitalized psychiatric patients (n=178) with patients hospitalized in a general hospital (n=687). The median age of all patients was 78 years (IQR 73.3-83.3), 53% were female. After correction for age and gender, we found significantly more often an elevated risk in the mental health care group, compared to the general hospital group of falls (Odds Ratio (OR) = 1.75; 95% Confidence Interval (CI) 1.18-2.57), malnutrition (OR = 4.12; 95% CI 2.67-6.36) and delirium (OR = 6.45; 95% CI 4.23-9.85). The risk on physical impairment was not statistically significantly different in both groups (OR = 1.36; 95% CI .90-2.07). Older mental health care patients have a higher risk to develop geriatric syndromes compared to general hospital patients with the same age and gender, which might be explained by a higher level of frailty.

[Benzodiazepin addiction: a silent addiction among older people]. / Benzodiazepineverslaving; een stille verslaving onder ouderen.

Benzodiazepines are frequently prescribed for a longer period of time for anxiety disorders and insomnia in spite of the many guidelines to prescribe these drugs only short-term. These guidelines are based on the risk-benefit balance between long-term effectiveness and side effects like addiction, anterograde amnesia, and increased risk on falling (resulting in hip fractures), traffic accidents and even mortality. Also low-dose benzodiazepine use can lead to benzodiazepine dependence. Although initially most attention has been paid to the physical withdrawal syndrome, psychological aspects of benzodiazepine dependence have received more and more attention in the past decades. Recently, a relationship between the brain-reward system, involved in addiction, and benzodiazepine use, was demonstrated. When long-term benzodiazepine use is recognised as problematic by both physician and patient, different treatment modalities are available to support patients in achieving abstinence. One of every four patients is able to stop by themselves with the aid of a minimal intervention providing psychoeducation and encouragement. Two out of three long-term uses are able to stop their usage with the aid of systematic tapering protocols guided by a physician or psychologist. In case of an underlying insomnia or anxiety disorder, cognitive-behavioural therapy should be added to the tapering protocol. In contrast to the general opinion, advanced old age has no negative impact on the treatment response.

[Frailty; a fragile concept]. / Frailty; een kwetsbaar begrip.

BACKGROUND: Frailty can be regarded as a condition in which the reserve capacity of various physical systems has sunk to a critical low, at which point minor disturbances can develop into serious health problems. AIM: To review the various operationalisations of the concept of frailty and describe the relationship between frailty and psychopathology. METHOD: We searched the literature up to October 2010 using PubMed, PsycINFO and CINAHL. RESULTS: We found 35 operationalisations of the concept of frailty; 4 single measurements as a proxy for frailty (e.g. muscle strength), 18 syndrome diagnoses which can be subdivided into single (n = 5) and multiple syndrome diagnoses (n = 13) and 13 dimensional operationalisations for which measurement instruments were used. Only 6 studies reported the relationship between frailty and psychopathology. The studies revealed an association between depression and psychopathology. An important finding was the association between depression and frailty, but the direction of the association is unknown. CONCLUSION: No consensus has been reached regarding the operationalisation of the concept of frailty. For the purpose of gerontopsychiatric research we recommend the inclusion of a syndrome diagnosis based on physical criteria (physical frailty) because this should make it possible to unravel the relationship between psychopathology and underlying ageing mechanisms.

[Benchmarken is 'work in progress']. / Benchmarken is 'werk-in-uitvoering'

BACKGROUND: In the March edition of this journal a group of professors criticised the methods adopted by the SBG (Benchmark foundation of the Dutch Mental Health Services). The critical comments relate to the alleged objectives ('pay-for-performance' in the Dutch Mental Health Services) and the methods involving confounding, bias and the use of insufficiently sensitive instruments. AIM: To provide more detailed information about the SBG and the role of the scientific council (WR) and about the social context within which rom and benchmarking are developing, and to give our views on the methodological criticisms. METHOD: We elucidate the methods of the SBG and the role of the WR and we clarify the ways in which ROM and benchmarking are currently being used. RESULTS: We recognise that there are methodological problems. The wr too warns against jumping to conclusions on the basis of data whose validity is still under discussion. The Dutch Mental Health Services have practically no experience of rom and benchmarking. The Dutch Mental Health Services need to gain more experience in this field. On the other hand, it is true that rom data and comparisons between institutions can lead to improvements in the standard of care, provided these procedures are carried out carefully. In the SGB methods the aforementioned problems have been removed, at least partially. The SBG is concerned not only with symptom reduction but also with the functioning of the individual and with his or her quality of life. CONCLUSION: The WR believes that the Dutch Mental Health Services should operate a scientifically validated benchmark system. Sofar, there has been hardly any research into whether benchmark data really say anything about quality and/or whether comparisons between institutions are valid. A national ROM-system is needed. Current initiatives are creating ways in which these matters can be investigated, preferably in conjunction with scientists and professionals.

The interaction between cerebrovascular disease and neuroticism in late-life depression: a cross-sectional study.

OBJECTIVE: Vascular disease and neuroticism are both risk factors for late-life depression. In this study we examined the interaction between vascular disease and neuroticism as determinants of clinically relevant depressive symptoms (CRDS) in late-life. METHODS: Multivariate logistic regression in a survey of 1396 population-dwelling people aged ≥70 years. CRDS were defined as scoring ≥16 on the CES-D. Vascular disease was categorised into four levels: none, ≥2 vascular risk factors, cardiac disease or stroke. RESULTS: Neuroticism was strongly associated with CRDS in women (OR: 1.6, 95% CI: 1.4-1.8). In men vascular disease interacted negatively but significantly with neuroticism (cardiac disease by neuroticism: OR: 0.8, 95% CI: 0.6-0.9; stroke by neuroticism: OR: 0.8, 95% CI: 0.6-0.96) when predicting CRDS. CONCLUSIONS: In men vascular disease attenuates the predictive value of neuroticism in CRDS, which might be mediated by apathy caused by cerebrovascular disease.