Social connections as determinants of cognitive health and as targets for social interventions in persons with or at risk of Alzheimer's disease and related disorders: a scoping review.

BACKGROUND: Social connections have a significant impact on health across age groups, including older adults. Loneliness and social isolation are known risk factors for Alzheimer's disease and related dementias (ADRD). Yet, we did not find a review focused on meta-analyses and systematic reviews of studies that had examined associations of social connections with cognitive decline and trials of technology-based and other social interventions to enhance social connections in people with ADRD. STUDY DESIGN: We conducted a scoping review of 11 meta-analyses and systematic reviews of social connections as possible determinants of cognitive decline in older adults with or at risk of developing ADRD. We also examined eight systematic reviews of technology-based and other social interventions in persons with ADRD. STUDY RESULTS: The strongest evidence for an association of social connections with lower risk of cognitive decline was related to social engagement and social activities. There was also evidence linking social network size to cognitive function or cognitive decline, but it was not consistently significant. A number of, though not all, studies reported a significant association of marital status with risk of ADRD. Surprisingly, evidence showing that social support reduces the risk of ADRD was weak. To varying degrees, technology-based and other social interventions designed to reduce loneliness in people with ADRD improved social connections and activities as well as quality of life but had no significant impact on cognition. We discuss strengths and limitations of the studies included. CONCLUSIONS: Social engagement and social activities seem to be the most consistent components of social connections for improving cognitive health among individuals with or at risk for ADRD. Socially focused technology-based and other social interventions aid in improving social activities and connections and deserve more research.

Treatment of behavioral and psychological symptoms of dementia using transcranial magnetic stimulation: a systematic review.

OBJECTIVE: Behavioral and psychological symptoms of dementia (BPSD) are a group of noncognitive symptoms that occur commonly among individuals with dementia. These symptoms worsen the morbidity and mortality among individuals with dementia and significantly increase the cost of caring for these individuals. Transcranial magnetic stimulation (TMS) has been shown to have some benefits in the treatment of BPSD. This review provides an updated summary of the effect of TMS on BPSD. METHODS: We conducted a systematic review of PubMed, Cochrane, and Ovid databases on the use of TMS to treat BPSD. RESULTS: We found 11 randomized controlled studies that evaluated the use of TMS among individuals with BPSD. Three of these studies examined the effect of TMS on apathy, two of which showed significant benefit. Seven studies showed that TMS significantly improves BPSD: six using repetitive transcranial magnetic stimulation (rTMS) and one using transcranial direct current stimulation (tDCS). Four studies, two evaluating tDCS, one evaluating rTMS, and one evaluating intermittent theta-burst stimulation (iTBS) showed a nonsignificant impact of TMS on BPSD. Adverse events were predominantly mild and transitory in all studies. CONCLUSION: Available data from this review indicate that rTMS is beneficial for individuals with BPSD, especially among individuals with apathy, and is well tolerated. However, more data are needed to prove the efficacy of tDCS and iTBS. Additionally, more randomized controlled trials with longer treatment follow-up and standardized use of BPSD assessments are needed to determine the best dose, duration, and modality for effective treatment of BPSD.

Electroconvulsive therapy in individuals with dementia/major NCD presenting with behavioral symptoms: a systematic review.

OBJECTIVE: This study aims to systematically review the literature on using electroconvulsive therapy (ECT) in patients with dementia/major NCD (Neuro cognitive disorder) presenting with behavioral symptoms. DESIGN: We conducted a PRISMA-guided systematic review of the literature. We searched five major databases, including PubMed, Medline, Embase, Cochrane, and registry (ClinicalTrials.gov), collaborating with "ECT" and "dementia/major NCD" as our search terms. MEASUREMENTS: Out of 445 published papers and four clinical trials, only 43 papers and three clinical trials met the criteria. There were 22 case reports, 14 case series, 4 retrospective chart reviews, 1 retrospective case-control study, 1 randomized controlled trial, and 2 ongoing trials. We evaluated existing evidence for using ECT in dementia/major NCD patients with depressive symptoms, agitation and aggression, psychotic symptoms, catatonia, Lewy body dementia/major NCD, manic symptoms, and a combination of these symptoms. SETTINGS: The studies were conducted in the in-patient setting. PARTICIPANTS: Seven hundred and ninety total patients over the age of 60 years were added. RESULTS: All reviewed studies reported symptomatic benefits in treating behavioral symptoms in individuals with dementia/major NCD. While transient confusion, short-term memory loss, and cognitive impairment were common side effects, most studies found no serious side effects from ECT use. CONCLUSION: Current evidence from a systematic review of 46 studies indicates that ECT benefits specific individuals with dementia/major NCD and behavioral symptoms, but sometimes adverse events may limit its use in these vulnerable individuals.

Perspectives on the Clinical Use of Pharmacogenetic Testing in Late-Life Mental Healthcare: A Survey of the American Association of Geriatric Psychiatry Membership.

OBJECTIVE: To assess perspectives on pharmacogenetic (PGx) testing among members of the American Association of Geriatric Psychiatry (AAGP). DESIGN: Cross-sectional survey. PARTICIPANTS: Members of the AAGP. MEASUREMENTS: Anonymous web-based survey consisting of 41 items covering experiences, indications, barriers, facilitators and ethical, legal and social implications for PGx testing. RESULTS: A total of 124 surveys were completed (response rate = 13%). Most respondents (60%) had used PGx testing but an equal proportion (58%) was uncertain about the clinical usefulness of PGx testing in late-life mental health. Despite self-reported confidence in the ability to order and interpret PGx testing, 60% of respondents felt there was not enough clinical evidence for them to use PGx testing in their practice. This was compounded by uncertainties related to their ethical obligation and legal liability when interpreting and using (or not using) PGx testing results. Respondents strongly affirmed that clinical and legal guidelines for PGx testing in older adults are needed and would be helpful. CONCLUSION: The findings suggest additional PGx research and physician education in late-life mental healthcare settings is required to reconcile uncertainties related to the clinical efficacy and ethico-legal aspects of PGx testing as well as address current knowledge barriers to testing uptake. These efforts would be further facilitated by the development of clinical practice guidelines to ensure equitable access to testing and standardized implementation of PGx-informed prescribing in older adults.

Managing Behavioral and Psychological Symptoms of Dementia (BPSD) in the Era of Boxed Warnings.

PURPOSE OF REVIEW: To provide a comprehensive overview on the evaluation and management of behavioral and psychological symptoms of dementia (BPSD) using evidence from literature. RECENT FINDINGS: Evidence indicates efficacy for some non-pharmacological techniques including education of caregivers and cognitive stimulation therapy and pharmacological agents like antidepressant and antipsychotics for the management of BPSD. The use of antipsychotics has generated controversy due to the recognition of their serious adverse effect profile including the risk of cerebrovascular adverse events and death. BPSD is associated with worsening of cognition and function among individuals with dementia, greater caregiver burden, more frequent institutionalization, overall poorer quality of life, and greater cost of caring for these individuals. Future management strategies for BPSD should include the use of technology for the provision of non-pharmacological interventions and the judicious use of cannabinoids and interventional procedures like ECT for the management of refractory symptoms.

Is there evidence for using anticonvulsants in the prevention and/or treatment of delirium among older adults?

OBJECTIVE: This systematic review aims to identify published randomized controlled trials (RCTs) that evaluated the use of anticonvulsants for the prevention and/or treatment of delirium among older adults. METHODS: A comprehensive search of databases: MEDLINE ALL (Ovid), Embase (Ovid), PsycINFO (Ovid), Web of Science Core Collection and Cochrane Central Register of Controlled was conducted. RESULTS: The search identified four RCTs that evaluated the use of anticonvulsants among older adults with delirium. One RCT evaluated the perioperative use of gabapentin among individuals undergoing spinal surgery and the development of postoperative delirium. One RCT evaluated the relationship between the use of perioperative gabapentin and the development of postoperative delirium among individuals undergoing spinal surgery and hip and knee arthroplasty. Two post-hoc analyses of RCTs evaluated the use of gabapentin and pregabalin among individuals undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). The perioperative use of gabapentin reduced the incidence of postoperative delirium among older adults undergoing spinal surgery. The perioperative use of gabapentin did not reduce the rates, severity or duration of postoperative delirium among older adults who were undergoing spine and hip and knee arthroplasty. The perioperative use of gabapentin did not reduce the incidence or duration of postoperative delirium among older adults undergoing elective TKA. The perioperative use of pregabalin did not reduce the incidence of postoperative delirium among older adults undergoing elective THA. Gabapentin and pregabalin were well tolerated among the individuals enrolled in these trials. There were no RCTs identified that evaluated the use of other anticonvulsants for the prevention and/or treatment of delirium among older adults. CONCLUSIONS: Based on current evidence, the routine use of anticonvulsants for the prevention and/or treatment of delirium among older adults cannot be recommended.

A systematic review of ketamine for the treatment of depression among older adults.

OBJECTIVE: To review the currently available data on the use of ketamine in the treatment of depression among older adults from randomized controlled studies. DESIGN: Randomized controlled trials. SETTING: Variable. PARTICIPANTS: 60 years and older with depression. INTERVENTION: Ketamine. MEASUREMENTS: Change in Montgomery-Asberg Depression Rating Scale (MADRS) scores. RESULTS: Two studies met the inclusion criteria. The first study showed a significant reduction in depression symptoms with use of repeated subcutaneous ketamine administration among older adults with depression. The second study failed to achieve significance on its primary outcome measure but did show a decrease in MADRS scores with intranasal ketamine along with a higher response and remission rates in esketamine group compared with the placebo group. The adverse effects from ketamine generally lasted only a few hours and abated spontaneously. No cognitive adverse effects were noted in either trial from the use of ketamine. CONCLUSIONS: The current evidence for use of ketamine among older adults with depression indicates some benefits with one positive and one negative trial. Although one of the trials did not achieve significance on the primary outcome measure, it still showed benefit of ketamine in reducing depressive symptoms. Ketamine was well tolerated in both studies with adverse effects being mild and transient.

American Association for Geriatric Psychiatry-Strategic Thinking.

Never has there been a more pressing time for the American Association for Geriatric Psychiatry (AAGP) to articulate a unified strategy to meet the challenges of our aging world. To this end, this report summarizes an AAGP leadership meeting that reviewed the results from a recent membership survey and launched a strategic planning process on behalf of AAGP members and stakeholders. This meeting was the first step in drafting a blueprint for the future that may serve as our guide in the context of finite resources to meet the infinitely complex and growing need for education, research, public advocacy, and clinical practice support. The following report serves to invite our valued colleagues to provide feedback and actively participate in defining our mission. Among the outcomes of the planning session, the following aspirations were identified by the participants 1) assert the AAGP as the "go to" organization for all things related to geriatric mental health, 2) prioritize activities that enhance the inclusivity/diversity of membership, and 3) collaborate across disciplines focused on geriatric mental health. From this initial framework, the group developed four general themes to guide AAGP's strategic future: 1) collaboration, 2) advocacy, 3) inclusivity, 4) high purpose. Inclusivity was further defined as encompassing growth, return on investment, and workforce development. Higher purpose was further defined as encompassing engagement, purpose, branding, communication, and expertise. The AAGP affirmed its commitment to serving the needs of its members and widening its scope of impact in view of staggering demands for better access to geriatric mental healthcare.

Systematic review of benzodiazepines for anxiety disorders in late life.

BACKGROUND: Benzodiazepines are currently the most commonly prescribed medication for the treatment of anxiety in older adults, although there is a dearth of good-quality data on this subject. The aim of this review was to systematically review studies examining the efficacy and tolerability of benzodiazepines for the treatment of anxiety disorders among older adults. METHODS: The authors conducted a systematic review, searching PubMed, Ovid MEDLINE, Ovid Embase, Web of Science, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. All searches were limited to English-language articles. The quality of each study was appraised using criteria developed by the Centre for Evidence-Based Medicine for randomized controlled trials. RESULTS: A total of 8,785 citations were retrieved and pooled in EndNote and de-duplicated to 3,753. This set was uploaded to Covidence for screening. Two separate screeners (AG and SAF) evaluated the titles, abstracts, and full text of the eligible articles. Five studies met the inclusion criteria. Across all studies, benzodiazepines were associated with decreased anxiety at the end of the study period. The limited tolerability data show mild adverse effects from the benzodiazepines studied. Limitations of the trials included limited data on the long-term use of benzodiazepines for anxiety and a preponderance of trials examining generalized anxiety disorder, with relatively less data on other anxiety disorders. CONCLUSIONS: Benzodiazepines are effective for treating anxiety disorders in late life, at least in the short term, but more data is needed to establish tolerability and their long-term benefits.

Advice on How to Choose a Geriatric Psychiatry Fellowship.

The population of older adults with mental health and substance use disorders in the United States is increasing at a significant rate. This growth creates a critical need for trained geriatric psychiatrists. Unfortunately, the number of psychiatrists choosing to receive subspecialty training in geriatric psychiatry has not kept pace with the growing needs of society. Many different methods for enhancing the recruitment of physicians interested in subspecialty training are being discussed nationally. One way to improve recruitment is to provide prospective residents a clear understanding of the process by which one may apply to and select a fellowship program. In this article, we discuss the process by which physicians interested in pursuing fellowship training in geriatric psychiatry can make an informed decision to apply to and choose programs that best fit their needs.

Evidence for using PRN pharmacotherapy to treat undifferentiated acute agitation or aggression.

BACKGROUND: This systematic review identified published studies that evaluated the use of pro re nata (PRN) medication in patients with acute agitation or aggression of undifferentiated etiology. METHODS: A literature search was conducted of PubMed and MEDLINE for randomized controlled trials (RCTs) that evaluated the use of PRN medications for individuals with undifferentiated agitation or aggression. Bibliographic databases of published articles were also searched for additional studies. RESULTS: A total of 15 studies were identified that assessed the effects of first-generation antipsychotics (FGAs), second-generation antipsychotics (SGAs), benzodiazepines, and combination therapies. All RCTs showed variable degrees of sedation and decreased agitation over time with the use of these medications, as well as variable levels of adverse events. CONCLUSIONS: Evidence exists to support the use of specific SGAs as firstline PRN medications in the management of acutely agitated individuals. While evidence exists to support the use of FGAs, benzodiazepines, and combination therapy, efficacy is similar for each class, and SGAs appear to have the most favorable adverse effect profile.

Sexuality and the Older Adult.

PURPOSE OF REVIEW: This paper provides an overview of biopsychosocial components of sexuality in older adults, sexual expression in older LGBTQ and cognitively impaired adults, and inappropriate sexual behaviors (ISBs) in dementia. RECENT FINDINGS: Sexual expression of older adults is influenced by diverse psychosocial and biologic determinants including ageist beliefs. Although the prevalence of sexual dysfunction increases with age, studies of sexual satisfaction reveal that only a minority experience significant distress. Stigma against sexual expression in LGBTQ older adults may cause concealment of sexual orientation from family or care providers due to fears of rejection. Cognitive impairment affects frequency of and satisfaction with sexual activity, as well as capacity to consent. Staff biases about sexuality can negatively impact sexual expression in healthcare settings. Dementia-related inappropriate sexual behaviors (ISBs) are common and distressing. Recent research has focused on early identification and prevention of ISB, in addition to management through non-pharmacologic and pharmacologic approaches. Sexuality remains integral to quality of life for many older adults and informed consideration of their needs is critical to healthcare delivery and institutional service planning. A comprehensive understanding of older adults' sexuality can enhance education, research, policy, and clinical care for this growing population.

Antidepressants for anxiety disorders in late-life: A systematic review.

BACKGROUND: Anxiety in late-life is a frequently encountered condition. The aim of this review is to systematically examine the efficacy and tolerability of antidepressants for treating anxiety disorders among older adults. METHODS: Electronic searches of The Cochrane Central Register of Controlled Trials and the standard bibliographic databases PubMed, MEDLINE, EMBASE, and PsycINFO were performed in August 2018 and updated in October 2018 for randomized controlled trials (RCTs) evaluating antidepressants for late-life anxiety. The quality of each study was appraised using criteria developed by the Centre for Evidence-Based Medicine. RESULTS: Data from 12 papers describing 10 RCTs of antidepressants for late-life anxiety are included in this review. There were 2 studies each of sertraline, escitalopram, and duloxetine, and 1 study each of citalopram, paroxetine, venlafaxine, and imipramine. Across all trials, antidepressants were associated with a significant reduction in anxiety symptoms at the end of the study period. Limitations of the trials include a preponderance of generalized anxiety disorder and relatively less data on other anxiety disorders, and limited data on long-term use of antidepressants for anxiety. CONCLUSIONS: Antidepressants are beneficial for treating anxiety disorders in late life and are generally well tolerated.

Use of cariprazine in psychiatric disorders: A systematic review.

BACKGROUND: Cariprazine was approved for treating schizophrenia and bipolar disorder, and currently is being evaluated for treating depression in clinical trials in the United States. We systematically reviewed the literature on the efficacy and safety of cariprazine. METHODS: We performed a literature search of the PubMed, MEDLINE, PsycINFO, EMBASE, and Cochrane collaboration databases through August 31, 2016. The search was not restricted by patient age. Articles published in English or official English translations were included. RESULTS: Eleven articles that evaluated the use of cariprazine in the treatment of psychiatric disorders were identified. Four trials evaluated the safety and efficacy of cariprazine in bipolar disorder. One trial investigated its use as an adjunct to antidepressants in major depressive disorder. Three trials evaluated its use in the treatment of acute exacerbations of schizophrenia. Two studies used risperidone or aripiprazole as comparators. Both low- and high-dose cariprazine were more effective than placebo in the treatment of acute mania, mixed episodes, and acute psychosis. Additionally, cariprazine showed efficacy as an adjunctive treatment for depression. CONCLUSIONS: Our review indicates that cariprazine demonstrates superior efficacy and good tolerability, both at low and high doses, in the treatment of individuals with psychosis, mania, and depression.

Is ondansetron beneficial for psychosis associated with dementia?.

BACKGROUND: This systematic review identified published studies that evaluated the use of ondansetron in individuals with psychosis associated with dementia. METHODS: A literature search was conducted of PubMed, MEDLINE, EMBASE, PsycINFO, and Cochrane Collaboration databases for randomized controlled trials (RCTs), cohort studies, and case reports that evaluated the use of ondansetron for individuals with psychosis associated with dementia. Bibliographic databases of published articles were also searched for additional studies. RESULTS: A total of 4 studies were identified, all of which were open-label trials of ondansetron for psychosis associated with Parkinson's disease. All trials showed improvements in visual hallucinations and paranoid ideations in most patients, as well as a modest improvement in functioning, but no evidence of cognitive improvement. CONCLUSIONS: Ondansetron appears to have benefit in improving positive symptoms of psychosis in individuals with Parkinson's disease, but RCTs are needed before routine use is recommended. There is a paucity of evidence for the use of ondansetron for psychosis associated with other forms of dementia.

Ethical, Legal and Forensic Issues in Geriatric Psychiatry.

PURPOSE OF THE REVIEW: To evaluate the ethical, legal and forensic issues that is faced by the older adult population. RECENT FINDINGS: Many older individuals will face a host of ethical, medical and legal issues associated with their care. Most prominent among these issues are the maintenance of autonomy while ensuring their safety and the safety of individuals who care for them. Decisions regarding end of life including the formulation of advance directives add to the complexity of care for these older adults. A significant portion of individuals in the criminal justice system are aging and many of these individuals have psychiatric disorders. Their care is compromised due to the lack of appropriate services within criminal justice system for providing care for these individuals. CONCLUSIONS: Ethical, legal and forensic issues among older are not uncommon and complicate the care of these vulnerable individuals.

Anticonvulsants as monotherapy or adjuncts to treat alcohol withdrawal: A systematic review.

BACKGROUND: This systematic review evaluates current literature on anticonvulsants to treat alcohol withdrawal symptoms (AWS). METHODS: We performed a literature search of PubMed, MEDLINE, PsycINFO, EMBASE, and Cochrane collaboration databases through September 30, 2016. The search was not restricted by patients' age. Articles published in English or with official English translations were included. RESULTS: We found 16 double-blind randomized controlled trials (RCTs) that evaluated the use of anticonvulsants as treatment of AWS. Available data indicates that anticonvulsants are as effective as sedatives/hypnotics in treating mild or moderate AWS. Two studies evaluated the use of anticonvulsants as adjuncts. Combining anticonvulsants with sedatives decreases the quantity of sedatives required and AWS may resolve quicker. There is some data that anticonvulsants can be used to treat AWS as monotherapy. Fourteen of these studies assessed adverse effects of these medications; 13 studies identified minor adverse effects and one found the adverse effects to be intolerable. CONCLUSIONS: Available evidence indicates that anticonvulsants have good efficacy as monotherapy and as adjuncts with sedatives/hypnotics in treating mild to moderate AWS.