Life-Course Brain Health as a Determinant of Late-Life Mental Health: American Association for Geriatric Psychiatry Expert Panel Recommendations.

This position statement of the Expert Panel on Brain Health of the American Association for Geriatric Psychiatry (AAGP) emphasizes the critical role of life course brain health in shaping mental well-being during the later stages of life. Evidence posits that maintaining optimal brain health earlier in life is crucial for preventing and managing brain aging-related disorders such as dementia/cognitive decline, depression, stroke, and anxiety. We advocate for a holistic approach that integrates medical, psychological, and social frameworks with culturally tailored interventions across the lifespan to promote brain health and overall mental well-being in aging adults across all communities. Furthermore, our statement underscores the significance of prevention, early detection, and intervention in identifying cognitive decline, mood changes, and related mental illness. Action should also be taken to understand and address the needs of communities that traditionally have unequal access to preventive health information and services. By implementing culturally relevant and tailored evidence-based practices and advancing research in geriatric psychiatry, behavioral neurology, and geroscience, we can enhance the quality of life for older adults facing the unique challenges of aging. This position statement emphasizes the intrinsic link between brain health and mental health in aging, urging healthcare professionals, policymakers, and a broader society to prioritize comprehensive strategies that safeguard and promote brain health from birth through later years across all communities. The AAGP Expert Panel has the goal of launching further activities in the coming months and years.

A Cross-Sectional, Retrospective, and Comparative Study between Delirium and Non-Delirium Psychiatric Disorders in a Psychogeriatric Inpatient Population Referred to Consultation-Liaison Psychiatry Unit.

Background and objectives: Delirium is the most prevalent psychiatric disorder in inpatient older people. Its presence is associated with higher rates of institutionalization, functional disability and mortality. This study aims to evaluate delirium in a hospitalized psychogeriatric population, focusing on which factors predict the appearance of delirium, the impact it generates and the diagnostic concordance between non-psychiatric physicians and psychiatrists. Material and methods: This is an observational, cross-sectional, retrospective, and comparative study. We obtained data from a sample of 1017 patients (≥65 years) admitted to general hospital and referred from different services to the consultation-liaison psychiatry (CLP) unit. Logistic regression was performed using delirium as the dependent variable. To estimate the concordance of the diagnoses, the Kappa coefficient was used. To assess the impact of delirium, an ordinal regression, Wilcoxon median test and Fisher's test were performed. Results: Delirium is associated with a higher number of visits, OR 3.04 (95% CI 2.38-3.88), longer length of stay and mortality, OR 2.07 (95% CI, 1.05 to 4.10). The model to predict delirium shows that being >75 years old has an OR of 2.1 (95% CI, 1.59-2.79), physical disability has an OR of 1.66 (95% CI, 1.25-2.20), history of delirium has an OR of 10.56 (95% CI, 5.26-21.18) and no use of benzodiazepines has an OR of 4.24 (95% CI, 2.92-6.14). The concordance between the referring physician's psychiatric diagnosis and the psychiatrist CLP unit showed a kappa of 0.30. When analysing depression and delirium, the concordance showed Kappa = 0.46. Conclusions: Delirium is a highly prevalent psychiatric disorder, but it is still underdiagnosed, with low diagnostic concordance between non-psychiatric doctors and psychiatrists from CLP units. There are multiple risk factors associated with the appearance of delirium, which must be managed to reduce its appearance.

Enhancing specialty training in geropsychology competencies: An evaluation of a VA Geriatric Scholars Program advanced topics workshop.

There is a growing need for psychologists with specialized training in geriatric mental health competencies. The Geriatric Scholars Program for Psychologists (GSP-P) was created to address this shortage within a large integrated healthcare system. In 2019, GSP-P piloted an advanced workshop designed to enhance expertise in geriatric mental health competencies among graduates of its foundational competencies core course. The workshop included 3.5 days of expert-led seminars regarding the biopsychosocial needs of older adults with chronic medical illness and was followed by completion of an individualized learning plan. This paper describes the evaluation of the course using a mixed methods with data collected prior to the workshop, immediately post-workshop, and six months post-workshop. Results indicated enthusiasm for the workshop, significant improvements in four geropsychology domains on the Pikes Peak Geropsychology Knowledge and Skill Assessment Tool, and benefit from completion of the independent learning plans. Our findings demonstrate that continued enhancement of geropsychology competencies through advanced coursework is feasible and improves knowledge and skill, particularly when combined with individualized learning plans.

Impact of standardizing care for agitation in dementia using an integrated care pathway on an inpatient geriatric psychiatry unit.

OBJECTIVES: This study examined the effectiveness of an integrated care pathway (ICP), including a medication algorithm, to treat agitation associated with dementia. DESIGN: Analyses of data (both prospective and retrospective) collected during routine clinical care. SETTING: Geriatric Psychiatry Inpatient Unit. PARTICIPANTS: Patients with agitation associated with dementia (n = 28) who were treated as part of the implementation of the ICP and those who received treatment-as-usual (TAU) (n = 28) on the same inpatient unit before the implementation of the ICP. Two control groups of patients without dementia treated on the same unit contemporaneously to the TAU (n = 17) and ICP groups (n = 36) were included to account for any secular trends. INTERVENTION: ICP. MEASUREMENTS: Cohen Mansfield Agitation Inventory (CMAI), Neuropsychiatric Inventory Questionnaire (NPIQ), and assessment of motor symptoms were completed during the ICP implementation. Chart review was used to obtain length of inpatient stay and rates of psychotropic polypharmacy. RESULTS: Patients in the ICP group experienced a reduction in their scores on the CMAI and NPIQ and no changes in motor symptoms. Compared to the TAU group, the ICP group had a higher chance of an earlier discharge from hospital, a lower rate of psychotropic polypharmacy, and a lower chance of having a fall during hospital stay. In contrast, these outcomes did not differ between the two control groups. CONCLUSIONS: These preliminary results suggest that an ICP can be used effectively to treat agitation associated with dementia in inpatients. A larger randomized study is needed to confirm these results.

[The role of the old age psychiatrist in a mobile geriatric team: an example in Tours city area (France)]. / Place du psychiatre de la personne âgée au sein d'une équipe mobile de gériatrie extrahospitalière : l'exemple tourangeau.

BACKGROUND: Demographic changes require an adaptation of the geriatric care offer, which is readily oriented towards the community and including the development of out-of-hospital mobile geriatric team (MGT). Although psychiatric disorders of older persons require a comprehensive, integrative and multidisciplinary approach, geriatrics and old age psychiatry mobile units often work in parallel without concertation for the management of complex pathologies. The aim of this paper is to present the organisation and the results of a out-of-hospital MGT with a geriatrician and old age psychiatrists (OAP) in a same unit. METHOD: Data were collected during the first-year (2018) of the out-of-hospital MGT of Tours University hospital. After initial geriatric assessment and when old age psychiatry (OAP) intervention was needed, referral mode and justification, patient's characteristics and recommendations made by the team were collected. RESULTS: During the study period, 151 patients were assessed, 53% (n=80) had out-of-medical follow-up or difficulties to access to healthcare; 40% (n=60) had behavioural and psychological symptoms of dementia (BPSD), 30% (n=45) falls, 15% (n=23) social problems, 10% (n=15) alteration of overall health status and 5% (n=7) drug conciliation; 40% (n=60) benefited from an OAP evaluation; 100% (n=60) had out of medical follow-up, 83% (n=50) had severe BPSD, 17% (n=10) psychological symptom with psychiatric condition, 10% (n=6) misused psychotropic medications in charge of general comorbidities decompensation; 32% (n=19) had geriatric, OAP consultations and 33% (n=20) were in denial of care; 23% (n=14) with severe BPSD had a second OAP consultation. DISCUSSION: Relationship between geriatrician and OAP in the same MGT enables to deliver comprehensive care, including organic, psychiatric and cognitive comorbidities and collaborative assessment of iatrogenicity. A strengthened relationship with general practitioners is a possible option for these frail older patients, out-of-medical follow-up allowing their reintegration in the geriatric healthcare system.

Substance Use Disorders in Later Life: A Review and Synthesis of the Literature of an Emerging Public Health Concern.

Substance use disorders (SUDs) among older persons are among the fastest growing health problems in the United States. The number of older persons is projected to exceed 72.1 million persons by 2030, following a trend of general population growth in the mid-1940s to 1960s. The generation, known as "baby boomers," who refashioned drug use during their 20-30s, are increasingly continuing drug habits into later life. This review aims to assess the epidemiology, impact, and treatment of geriatric SUDs. Academic databases including PubMed, PsychInfo, Ovid, and Medline, were queried up to December 2018 for terms of "geriatric," "older," "elderly," "substance abuse," "drug," "drug use," "drug abuse," "drug dependency," "illicit drugs," and "geriatric psychiatry." Articles identified included 17 government documents, 29 studies based upon government documents, 43 studies not related to US government surveys, 19 review articles, 9 commentary pieces, 4 newspaper articles, 2 textbooks, and 1 published abstract. Evaluated studies and documents together suggest that older individuals are using illicit drugs and meeting criteria for SUDs at higher rates than previous geriatric cohorts resulting in substantial negative impacts on medical and psychiatric conditions. These findings represent a novel trend since previous cohorts of older individuals were thought to rarely use illicit substances. Current treatment models are inadequate to address the new wave of older individuals with SUDs. The fields of geriatrics, addiction, and geriatric psychiatry must work together to establish comprehensive care models and treatment modalities for addressing this emerging public health concern.

Implementing physical exercise and music interventions for patients suffering from dementia on an acute psychogeriatric inpatient ward.

Background: Increasing attention is focusing on psychosocial interventions for treating patients with dementia. Aims: This observational intervention study investigated the impact of physical exercise and music interventions among patients with dementia on an acute psychogeriatric ward. Materials and methods: The data were collected during February 2009-December 2010 (n = 89; treatment as usual) and during April 2011-March 2013 (n = 86; treatment as usual with physical exercise, e.g. balance, flexibility, strength training, and music interventions, e.g. singing, listening to music and playing instruments). The primary outcome measure was the Neuropsychiatric Inventory and the secondary outcome measures were the Alzheimer's Disease Cooperative Study-Activities of Daily Living, the Barthel Index, and the Mini-Mental State Examination. Results: In both groups, neuropsychiatric symptoms (NPS) decreased (p < .001) but daily functioning deteriorated (p < .001). No significant between-group differences for either outcome variable were found. Based on linear mixed models, fewer exercise sessions associated with more severe symptoms (p = .030), and the time variable (admission/discharge) with a decline in the level of NPS (p < .001). Moreover, female gender (p = .026) and more exercise sessions (p = .039) associated with an increased level of functioning (p = .031) and the time variable (admission/discharge) with a drop in the level of functioning during hospitalization (p < .001). Conclusion: Although no differences were found between the study groups, analysis within the intervention group suggest that physical exercise may have some positive effects for both NPS and the level of functioning in some patients with dementia while no positive effects regarding music interventions were found.

An integrated, collaborative healthcare model for the early diagnosis and management of dementia: Preliminary audit results from the first transdisciplinary service integrating family medicine and geriatric psychiatry services to the heart of patients' homes.

BACKGROUND: The number of dementia cases is expected to rise exponentially over the years in many parts of the world. Collaborative healthcare partnerships are envisaged as a solution to this problem. Primary care physicians form the vanguard of early detection of dementia and influence clinical care that these patients receive. However, evidence suggests that they will benefit from closer support from specialist services in dementia care. An interdisciplinary, collaborative memory clinic was established in 2012 as a collaborative effort between a large family medicine based service and a specialist geriatric psychiatry service in Singapore. It is the first service in the world that integrates a family medicine based service with geriatric psychiatry expertise in conjunction with community-based partnerships in an effort to provide holistic, integrated care right into the heart of patients' homes as well as training in dementia care for family medicine physicians. We describe our model of care and the preliminary findings of our audit on the results of this new model of care. METHODS: This was a retrospective audit done on the electronic medical records of all patients seen at the Memory Clinic in Choa Chu Kang Polyclinic from August 2013 to March 2016. The information collected included gender, referral source, patient trajectories, presence of behavioural and psychological symptoms of dementia and percentage of caregivers found to be in need of support. A detailed outline of the service workflow and processes were described. RESULTS: A majority (93.5%) of the patients had their memory problems managed at the memory clinic without escalation to other specialist services. 22.7% of patients presented with behavioural and psychological symptoms of dementia. When initially assessed, a majority (82.2%) of patients' caregivers were found to be in need of support with 99.5% of such caregivers' needs addressed with memory clinic services. CONCLUSION: Our model of care has the potential to shape future dementia care in Singapore and other countries with a similar healthcare setting. Redesigning and evolving healthcare services to promote close collaboration between primary care practitioners and specialist services for dementia care can facilitate seamless delivery of care for the benefit of patients.

Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy with Older Adults: A Qualitative Review of Randomized Controlled Outcome Research.

Objective: Many older adults cope with various chronic physical health conditions, and in some cases, with mental health and/or cognitive difficulties. Mindfulness-based interventions offer an evidence-based, mind-body complementary treatment approach for a wide range of comorbidities, yet most investigations were conducted with young or middle-aged adults. The purpose of this review was to identify randomized controlled trials (RCTs) of two leading mindfulness-based interventions conducted with older adults. Methods: Our search of five databases identified seven RCT investigations of either Mindfulness-Based Stress Reduction (MBSR) or Mindfulness-Based Cognitive Therapy (MBCT) conducted exclusively with older adults. Results: Results generally supported the use of MBSR for chronic low back pain, chronic insomnia, improved sleep quality, enhanced positive affect, reduced symptoms of anxiety and depression, and improved memory and executive functioning. In a sample of older adults exhibiting elevated anxiety in the absence of elevated depression, MBCT effectively reduced symptoms of anxiety. Conclusions: This review highlights the feasibility and possible benefits of MBSR and MBCT for older adults. Additional large scale RCTs conducted with older adults coping with the range of physical, behavioral, and cognitive challenges older adults commonly face still are needed. Clinical Implications: MBSR may be a promising intervention for older adults experiencing a variety of health concerns and possibly even cognitive decline. MBCT may reduce geriatric anxiety, although its effects on geriatric depression were not measured.

Management of behavioral and psychological symptoms in people with Alzheimer's disease: an international Delphi consensus.

ABSTRACTObjectives:Behavioral and psychological symptoms of dementia (BPSD) are nearly universal in dementia, a condition occurring in more than 40 million people worldwide. BPSD present a considerable treatment challenge for prescribers and healthcare professionals. Our purpose was to prioritize existing and emerging treatments for BPSD in Alzheimer's disease (AD) overall, as well as specifically for agitation and psychosis. DESIGN: International Delphi consensus process. Two rounds of feedback were conducted, followed by an in-person meeting to ratify the outcome of the electronic process. SETTINGS: 2015 International Psychogeriatric Association meeting. PARTICIPANTS: Expert panel comprised of 11 international members with clinical and research expertise in BPSD management. RESULTS: Consensus outcomes showed a clear preference for an escalating approach to the management of BPSD in AD commencing with the identification of underlying causes. For BPSD overall and for agitation, caregiver training, environmental adaptations, person-centered care, and tailored activities were identified as first-line approaches prior to any pharmacologic approaches. If pharmacologic strategies were needed, citalopram and analgesia were prioritized ahead of antipsychotics. In contrast, for psychosis, pharmacologic options, and in particular, risperidone, were prioritized following the assessment of underlying causes. Two tailored non-drug approaches (DICE and music therapy) were agreed upon as the most promising non-pharmacologic treatment approaches for BPSD overall and agitation, with dextromethorphan/quinidine as a promising potential pharmacologic candidate for agitation. Regarding future treatments for psychosis, the greatest priority was placed on pimavanserin. CONCLUSIONS: This international consensus panel provided clear suggestions for potential refinement of current treatment criteria and prioritization of emerging therapies.

Spirituality in geriatric psychiatry.

PURPOSE OF REVIEW: Academic recognition of the implications of religion/spirituality (R/S) for mental health is increasing, with a growing number of studies involving older adults. The present review provides an overview of these studies, highlighting the influence of R/S on older adults' mental health and the clinical implications of addressing R/S in the geriatrics and gerontology context. RECENT FINDINGS: The available evidence suggests that R/S involvement is usually associated with lower levels of depression, substance use/abuse, and cognitive declining and better quality of life, well being, and functional status in older persons. Despite the number of studies showing this relationship, few have yet investigated the effects of addressing spiritual needs or carrying out R/S interventions in this age group. SUMMARY: Evidence is mounting that R/S is most important in geriatric psychiatry. In general, studies have shown a positive relationship between R/S and mental health in the older population. Health professionals should be attentive to these spiritual needs. Nevertheless, more studies are needed to investigate the mechanisms of the R/S-mental health association and how to integrate R/S in clinical practice.

Mind-Body Therapies for Late-Life Mental and Cognitive Health.

PURPOSE OF REVIEW: A growing body of research supports the use of mind-body therapies (MBTs) as minimally invasive and effective approaches for the management of late-life mood and cognitive disorders. RECENT FINDINGS: Recent randomized controlled trials and meta-analyses indicate that MBTs are effective for enhancing well-being, mood, sleep, and cognition in older adults. Evidence suggests that mindful movement (e.g., yoga, tai chi, walking meditation) may even outperform conventional physical exercise with regard to effects on quality of life, mood, and cognitive functioning. Practitioners may recommend MBTs as holistic, effective approaches for the management of common late-life mood and cognitive disorders. Continued research on MBTs will inform the development of even more effective/targeted interventions and contribute to greater acceptance and integration of these therapies into geriatric medicine and psychiatry.

[From boxing to geriatric psychiatry : Facets from the work of East German social psychiatrist Bernhard Schwarz (1918-1991)]. / Vom Boxsport bis zur Gerontopsychiatrie : Facetten des Schaffens des DDR-Sozialpsychiaters Bernhard Schwarz (1918­1991).

For the first time, this study presents publications representative for the work of the neurologist and sports physician Bernhard Schwarz, whose career spans from the 1950s to the 1970s. His work is characterized by exceptional originality. Schwarz acted as the physician of the GDR national boxing team and conducted a systematic long-term study of 800 boxers. He found increased occurrences of depression, Alzheimer's and Parkinson's diseases and suggested that these were linked to recurring craniocerebral injury. He was concerned about avoiding such long-term health effects in boxers and suggested a range of preventive measures that were later reflected in the guidelines of international boxing associations. Schwarz was distinguished by his drive to directly implement social psychiatric approaches in the hospital. As head of the psychiatric clinic at Leipzig University, he initiated a club for geriatric patients to help older patients with the problematic transition from hospitalization to outpatient assistance at home. Influenced by holistic anthropological thinking, he regarded geriatric mental illness as a consequence of social isolation. In addition, Schwarz was involved in a model project that assessed the work resilience of patients in the hospital with the goal of optimizing psychiatric rehabilitation. Both projects were successes, according to his published accounts.

Integrating iCBT for generalized anxiety disorder into routine clinical care: Treatment effects across the adult lifespan.

The burden attributable to late-life Generalized Anxiety Disorder (GAD) is set to increase alongside the ageing population. Yet, the psychogeriatric workforce is limited in size and few studies have focused on the treatment of GAD among older patients. Internet-delivered cognitive behavioral therapy (iCBT) could be integrated into existing infrastructure and scale the psychogeriatric workforce, if shown to be effective across the adult lifespan. This study examined age-related differences in presentation, adherence and effects of iCBT for GAD among patients in routine clinical care (N=942; 18-29years (n=267); 30-39years (n=260); 40-49years (n=180); 50-59years (n=124); and 60+ years (n=111)). Compared to younger patients, older patients were less likely to present with probable GAD and MDD diagnoses (<60years vs. 60+ years) and more likely to complete treatment (<50years vs. 50+ years). iCBT produced moderate to large effect size reductions in symptom severity, distress and impairment independent of age. iCBT is therefore an effective treatment for GAD across the adult lifespan, which can be delivered in routine clinical care. Continuing to integrate iCBT into existing services has the potential to improve the capacity of the existing workforce to manage those seeking help for GAD particularly as the population ages.

Estudio de la implicación en un grupo de personas con demencia con atención tradicional y un grupo con atención centrada en la persona / Study of engagement in a group of people with dementia in traditional care settings and a group with person centred care

Introducción. Las personas con demencia en contexto residencial presentan un grado elevado de apatía y desconexión con el entorno. La ausencia de estimulación y la baja frecuencia de actividades personalizadas, características en los centros residenciales, podrían ser elementos contextuales que favorecen estos comportamientos. El modelo de atención centrado en la persona (MACP) promueve la participación de las personas en actividades cotidianas acorde con sus recursos, sus intereses y necesidades. El objetivo de este estudio es comparar la frecuencia de conductas de implicación y desimplicación en las actividades cotidianas en 2 grupos de usuarios residentes en unidades psicogeriátricas, asistido uno de ellos según el modelo tradicional y el otro según el MACP. Metodología. Participaron en el estudio 28 sujetos con deterioro cognitivo y residentes en unidades psicogeriátricas: 14 usuarios de una unidad tradicional (grupo control) y 14 en una unidad en la que se incorporaron intervenciones relativas al MACP (grupo experimental). Los grupos fueron equivalentes en deterioro cognitivo, capacidades funcionales y años de ingreso. Se utilizó el Registro de Implicación/Engagement para observar en ambos grupos la frecuencia de 12 categorías de comportamiento de implicación en 2 períodos diferenciados: antes de las intervenciones asociadas al MACP y 18 meses después de haber comenzado las mismas. Resultados. Ambos grupos vieron incrementada la frecuencia de sus conductas de implicación en el período post; sin embargo, el grupo experimental disminuyó los comportamientos de desimplicación, mientras que el grupo control los aumentó. Conclusiones. Acorde con los datos, intervenciones asociadas al MACP podrían minimizar los comportamientos de desconexión con el entorno que suceden en el contexto residencial vinculando a las personas al contexto y facilitando la participación e implicación en las actividades de la vida diaria (AU)

Introduction. People with dementia in the residential care setting have a high level of apathy and disengagement. The lack of stimulation and customised activities, a common aspect in residential centres, could be contextual elements that promote these behaviours. The person-centred care model (PCCM) promotes the participation of people in their daily activities in relation to their resources, interests, and needs. The aim of this study is to compare the frequency of engagement behaviours in the daily activities in two groups of users residing in Psychogeriatric Units, one receiving a traditional care model and the other assisted under PCCM. Methodology. The study involved 28 patients with cognitive impairment in Psychogeriatric Units, 14 of whom were in a traditional unit (control group), and 14 were in a unit where PCCM (experimental group) was implemented. Groups were equivalent in cognitive impairment, functional capabilities, and years in the long-term care institution. The Registering Engagement Instrument (REI) was used to observe the frequency of 12 categories of engagement behaviour in two distinct periods in both groups: before the interventions associated with PCCM, and 18 months after starting them. Results. Both groups increased the frequency of their engagement behaviours in the post-evaluation, but the experimental group decreased their disengagement behaviours while the control group increased them. Conclusions. According to the data, PCCM interventions could reduce disengagement behaviours in the residential context, and could facilitate the participation and involvement in the activities of daily living (AU)

Mental health disorders in home care elders: An integrative review.

Home care is the fastest growing U.S. health care sector, serving a predominance of highly vulnerable elderly patients. Mental health disorders (MHDs) are a major health concern in this population, however, current knowledge regarding their occurrence and associated correlates is inadequate. To address this gap, this integrative review examined existing findings regarding the prevalence and correlates of MHDs in home care elders. A search of six electronic databases and a hand search produced a final group of 36 articles for review. Poor data representativeness and methodological limitations impacted the quality of these studies, as reflected in an extremely wide range of prevalence estimates for these disorders (12% - 62%). A number of recommendations are made with respect to future research in this area. These include conducting multi-site investigations and the use of consistent and clear protocols for identification of MHDs in home care elders, a growing and significantly under-served population.

Clinical Advances in Geriatric Psychiatry: A Focus on Prevention of Mood and Cognitive Disorders.

The world population is aging at a rate unprecedented in human history, placing substantial pressure on health systems across the world along with concurrent rises in chronic diseases. In particular, rates of cognitive disorders and late-life affective disorders are expected to increase. In tandem with aging, there are robust predictions suggesting that rates of age-related cognitive decline and dementia, and geriatric depression, will increase, with serious consequences. Clearly innovative prevention and treatment strategies are needed. This article reviews the latest promising clinical advances that hold promise for assisting the prevention and treatment of depression, cognitive decline, and dementia.

Meditation for older adults: a new look at an ancient intervention for mental health.

New research is providing health care professionals with evidence for the effectiveness of mindfulness meditation as an intervention for older adults. Recent studies have provided evidence that meditation results in observable changes in brain structure related to memory, sense of self, empathy, and stress. Health care professionals should consider mindfulness training as a helpful intervention for older adults with problems such as depression, anxiety, chronic pain, loneliness, and caregiver burden.