Treating Symptoms of Posttraumatic Stress in People with Dementia: Expert Consensus Using the Delphi Method.

OBJECTIVES: Posttraumatic stress disorder is frequently present in people with dementia, but the symptoms are difficult to recognize and suitable treatments are lacking. The aim of the present study was to investigate which trauma-focused treatments are applicable to these patients. METHODS: The Delphi method is a process which is used to reach consensus from a panel of experts. The study was conducted online and consisted of three rounds with statements about support for treatment, treatment, and implementation. RESULTS: There are several treatment options available, but it depends on the symptoms, and the severity of PTSD and dementia which treatment is most suitable. CONCLUSIONS: The outcomes offer some practical tips for health care workers, and they provide a fundamental base for future research. CLINICAL IMPLICATIONS: Clinicians should pay attention to the treatment of PTSD symptoms in people with dementia and it is necessary to examine the type and severity of both PTSD symptoms and dementia. Taking these factors into account, clinicians are able to focus on the best treatment option in order to improve the quality of life of these specific type of patients.

Gender-specific characteristics of alcohol use in community-dwelling older adults in Belgium.

OBJECTIVES: Gender has been identified as an important social determinant for health. This study investigates gender-specific characteristics for alcohol use (AU) among community-dwelling older adults. METHODS: This is a retrospective cross-sectional study in 1,406 community-dwelling older adults. We used standardized questionnaires to collect self-reported data on alcohol use behavior, mental health, drinking motives and resilience by using, respectively, the Alcohol Use Identification Test (AUDIT), the Brief Symptom Inventory (BSI), the Drinking Motives Questionnaire (DMQ), and the Connor-Davidson Resilience Scale (CD-RISC). Multiple linear regression was used to identify the joint contribution of those factors on AU. Hierarchical regression was used to investigate the influence of the interaction between gender and those factors on AU. RESULTS: Linear regression analyses showed different associations with AU in men and women. Hierarchical regression analyses showed that gender presented a two-way interaction effect with enhancement and anxiety variables related to AU. CONCLUSIONS: Different characteristics were found as predictors for AU among older men and women. CLINICAL IMPLICATIONS: Clinicians and health-care providers should be aware of these differences in order to provide tailored screening and intervention programs to reduce AU in older adults.

Resilience, depression and anxiety and hazardous alcohol use behaviour among community dwelling older adults.

INTRODUCTION: We examined the psychometric properties of the CD-RISC, including factor structure. Secondly, we examined if resilience factors moderate the association between negative affect and hazardous alcohol use. METHOD: The sample population consisted of 1,368 community-dwelling older adults. We used standardized questionnaires to collect self-reported data on alcohol use behaviour, depression and anxiety and resilience by using respectively the Alcohol Use Identification Test (AUDIT), the Brief Symptom Inventory (BSI) and the Connor-Davidson Resilience Scale (CD-RISC). RESULTS: Of the total sample (N 1.368), 80.1% reported using alcohol. The total sample and the drinking sample reported, respectively, a mean of 65.75 (SD 15.40) and 65.79 (SD 15.90) on the CD-RISC. Concerning the CD-RISC, exploratory factor analysis presents four factors of which three with a good reliability. Moderation analyses reflects that older adults with higher levels of resilient characteristics didn't report an association between negative affect and hazardous drinking. Alternatively, low resilient older adults did report an positive and significant association between negative affect and hazardous drinking. CONCLUSION: The CD-RISC appeared to be a reliable instrument, containing three factors. In our sample, high resilience moderated the association between negative affect and hazardous drinking and may serve as a buffer against hazardous drinking.

Features and Needs of Autistic Older Adults: A Delphi Study of Clinical Experiences.

OBJECTIVES: In geriatric psychiatry Autism Spectrum Disorders (ASD) are increasingly recognized. This study explores what clinicians know about diagnostic and/or therapeutic aspects of autistic older adults and how aging plays a role in the course of ASD. METHODS: A Delphi study outlines the point of view of 11 clinical experts in the Netherlands and Belgium (Flanders). RESULTS: Regarding diagnostics, age-specific aspects need to be considered. Age-related characteristics (cognitive differences, life events, co-occurring conditions) influence detecting autistic features in older adults. Regarding treatment, counseling methods need to be adapted. Psychoeducation, family therapy, couples therapy, behavioral counseling and psychopharmaca can be helpful in meeting the needs of autistic older adults. There was no consensus on the effects of aging on autistic older adults. CONCLUSIONS: Diagnosis and treatment of ASD need adaptation for autistic older adults. Further research is needed on the validation of measurement tools, recorded treatment, therapy, psychoeducation, and the effects of aging among people on the autism spectrum. CLINICAL IMPLICATIONS: Available knowledge helps clinicians to detect ASD in older adults and adapt to the specific features and needs of autistic older adults. The effects of aging on the course of ASD are unclear yet.

[Psychopathology in older adults: inter-individual variability, specific presentation and ageism]. / Psychiatrische aandoeningen bij ouderen: interindividuele variabiliteit, specifieke presentatie en leeftijdsdiscriminatie.

Background Geriatric psychiatry is still a relatively young field, but it has made itself indispensable in recent years. This article examines specific features of psychopathology in older adults. Aim To examine what makes older adults ‘different’ compared to younger cohorts. Method Non-systematic literature search. Results Older adults are characterized by a large inter-individual variability, sometimes specific clinical presentation of psychopathology and/or multi-morbidity, including polypharmacy, which results in a specific integrated care with attention to age-specific adjustments in the treatment. Conclusion Psychopathology in older adults requires specialist expertise and multidisciplinary collaboration. In order to optimally treat older adults, ageism must also be tackled thoroughly.

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.

A Delphi study of late-onset personality disorders.

OBJECTIVES: The DSM-5 describes personality disorders (PDs) as emerging in early life and remaining continuous throughout the life-span. Yet case studies and expert opinion support the existence of late-onset PDs. Little is known about PDs in late life, and our instruments for assessing them are not well validated. Thus, the focus of this exploratory Delphi study was the late-onset PD, with special attention to the accuracy of the core criteria for the diagnosis. DESIGN: A Delphi study was designed to assess the presentation of PDs in late life. The Delphi consisted of three successive rounds of inquiry. Between rounds, the participants were provided with a summary of the panel's responses. PARTICIPANTS: A panel of 21 experts included published authors, researchers, and teachers from the USA, the UK, Australia, France, Belgium, and the Netherlands. MEASUREMENTS: Researchers designed a survey that included an introduction, a demographic questionnaire, and five questions that varied in presentation and response format. RESULTS: Experts reached consensus that a variant of PD appears de novo in old age. The core features of inflexibility and pervasiveness may not pertain to late-onset PD. There was agreement that frequently occurring life events contribute selectively to the expression of late-onset PD, with the major ones being death of a spouse or partner and transition to a nursing or assisted-living facility. CONCLUSIONS: Nearly all participants took the position that PD can present for the first time in old age and be clinically identifiable without having been so identified earlier in life.

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.

A cross-validation Delphi method approach to the diagnosis and treatment of personality disorders in older adults.

INTRODUCTION: The Delphi method is a consensus-building technique using expert opinion to formulate a shared framework for understanding a topic with limited empirical support. This cross-validation study replicates one completed in the Netherlands and Belgium, and explores US experts' views on the diagnosis and treatment of older adults with personality disorders (PD). METHODS: Twenty-one geriatric PD experts participated in a Delphi survey addressing diagnosis and treatment of older adults with PD. The European survey was translated and administered electronically. RESULTS: First-round consensus was reached for 16 out of 18 items relevant to diagnosis and specific mental health programs for personality disorders in older adults. Experts agreed on the usefulness of establishing criteria for specific types of treatments. The majority of psychologists did not initially agree on the usefulness of pharmacotherapy. Expert consensus was reached following two subsequent rounds after clarification addressing medication use. CONCLUSIONS: Study results suggest consensus among regarding psychosocial treatments. Limited acceptance amongst US psychologists about the suitability of pharmacotherapy for late-life PDs contrasted with the views expressed by experts surveyed in Netherlands and Belgium studies.

A first step toward integrating schema theory in geriatric psychiatry: a Delphi study.

BACKGROUND: Schematherapy (ST) is an effective therapy for personality disorders (PD's) in adults, however, empirical research into ST in older adults is limited. The manifestation of schemas over the life course is unclear. Besides, long-term patterns of schemas in old age and whether schemas change during the aging process remain unknown. METHODS: We performed a Delphi study involving a group meeting of nine experts in the field of ST in older adults. RESULTS: Full consensus was achieved that schemas vary later in life, and that this is due to biopsychosocial factors. The concepts of schema triggering (the chance that a maladaptive schema is activated) and schema coping (the psychological and behavioral effort a person makes to minimize the stress that comes with the schema) in the past are important in clinical practice. Understanding how schemas are triggered during the life course and how patients deal with their schemas throughout life will help the therapist to complete the diagnostic puzzle in older individuals and to choose appropriate interventions. CONCLUSION: Schemas are flexible and dynamic constructs that can fade or intensify due to multiple factors. This study is a first step toward advancing the state of knowledge regarding schema theory in an aging population. The results will contribute to improvements in ST in older adults by developing an understanding of the plasticity of schemas during the life course.

Measuring personality functioning in older adults: construct validity of the Severity Indices of Personality Functioning - Short Form (SIPP-SF).

OBJECTIVE: The dimensional personality disorders model in the Diagnostic and Statistical Manual (DSM)-5 section III conceptually differentiates impaired personality functioning (criterion A) from the presence of pathological traits (criterion B). This study is the first to specifically address the measurement of criterion A in older adults. Moreover, the convergent/divergent validity of criterion A and criterion B will be compared in younger and older age groups. METHOD: The Severity Indices of Personality Functioning - Short Form (SIPP-SF) was administered in older (N = 171) and younger adults (N = 210). The factorial structure was analyzed with exploratory structural equation modeling. Differences in convergent/divergent validity between personality functioning (SIPP-SF) and pathological traits (Personality Inventory for DSM-5; Dimensional Assessment of Personality Pathology-Basic Questionnaire) were examined across age groups. RESULTS: Identity Integration, Relational Capacities, Responsibility, Self-Control, and Social Concordance were corroborated as higher order domains. Although the SIPP-SF domains measured unique variation, some high correlations with pathological traits referred to overlapping constructs. Moreover, in older adults, personality functioning was more strongly related to Psychoticism, Disinhibition, Antagonism and Dissocial Behavior compared to younger adults. DISCUSSION: The SIPP-SF construct validity was demonstrated in terms of a structure of five higher order domains of personality functioning. The instrument is promising as a possible measure of impaired personality functioning in older adults. As such, it is a useful clinical tool to follow up effects of therapy on levels of personality functioning. Moreover, traits were associated with different degrees of personality functioning across age groups.

Eye movement desensitization and reprocessing therapy for personality disorders in older adults?

Eye Movement Desensitization and Reprocessing (EMDR) is a kind of psychotherapy, which is growing in popularity, particularly for treatment of post-traumatic stress disorder (PTSD). When Shapiro first introduced EMDR in 1989, it was approached as a controversial treatment because of lack of evidence. However, nowadays there is growing evidence for EMDR efficacy in PTSD (Mc Guire et al., 2014) and EMDR is recommended by international and national treatment guidelines for PTSD. Moreover, EMDR is also used for the treatment of other anxiety disorders, such as panic disorders (De Jongh et al., 2002). Furthermore, research continues on effects of EMDR in addiction, somatoform disorders and psychosis. So far, there is no empirical research on the efficacy of EMDR treatment in older adults.

[Diagnostics and treatment of autism spectrum disorders in older adults: a study by experts]. / Diagnostiek en behandeling van autisme-spectrumstoornissen bij ouderen: een expertstudie.

BACKGROUND: Empirical research into the diagnostics and treatment of older adults with autism spectrum disorders (ASD) is very limited; so far, only 17 studies have been published. ASD, however, is not confined to child and adult psychiatry. Increasingly, ASD is being identified and treated within the domain of geriatric psychiatry.
AIM: To investigate diagnostic and therapeutic aspects of ASD in older adults, and to obtain insight into how these aspects are related to ageing.
METHOD: Delphi techniques were employed via rounds of questionnaires put to experts; consensus was considered to have been achieved when a minimum of two-thirds of the experts 'agreed' or 'fully agreed' to a statement on a five-point scale.
RESULTS: Consensus was achieved for 10 of the 17 statements. According to the experts, older patients with ASD, form a specific group in psychiatry. With regard to diagnosis, there was a consensus that increased attention needs to be given to age-related aspects by linking symptoms more specifically to the patient's phase of life and to the ageing process. In the treatment of older adults with ASD, adjustments need to be made in relation to ageing.
CONCLUSION: This study by experts provides additional starting points for more research into specific topics relating to diagnostic and therapeutic aspects of ASD in geriatric psychiatry; these topics include validation of screening and diagnostic instruments, the adjustment of protocols for treatment, psycho-education and the effects of ageing in patients with ASD.

[An 87-year-old-man with late-onset frontotemporal dementia: a case-study]. / Een 87-jarige man met late-onset frontotemporale dementie.

An 87-year-old man showed behavioral disinhibition and nocturnal restlessness as well as short-term memory problems. We diagnosed late-onset frontotemporal dementia (LO-FTD), a relatively rare disease. Based on the course of the disease progress, we ruled out medication-induced mania and bipolar disorder. Given the results of the CT-scan, we also dismissed the possibility that the patient was suffering from dementia based on Alzheimer's disease and vascular factors that followed an atypical course. Our article illustrates the complexity of the diagnostic process investigating LO-FTD.

Personality disorders in older adults: emerging research issues.

Empirical research focusing on personality disorders (PDs) among older adults is mainly limited to studies on psychometric properties of age-specific personality tests, the age neutrality of specific items/scales, and validation of personality inventories for older adults. We identified only two treatment studies-one on dialectical behavior therapy and one on schema therapy-both with promising results among older patients despite small and heterogeneous populations. More rigorous studies incorporating age-specific adaptations are needed. Furthermore, in contrast to increasing numbers of psychometric studies, the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 pays little attention to the characteristics of older adults with PDs. Moreover, the constructs "personality change due to another medical condition" and "late-onset personality disorder" warrant further research among older adults. These needs will become even more pressing given the aging society worldwide.

Age Neutrality of Categorically and Dimensionally Measured DSM-5 Section II Personality Disorder Symptoms.

Studies on the face validity of DSM-5 Section II categorical personality disorder (PD) symptoms indicate a bias against older adults. To extend these results, this article explores whether categorically and dimensionally scored PD symptoms of DSM-5 Section II, as measured in the Assessment of DSM-IV Personality Disorders (ADP-IV; Schotte & de Doncker, 1994), corroborate potential age bias across younger (aged 18-34), middle-aged (35-59 years), and older adults (aged 60-75). Differential item functioning (DIF) analyses, following a classical test theory approach, showed that 2 of the 79 symptoms were measured differently across 3 age groups when categorically assessed, and 4 when dimensionally measured. Nevertheless, subsequent differential test functioning analyses supported a low aggregated impact of DIF on the dimensional scales, justifying mean-level comparisons across age groups. Generalizability of the results is discussed in light of methodological issues concerning the research of age neutrality of PD symptoms, including the employed measurement instrument, PD symptom measurement approach, and sample and age range used to describe older adults.

Interference of attention-deficit hyperactivity disorder in an older adult with a severe personality disorder and dermatillomania.

This case of a 65-year-old male with dermatillomania, diffuse anxiety symptoms, and avoidant personality disorder (PD) illustrates the interference of attention-deficit hyperactivity disorder (ADHD) in the diagnostic process and during schema-focused therapy. In conclusion, ADHD in older adults and interference with PD is a subject of clinical importance and worth further investigation.

Effects of schema group therapy in older outpatients: a proof of concept study.

BACKGROUND: Short-term group schema cognitive behavior therapy (SCBT-g) showed improvements in overall symptomatology, early maladaptive schemas (EMS) and schema modes, both in adults and adolescents with personality disorder (PD) features and long-standing mood disorders. However, no research has yet been carried out on the effect in older adults. Therefore, in a proof of concept study, we explored the effect of SCBT-g in older outpatients with PD features and longstanding mood disorders. METHOD: Thirty-one older outpatients, aged 60-78 years with PD features and/or longstanding mood disorders were included in a proof of concept study with pre-mid-post design. Primary outcome was psychological distress (Brief Symptom Inventory) and intermediate outcomes were EMS (Young Schema Questionnaire) and schema modes (Schema Mode Inventory), assessed at baseline, mid-treatment and end-of-treatment. Paired samples t-tests were conducted, and Cohen's d effect sizes reported for pre mid- and post-treatment. As proof of concept analysis, hierarchical regression analyses with residual change scores were used to analyse whether early process changes in EMS (intermediate outcomes) predicted later outcome changes in symptoms. RESULTS: SCBT-g led to significant improvement in all three measures of psychological symptoms, EMS and modes with medium effect sizes. Pre-treatment to mid-treatment changes in schema severity predicted symptom improvement from mid- to end-of-treatment. CONCLUSION: This proof of concept study shows that SCBT-g has potential to change EMS and to show significant effect at symptom level in older outpatients with PD features. A control condition in a randomized controlled trial is a necessary step for further research.

Age neutrality of the young schema questionnaire in patients with a substance use disorder.

BACKGROUND: Young's Schema Focused Therapy (SFT) is gaining popularity in the treatment of older adults. In the context of this therapy, the Young Schema Questionnaire (YSQ) was developed to assess the early maladaptive schemas (EMS). EMS are considered to be relatively stable over time, but research shows that questionnaires often lack face validity in older adults, which makes it difficult to investigate EMS in older adults and their stability across the lifespan. METHODS: In the present cross-sectional study, we investigated the age neutrality of the Young Schema Questionnaire--Long Form in young (aged 18-34 years), middle-aged (aged 35-59 years), and older (aged 60-75 years) adults in a clinical sample of substance use disorders (N = 321) by examining potential differential item functioning (DIF). While investigating the stability of the schemas, we controlled for substance dependency and clinical symptoms by means of, respectively, the Drug Use Screening Inventory - Revised and the Symptom Checklist-90-R. RESULTS: The Bonferroni-adjusted Liu-Agresti Cumulative Common Log-Odds Ratio confirmed large DIF for six items, divided across five schema scales (Mistrust/Abuse, Subjugation, Entitlement, Enmeshment and Self-sacrifice). Of the six items that presented DIF, only one item showed differential test functioning (Entitlement). Overall results show only 3% DIF, implying age neutrality of the questionnaire. CONCLUSIONS: Current results corroborate that most EMS scales are equally measured across age, and reliable comparisons can be made across the lifespan, allowing for good clinical practice and further research on SFT in older adults. Only for Entitlement, Enmeshment, and Insufficient Self-control, caution is needed when comparing mean scores across the age groups.

[Mediative therapy in home care for older adults: unknown and unused]. / Mediatieve therapie in de thuiszorg: Onbekend en onbenut.

Little is known concerning specific psychological interventions in home care for older adults with behavioral problems. This case study of a male with offensive verbal behaviour gives an impression of a targeted psychosocial intervention program. Interventions in which irrational cognitions are detected and challenged, and replaced with more helpful attitudes, were trained in role-playing. Psychosocial interventions are of importance in homecare. The dependency and vulnerability of the elderly patient make explicit principles relevant, which are outlined in this article.