COVID-19 Associated Suicidal Ideation in Older Adults: Two Case Reports With a Review of the Literature.

The COVID-19 pandemic may profoundly harm the mental health and emotional well- being of many older adults. Public health interventions to minimize the spread of the virus have had the unintended consequences of worsening social isolation, financial stress, and unemployment. Results of early research efforts assessing the impact of these interventions on the mental health of older adults have been mixed. Available findings suggest that a subset of community-dwelling older adults have been less negatively impacted than younger adults, while people of color, the poor, residents of nursing homes and other communal living environments, and those living with dementia and their caregivers are more likely to suffer from COVID-related health problems. This manuscript describes two older adults for whom COVID-19 associated stresses caused significant worsening in their psychiatric illnesses, including the emergence of suicidal ideation, summarizes the literature on the impact of interactions between psychosocial stresses and biological factors on the mental health and well-being of older adults, and discusses interventions to help older adults whose mental health has worsened due to COVID-19. Timely and accurate diagnosis, prompt provision of individualized care using both pharmacologic and psychotherapeutic interventions, adoption of new technologies that permit care to be provided safely at a distance and which allow for virtual social interactions, coupled with ongoing advocacy for policy changes that address significant health care disparities and provide older adults continued access to health care and relief from financial hardship, will help older adults remaining as healthy as possible during the pandemic.

Assessing the LGBT cultural competency of dementia care providers.

INTRODUCTION: Although dementia risk factors are elevated in lesbian, gay, bisexual, and transgender (LGBT) older adults and are perpetuated by a lack of cultural competency, no known studies have quantified LGBT cultural competency among dementia care providers. METHODS: Dementia care providers (N = 105) across the United States completed a survey consisting of the 7-point Likert LGBT-Development of Clinical Skills Scale. RESULTS: Dementia care providers reported very high affirming attitudes (M = 6.67, standard deviation [SD] = 0.71), moderate knowledge (M = 5.32, SD = 1.25), and moderate clinical preparedness (M = 4.93, SD = 1.23). Compared to previously published data, they reported significantly lower knowledge than medical students. There were no differences compared to psychiatry residents. DISCUSSION: The current state of dementia care providers' LGBT cultural competency has significant, yet modifiable, gaps. Better education, including more LGBT patient exposure, is necessary to improve the care being provided to members of the LGBT community impacted by dementia illness.

Central Nervous System Systemic Lupus Erythematosus (CNS-SLE) Vasculitis Mimicking Lewy Body Dementia: A Case Report Emphasizing the Role of Imaging With an Analysis of 33 Comparable Cases From the Scientific Literature.

INTRODUCTION: Neuropsychiatric symptoms occur in 30% to 40% of patients living with systemic lupus erythematosus (SLE). Brain imaging may play a pivotal role in determining the etiology as it did for the case presented here. METHODS: A new case of central nervous system (CNS) SLE is presented along with an analysis of 33 comparable cases from the scientific literature. RESULTS: A 70-year-old female with subacute cutaneous lupus presented to a university-based geropsychiatry program after 1 year of benign visual hallucinations and several months of shuffling gait, recurrent falls, and forgetfulness. These symptoms were highly suggestive of Lewy body dementia; however, the patient's history of basal ganglia infarct, cognitive testing demonstrating inattention and executive dysfunction, and follow-up brain imaging, which did not reveal acute findings, aligned with cerebral pathology previously attributed to vasculitis and supported the diagnosis of subcortical dementia due to SLE-CNS vasculitis. Oral prednisone 20 mg daily resolved her symptoms. Over the next 19 months, her prednisone was tapered completely and her symptoms did not return. A systematic literature search identified 33 comparable cases. CONCLUSION: An analysis of previously published cases suggests that extending the duration of the prednisone taper beyond 1 year may decrease the risk of later occurring neuropsychiatric symptoms in this patient population.

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.

Gay and Gray Session: An Interdisciplinary Approach to Transgender Aging.

With the overarching goals of improving the healthcare of older transgender individuals and of inspiring pertinent clinical research, a session at the 2017 American Association for Geriatric Psychiatry Annual Meeting focused on an interdisciplinary approach to transgender aging. The older the transgender adult, the more likely the individual grew up in a historical context when there was greater social stigma towards their gender identity, even among mental health professionals. In order to provide optimal healthcare to transgender adults, mental health care providers should become familiar with the basic terminology presented in this article. Transgender older adults face greater risks of poor physical health, disability, anxiety and depressive symptoms, victimization, and stigma, and higher rates of smoking, excessive alcohol use, and risky sexual behavior compared with non-transgender older adults. In spite of notable health disparities, some evidence points to resilience among transgender older adults. The mental health professional often serves as the first contact for a patient who is struggling with gender identity. The role of a mental health professional can be divided into five categories: 1) assessment of gender dysphoria; 2) psychoeducation of patients and family members about the diversity of gender identities and various options for alleviating gender dysphoria; 3) referral to and collaboration with other healthcare professionals; 4) treatment of coexisting mental health concerns; 5) advocating for transgender patients and for the transgender community. Recently, the criteria for medical and surgical transition have been simplified. End-of-life preparations are especially important for transgender individuals.

Effect of short-term research training programs on medical students' attitudes toward aging.

Strategies to build a larger workforce of physicians dedicated to research on aging are needed. One method to address this shortage of physician scientists in geriatrics is short-term training in aging research for early-stage medical students. The authors examined the effects of two summer research training programs, funded by the National Institutes of Health, on medical students' attitudes toward aging, using the Carolina Opinions on Care of Older Adults (COCOA). The programs combined mentored research, didactics, and some clinical exposure. In a sample of 134 participants, COCOA scores improved significantly after completion of the research training program. There was a significant interaction of gender, such that female students had higher baseline scores than males, but this gender difference in COCOA scores was attenuated following the program. Four of the six COCOA subscales showed significant improvement from baseline: early interest in geriatrics, empathy/compassion, attitudes toward geriatrics careers, and ageism.

Use of Tablet Devices in the Management of Agitation Among Inpatients with Dementia: An Open-Label Study.

OBJECTIVE: To investigate the feasibility, safety, and utility of tablet devices as novel nonpharmacologic tools in managing older psychiatric inpatients with agitation and dementia. METHODS: Thirty-six patients at a geriatric psychiatry inpatient unit were provided with tablets when agitated and used various apps on the tablet related to communication, games, music, web browser, and photography during their stay. Study staff documented the frequency, duration, and app usage history and rated the extent to which agitation improved after tablet use. RESULTS: All participants, regardless of dementia severity, were able to use apps and were rated by staff to have clinical benefit. Dementia severity was negatively associated with app complexity. Age was negatively associated with frequency and duration of tablet use. CONCLUSION: Tablet use as a nonpharmacologic intervention for agitation in older adults, including those with severe dementia, appears to be feasible, safe, and of potential utility.

The Mental Health of Older LGBT Adults.

There are approximately one million older lesbian, gay, bisexual, and transgender (LGBT) adults in the USA. Their mental health issues result from interactions between genetic factors and stress associated with membership in a sexual minority group. Although advancements in acceptance and equal treatment of LGBT individuals have been occurring, sexual minority status remains associated with risks to physical and mental well-being. Older LGBT adults are more likely to have experienced mistreatment and discrimination due to living a majority of their lives prior to recent advancements in acceptance and equal treatment. All LGBT adults experience one common developmental challenge: deciding if, when, and how to reveal to others their gender identity and/or sexual orientation. LGBT individuals have higher rates of anxiety, depression, and substance use disorders and also are at increased risk for certain medical conditions like obesity, breast cancer, and human immunodeficiency virus (HIV). Improved education and training of clinicians, coupled with clinical research efforts, holds the promise of improved overall health and life quality for older LGBT adults.

The value and underutilization of simple reading glasses in geropsychiatry inpatient settings.

For almost everyone, the need for reading glasses is an inevitable part of the second half of life. Forgetting one's reading glasses at a restaurant can be a disturbing reminder of one's dependence on them. For geriatric inpatients, however, the value of reading glasses in improving quality of life and preventing delirium may be overlooked. Subsequently, the authors present a brief review of visual impairment, the relationship of visual impairment and cognition and the cost of reading glass, and the results of a survey that was conducted to determine the proportion of inpatient geriatric psychiatry inpatient units in the United States, which provide reading glasses to inpatients as well as to assess the knowledge of medical directors of these units regarding the cost and perceived value of providing reading glasses to hospitalized patients.

Older adults are less accurate than younger adults at identifying symptoms of anxiety and depression.

The present study examined age differences in the identification of anxiety and depressive symptoms in a community sample of 374 adults, ages 18 to 93. Older adults were less accurate and more likely than younger adults to label symptoms as neither anxiety nor depression. Both older and younger adults were more accurate in their classification of depressive than anxiety symptoms. These findings suggest that additional efforts are needed to educate the general public, particularly older adults, about anxiety and its symptoms.

Reduction of suboptimal prescribing and clinical outcome for dementia patients in a senior behavioral health inpatient unit.

BACKGROUND: Suboptimal prescribing in older psychiatric patients causes iatrogenic morbidity. The objectives of this study were to compare the prevalence of suboptimal prescribing before and after admission to a geropsychiatry inpatient unit and to evaluate a possible correlation between optimal medication use and functional improvement in patients with dementia. METHODS: The study sample comprised 118 consecutively admitted patients to a 14-bed university hospital-based geropsychiatry inpatient unit over a period of 20 months who met the DSM-IVTR criteria for an Axis I psychiatric illness and co-morbid dementia. At admission demographic information, Mini-mental State Examination (MMSE) Score, Mattis Dementia Rating Scale Score (DRS), and number of active medical illnesses were recorded. At admission and discharge the number and type of medications, number of Revised Beers Criteria (RBC) medications (a published list of potentially inappropriate medications in older adults independent of diagnoses or conditions), Global Assessment of Functioning (GAF) scores, and Scale of Functioning (SOF) scores were tabulated. chi2 tests, paired t-tests and Pearson correlations were used to test the medication prevalence and associations between measures of clinical function and other variables. RESULTS: The mean age (standard deviation) of the sample was 81.5 (6.2) years. The mean scores on the MMSE and DRS were 22.1 (6.2) and 116.6 (18.7), respectively. From admission to discharge, the mean number of RBC medications per patient decreased significantly from 0.8 (1.1) to 0.4 (0.6). There was also a significant correlation between reduction in Beers criteria medications and improved SOF score from time of admission to time of discharge. CONCLUSION: Suboptimal medication use is a potential source of decreased function in older patients with dementia.

Falls associated with electroconvulsive therapy among the geriatric population: a case report.

Electroconvulsive therapy (ECT) is the treatment of choice in many older individuals with depression and a few other conditions. Like all medical treatments, this intervention has certain possible risks, which include undesirable reactions associated with general anesthesia and those attributed specifically to ECT itself, such as short-term memory loss. The potential association of falls with ECT has not been well studied. Our recent literature search revealed that information on this topic consists mainly of chart reviews and case reports. We present a case of an older woman with a history of recurrent major depressive disorder that required intervention with ECT. She suffered 2 falls during her course of ECT. This case adds to the growing body of anecdotal evidence supporting an association of falls with ECT and highlights the need for more scientifically rigorous data to clarify whether this apparent association is real and/or causally related.

Chronic pain and depression among geriatric psychiatry inpatients.

OBJECTIVES: We examined whether chronic pain among depressed geriatric inpatients was associated with several clinical variables-comorbid psychiatric and medical diagnoses, length of hospitalization, suicidal ideation, and sleep duration. METHODS: Medical charts of inpatients admitted to a geriatric psychiatry unit over 2 years were examined retrospectively; 148 patients with a depressive disorder were identified. Admission pain assessments were used to classify whether patients had chronic pain. Other variables of interest were collected from charts. RESULTS: 62% of patients reported chronic pain. In multivariate regression analysis, depressed older adults with chronic pain were more likely to report suicidal ideation, be diagnosed with personality disorder, have higher medical burden, and experience decreased total sleep time compared to depressed older adults without chronic pain. CONCLUSIONS: Chronic pain--common in depressed older adults--may influence clinical features of depression and should be assessed as a possible suicide risk factor. Prospective studies should examine causal relationships and determine the effects of adequate pain treatment on depression course and suicide risk in older adults.

Factors associated with frequent admissions to an acute geriatric psychiatric inpatient unit.

As a first step toward developing strategies to reduce the frequency of psychiatric hospitalizations, the authors retrospectively collected and analyzed demographic and clinical variables from 424 consecutive admissions to a university-based geriatric psychiatry inpatient unit over a 20-month period. The study sample was dichotomized into patients who were admitted more than one time (35.6%) versus those with a single admission. Factors associated with rehospitalization were examined with multivariate logistic regression analysis. The great majority of readmissions (81%) occurred in the first 3 months after discharge. The logistic regression model indicated that significant predictors of rehospitalization were single relationship status, male gender, and bipolar disorder diagnosis. Our findings overlap with findings from previous similar studies and suggest that information readily obtainable on admission to an acute geriatric psychiatry inpatient unit may provide a useful indication of risk for frequent psychiatric hospitalizations and may contribute to readmission prevention strategies.

The clock drawing test as a measure of executive dysfunction in elderly depressed patients.

The aims of this research were to determine whether performance on the Clock Drawing Test (CDT) could accurately distinguish between older patients with depression and older patients with depression and previously undocumented executive dysfunction and to determine if there was a correlation between CDT and depression severity. The authors studied 52 patients consecutively admitted to a geriatric psychiatry inpatient unit of a university hospital who met DSM-IV criteria for major depression or depression not otherwise specified but had no concurrent diagnosis of dementia. All the subjects completed the Mini-Mental State Examination (MMSE), Mattis Dementia Rating Scale (DRS), and the CDT, as well as the Geriatric Depression Scale (GDS). The patients were divided into 2 subgroups based on the DRS score: <129 (cognitive impairment) versus = 129. Results indicated that the depressed patients with a score of DRS <129 had significantly lower CDT scores than did patients with DRS = 129 and normal comparison subjects (P< .01). The results support the hypothesis that CDT score is lower in elderly depressed patients with executive dysfunction versus nondepressed seniors as well as depressed patients without executive dysfunction.