Psychogeriatric Research Articles

Nine-Year Analysis of Industry Payments to Geriatricians in the United States Between 2014 and 2022

ObjectivesFinancial interactions between physicians and the health care industry might create potential conflicts of interest among physicians. However, little is known about the financial relationships between geriatricians and the health care industry. This study aimed to explore the whole picture of geriatricians-industry financial relationships in the United States. DesignCross-sectional analysis using the Open Payments Database from 2014 to 2022. Setting and ParticipantsAll geriatricians and geriatric psychiatrists in the United States, identified from the National Plan and Provider Enumeration System database. MethodsThis study assessed the extent of geriatrician-industry financial relationships in the United States, using the 2014–2022 Open Payments Database. Descriptive analysis was performed on the payment data. Payment trends were examined by interrupted time series analysis with generalized estimating equation models. ResultsOf 6688 physicians specializing in geriatric medicine or geriatric psychiatry, 4089 (61.1%) received 1 or more payments from the health care industry, totaling $249.6 million between 2014 and 2022. Even though 61.5% to 80.2% of geriatricians did not receive general payments each year, 4078 geriatricians (61.0%) received 1 or more general payments during the 9-year period. Median annual per-geriatrician general payment ranged from $116 to $199 in inflation-adjusted value. The top 1% and 5% of geriatricians received 62.4% ($18.2 million) and 82.2% ($24.0 million) of overall general payments, respectively; 88.3% of all industry payments were distributed for research purposes, but only 1.4% and 2.6% of all geriatricians received direct and associated research payments, respectively. The number of geriatricians receiving payments significantly decreased by 4.2% (95% CI, −4.8 to −3.6; P < .001) in general payments and 4.8% (95% CI, −9.8 to −0.6; P = .03) in associated research between 2014 and 2019. Conclusions and ImplicationsMore than 60% of geriatricians received at least 1 payment between 2014 and 2022. Although most payments were made for research purposes, both general and research payments have been concentrated on the small number of geriatricians.

Attitudes towards deprescribing in geriatric psychiatry: A survey among older psychiatric outpatients.

Understanding the patient perspective is a significant part of the deprescribing process. This study aimed to explore the attitudes of older patients with psychiatric disorders towards deprescribing. A total of 72 of psychiatric outpatients (68% women; median age 76 years) completed the validated Danish version of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Patients used a median of eight medications (interquartile range 6-12), with 88%, 49% and 24% using antidepressants, antipsychotics and anxiolytics, respectively. Fifty-one percent of patients reported an intrinsic desire to stop one of their medications, while 92% would be willing to stop one on their physician's advice. Seventy-five percent of patients would be worried about missing out on future benefits following deprescribing and 37% had previous bad deprescribing experiences. Use of ≥8 regular medications was associated with more concerns about stopping medication and greater perceived burden of using medication, while use of antipsychotics was not associated with any differences in rPATD factor scores. It is crucial for health care professionals to be aware of patients' specific concerns and past experiences to promote a patient-centred deprescribing approach that takes into account the needs and preferences of older patients with psychiatric disorders.

Why Does the US Overly Rely on International Medical Graduates in Its Geriatric Psychiatric Workforce?

International medical graduates (IMGs) tend to choose careers in geriatric psychiatry likely because high-quality training and robust mentorship opportunities from other IMGs are available. Geriatric psychiatry offers stable career prospects and opportunities to express humanitarian impulses by working closely with elders. IMGs currently constitute almost a quarter of the psychiatry workforce and approximately 53% of the geriatric psychiatry work force in the United States. However, the number of IMGs entering psychiatry residencies-and, subsequently, geriatric psychiatry fellowships-has recently declined. Overreliance on IMGs in the US geriatric psychiatric workforce means these shortages will further burden an already-limited geriatric mental health care workforce and further compromise US health system capacity to meet its elders' needs.

Three-Year Prognosis of Late-Life Depression in an Outpatient Geriatric Psychiatry Clinic: Medical Comorbidities Worsen Outcomes.

Depression is one of the most important reasons for psychiatric referrals in elderly patients. Geriatric depression can be chronic and is associated with an increased risk of dementia. We aimed to determine the prognosis of major depression patients and associated risk factors regarding persistence of depression. Patients who were admitted to the tertiary geriatric psychiatric outpatient unit of Istanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul between January and December 2018 and were diagnosed with major depression according to DSM-5 diagnostic criteria were included in the study. A structured telephone interview was conducted with between February-April 2022. For detailed clinical evaluation, Turkish version of Structured Clinical Interview for DSM-5-Disorders/Clinician Version (SCID-5/CV-TR), Telephone Cognitive Screen (T-cogS-TR), Geriatric Depression Scale (GDS), Clinical Dementia Rating Scale (CDR), Lawton-Brody Instrumental Activities of Daily Living Scale (IADL) and Beck Anxiety Inventory (BAI) were used. Of the 123 patients interviewed, 40.9% were diagnosed with major depression and 14.6% with minor depression. 43.4% showed significant anxiety and depression symptoms. Dementia developed in 14.6% of the patients. Only 29.5% of the patients recovered completely. Hypertension, orthopedic disease or arthritis, cancer, and absence of prior work experience were found to be predictors of current depression diagnosis. Geriatric depression has an unfavorable prognosis despite continued antidepressant treatment and may even serve as a prodrome for future dementia. Timely management of co-morbid medical conditions such as hypertension can potentially improve the prognosis of geriatric depression.

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.

Geroscience-Centric Perspective for Geriatric Psychiatry: Integrating Aging Biology With Geriatric Mental Health Research

The geroscience hypothesis asserts that physiological aging is caused by a small number of biological pathways. Despite the explosion of geroscience research over the past couple of decades, the research on how serious mental illnesses (SMI) affects the biological aging processes is still in its infancy. In this review, we aim to provide a critical appraisal of the emerging literature focusing on how we measure biological aging systematically, and in the brain and how SMIs affect biological aging measures in older adults. We will also review recent developments in the field of cellular senescence and potential targets for interventions for SMIs in older adults, based on the geroscience hypothesis.

Artificial Intelligence in Geriatric Psychiatry Through the Lens of Contemporary Philosophy

Artificial Intelligence in Geriatric Psychiatry Through the Lens of Contemporary Philosophy

Clozapine for the treatment of aggressiveness and agitation in advanced dementia.

Distressing behavioural symptoms, particularly agitation and aggressiveness, remain a difficult problem in everyday clinical practice in the treatment of multimorbid patients with dementia. Clozapine may be an effective therapeutic alternative in this context. In a retrospective study, patients who had a diagnosis of dementia and had been treated in a specialized geriatric psychiatry unit with clozapine between August 2018 and February 2022 were included, and medical records were systematically reviewed. The Clinical Global Impressions Scale was used to assess improvement, and the Pittsburgh Agitation Scale for symptom reduction. In addition, side effects and clinical features were documented in detail. A total of 31 patients (median age 82 years) were identified with a mean clozapine dose of 47.2 (SD 35.6) mg. A total of 13 patients tolerated clozapine very well, 10 showed tolerable side effects, and in 10 patients side effects were the reason for stopping clozapine. Behavioural symptoms improved significantly, as indicated by the assessment scores. In summary, clozapine was effective and well tolerated in 23 patients, suggesting that low-dose clozapine may help to alleviate the suffering of difficult-to-treat multimorbid patients with advanced dementia and their caregivers. However, particular attention should be paid to adverse drug reactions, especially in patients with cardiovascular and pulmonary impairment.

“She made me feel like a valuable part of the care”: A geriatric psychiatrist's impact on caregivers’ self-efficacy via tele-consultation

“She made me feel like a valuable part of the care”: A geriatric psychiatrist's impact on caregivers’ self-efficacy via tele-consultation

Telemedicine Readiness in a Large Cohort of Geriatric Psychiatry Clinic Patient Referrals

Telemedicine Readiness in a Large Cohort of Geriatric Psychiatry Clinic Patient Referrals

Abstracts from the 2022 Annual Scientific Meeting of the Canadian Academy of Geriatric Psychiatry and Canadian Coalition for Seniors’ Mental Healths

Abstracts from the 2022 Annual Scientific Meeting of the Canadian Academy of Geriatric Psychiatry and Canadian Coalition for Seniors’ Mental Healths

Evaluation of the Online Component of a Blended Learning Electroconvulsive Therapy Curriculum for Psychiatry Residents to Treat Depression in Older Adults.

The objective of this study was to evaluate the online component of a blended curriculum for psychiatry residents on the use of electroconvulsive therapy (ECT) to treat depression in older adults. Second- and third-year general psychiatry residents completed a blended learning curriculum during their core geriatric psychiatry rotation. The curriculum consisted of didactic seminars, hands-on clinical management, and two online clinical cases focused on the management of late-life depression with ECT. Knowledge acquisition following module completion was measured using a nine-question multiple-choice test. The authors adapted the Medical E-Learning Evaluation Survey (MEES) to measure resident satisfaction, clinical relevance, and instructional design. A total of 37 residents completed both online modules. Of these, 35 residents completed the knowledge test and 23 completed the adapted MEES. Almost all participants (96%) agreed or strongly agreed that the modules were relevant to their clinical work, evidence-based, able to be completed in a reasonable amount of time, and a valuable learning experience. The average score on the knowledge test, after removing one outlier, was 83%. Psychiatry residents are very satisfied with the content and delivery of the online component of a blended curriculum for understanding the use of ECT for late-life depression. Future work should examine satisfaction with the remainder of the curricula as well as the impact on longer-term knowledge acquisition and patient care.

Method of differential diagnosis of mild cognitive impairment of various origins: cross sectional study

INTRODUCTION:The differential diagnosis of mild cognitive impairment (MCI), due to the high prevalence in the population and the rapid increase in incidence, is an urgent task. The most common causes leading to the development of cognitive impairment are Alzheimer’s disease (AD), cerebrovascular pathology, and their combination. AD usually manifests as an amnestic type of mild cognitive impairment (aMCI) at the pre-dementia stage. Subcortical vascular mild cognitive impairment (svMCI) is considered as the prodromal stage of subcortical vascular dementia. According to the results of pathomorphological studies, it was found that subfields of the hippocampal formation are selective vulnerability to AD, ischemia/hypoxia, and aging.Currently, using the FreeSurfer 6.0 software, it is possible to obtain quantitative indicators of the hippocampal formation subfieldsin vivo.The current trend in medicine is the development and implementation of new diagnostic solutions based on artificial intelligence and machine learning. One of the machine learning algorithms is binary logistic regression, which we used in the course of the study for the differential diagnosis of MCI of various origins.OBJECTIVE:To develop a method for the differential diagnosis of mil cognitive impairment of various origins.MATERIALS AND METHODS:The study included patients with the syndrome of mild cognitive impairment who were examined in the department of geriatric psychiatry of the V.M.Bekhterev National Medical Research Center for Psychiatry and Neurology, from which two groups were formed: group 1 — patients with aMCI, group 2 — patients with svMCI. Conditionally healthy volunteers, comparable in age, sex and level of education, made up the 3rdgroup (control). MRI examination was performed using a Excelart Vantage Atlas XGV magnetic resonance imaging system (Toshiba, Japan) with a magnetic field strength of 1.5 T, followed by MR morphometry of the subfields of the hippocampal formation.Statistics:Statistical analysis was carried out using data that was converted from a database in Microsoft Excel to the statistical package IBM SPSS 21. To develop a differential diagnosis method, based on the data obtained, the binary regression method and ROC analysis were used.RESULTS:Based on the obtained MR-morphometry data, a method was developed using the binary logistic regression equation. The value of p≥0.5 makes it possible to classify the patient to the aMCI group, and the value of p&lt;0.5 — to the svMCI. The sensitivity of the method is 90%, the specificity is 80%, and the accuracy is 85%.DISCUSSION:Using binary logistic regression, the selection of variants of sets of variables (quantitative indicators) was carried out, for which ROC curves were constructed. The selection criterion was the area under the ROC curve — the AUC criterion (Area Under the Curve). The largest area under the curve (AUC=0.824) in the differential diagnosis of aMCI from svMCI was determined for the combination of the volume of the left subiculum and the thickness of the right entorhinal cortex.Since patients in the aMCI group have a significantly lower number of vascular foci than in the svMCI group (p&lt;0.05), at the next stage, one more variable, the volume fraction, was added to the selected combination of two variables (volume of the left subiculum and thickness of the right entorhinal cortex) hypointense foci. When conducting an ROC analysis with a combination of three variables, an increase in AUC to 0.892 was noted. Further, using a combination of three variables and a binary logistic regression equation, a method for differential diagnosis of aMCI from svMCI was developed.CONCLUSION:The method of differential diagnosis based on binary logistic regression using MR morphometry data allows to distinguish patients with aMCI from patients with svMCI with high sensitivity and specificity.

A survey of the psychiatric care provided for medically ill older adults in general hospitals in New Zealand.

The aim of this study was to conduct an in-depth survey of the psychiatric care provided for medically ill older adults in general hospitals in New Zealand (NZ). As part of a larger survey of Consultation-Liaison Psychiatry (CLP) services for all ages in NZ (CLPSNZ-2), a 44-question survey was emailed to clinicians who were involved in providing psychiatric care for medically ill older adults at each of the 16 general hospitals with designated CLP services. Responses were obtained from 22 services at 16 hospitals - 14 CLP services and eight Psychiatry of Old Age (POA) in-reach services. These services were found to be under-resourced, operate with highly variable service models, and predominantly provide inpatient consultations. Services could be conceptualised as six prototypes with variations of POA in-reach to hospitals, scope of CLP cover and collaboration between services. The heterogeneity in the psychiatric care for medically ill older adults in NZ means that there is an urgent need to develop more consistent CLP service models that better serve the specialist needs of older adults, and establish the policies, resources and standards needed to support them.

The tradeoff between an open or closed unit for residents with dementia: a qualitative study

There is growing attention for freedom of movement as part of person-centred dementia care. Although a closed door can reduce safety risks, it also reduces quality of life. Care organization tanteLouise strives for maximum responsible freedom for residents with dementia. Nevertheless, residents are sometimes transferred from an open to a closed psychogeriatrics (PG) department. To explore healthcare professionals' considerations in transferring residents from an open to a closed psychogeriatrics [PG] ward within tanteLouise. Semi-structured in-depth interviews with carers and nurses from open and closed PG and a multidisciplinary focus group. The data has been analyzed thematically. According to the participants, both open and closed PG can provide a suitable living environment, depending on individual residents. Open PG facilitates freedom and self-direction, and closed PG offers security, structure and expert guidance. Before a transfer, the multidisciplinary team discusses possibilities and risks on open PG. Despite this, residents regularly move to closed PG without a valid reason. Participants strive for more freedom for residents with dementia, for which they believe preconditions are still lacking. The provided structure and expert guidance on closed PG must also be present on open PG to maintain freedom for residents with dementia. In addition, a culture change and preconditions from the organization are necessary.

Substance Use Disorders in the Geriatric Population: a Review and Synthesis of the Literature of a Growing Problem in a Growing Population.

Substance use disorders are becoming increasingly prevalent in the geriatric population, necessitating an updated understanding of the existing literature. This review aims to describe the epidemiology, special considerations, and management of substance use disorders in older adults. PubMed, Ovid MEDLINE, and PsychINFO databases were searched from their inception through June 2022 using the following keywords: "substance use disorder," "substance abuse," "abuse," "illicit substances," "illicit drugs," "addiction," "geriatric," "elderly," "older adults," "alcohol," "marijuana," "cannabis," "cocaine," "heroin," "opioid," and "benzodiazepine." Our findings suggest an increasing trend in substance use in older adults despite medical and psychiatric consequences when using such substances. The majority of older patients admitted to substance abuse treatment programs were not referred by healthcare providers, suggesting room for improvement in the screening and discussion of substance use disorders. Our review also suggests that there should be careful consideration of COVID-19 and racial disparities when screening, diagnosing, and treating substance use disorders in the older population. This review provides updated information on epidemiology, special considerations, and management of substance use disorders in older adults. As substance use disorders become more prevalent in older adults, primary care physicians must be prepared to recognize and diagnose substance use disorders as well as collaborate with and refer patients to geriatric medicine, geriatric psychiatry, and addiction medicine.

The 2023 New Zealand psychiatry of old age services and workforce survey.

The primary objective was to survey the Psychiatry of Old Age (POA) service resources in New Zealand: number of psychiatrists, inpatient beds, and community psychogeriatric beds. A secondary objective was to compare the POA service resources reported by frontline clinicians with official government data. The New Zealand Branch of Faculty of POA collected information from a POA representative in each of the 20 districts, along with official government data. Information from 17 services were obtained. POA service resources varied greatly between districts. There were discrepancies between the New Zealand Branch of Faculty of POA and official government data. The number of old age psychiatrist FTEs per 10,000 older adults ranged from 0.3 to 1.1 (mean = 0.7). The number of inpatient beds per 10,000 older adults ranged from 0.0 to 4.1 (mean = 1.6); and the number of psychogeriatric beds per 10,000 older adults ranged from 0.0 to 22.7 (mean = 12.6). There is an urgent need to address the official government data discrepancies and POA service resource inequalities. This can ensure the "postcode" system that determines psychiatric care for older adults can be effectively eliminated. We also found the number of POA inpatient beds is below the internationally recommended level.

Trainee doctors' preparedness for clinical work in geriatric psychiatry: A survey on 18 preliminary entrustable professional activities.

Research concerning transitions from one rotation to another during medical specialist training is scarce. This study examined trainee doctors' perceived preparedness for core clinical activities, trainee doctors' preparedness levels, and general perceptions of medical specialist training in geriatric psychiatry. Swiss trainee doctors in geriatric psychiatry were surveyed about their perceived preparedness for 18 preliminary entrustable professional activities (EPAs), curricular support, and general perceptions of their medical specialist training. Closed questions were analysed using descriptive statistics, while open questions were subjected to content analysis. The participants comprised 48 trainee doctors (30.4% response rate) who differed in their educational experience (years of residency and specialism) and clinical subspecialisation goals. Trainee doctors felt adequately prepared for most EPAs but less prepared for some, including electroconvulsive therapy, psychotherapy, and treating older adults in the home environment or residential facilities. Despite the trainee doctors' diversity, they did not differ significantly in perceived preparedness for most EPAs. The most often offered suggestions for improving geriatric psychiatry training were intensified clinical supervision and a structured induction programme. Trainee doctors reported that they felt sufficiently prepared for most EPAs, regardless of their backgrounds and professional goals. However, several professional activities in geriatric psychiatry warrant further training. Our findings indicate the need for a higher intensity of clinical supervision (e.g. more direct observation and specific feedback), the introduction of structured induction programmes (e.g. orientation week), and specific teachings (e.g. on neurocognitive assessment).

Associates of cognitive functions in aged Turkish adults: Insights from a psychiatry outpatient clinic

Introduction: The aim of this study was to determine the cognitive function and its influential factors in elderly adults in Turkey. Materials and Methods: 127 patients aged over 65 years referred to a psychiatry outpatient clinic for the first time were included to cross-sectional and descriptive study. Patients were assessed by Carlson Comorbidity index, Montreal Cognitive Assessment Test, Geriatric Depression Scale, Beck Anxiety Inventory, Nottingham Health Profile and Lawton Instrumental Activities of Daily Living Scale. Results: The mean age of the patients was 69.7±4.2 years and 55.1% (n=70) of the participants were female. The primary diagnosis was Generalized Anxiety Disorder in 48.8% and Major depressive disorder in 51.2% of the patients. In multivariate analysis, age (OR:0.759, 95% CI:0.630-0.914, p=0.004), income &lt;3800 TL (OR:14.72, 95% CI:1.78-121.51, p=0.013), medication usage (OR:0.171, 95% CI:0.035-0.845, p=0.030) and Geriatric Depression Scale score (OR:0.876, 95% CI:0.785-0.977, p=0.017) remained as independent predictors of Montreal Cognitive Assessment Test score. Conclusion: In Turkish adults with Generalized Anxiety Disorder or Major depressive disorder who admit to a psychiatry outpatient clinic for the first time, various parameters including age, education, income, leisure activity, medication usage, depression, Lawton Instrumental Activities of Daily Living Scale score and Nottingham Health Profile score are linked with cognitive impairment. However, only age, income, medication usage and depression independently associate with cognitive impairment in this highly specific patient population. Keywords: Cognitive Dysfunction; Geriatric Psychiatry; Depression; Quality of Life.

Identifying prognostic factors of dementia in individuals with mild cognitive impairment (MCI): Are statistical models adequate?

AbstractBackgroundIdentifying prognostic factors of MCI to dementia conversion is crucial. Most risk scores are developed based on selected variables using data‐driven methods from available variables in patient data. However, there is mixed evidence about the reliability of predictors selected based on data alone. Structured expert elicitation (SEE) is one approach to elicit clinician expert knowledge about relevant predictors for dementia risk. This study aims to identify critical predictors of dementia risk in persons with MCI from both SEE and random survival forests (RSF) and compare the differences between the two approaches.MethodClinical expert knowledge was quantified using SEE methodology: 11 experts (6 neurologists, 3 geriatricians, and 2 geriatric psychiatrists) were recruited to complete two rounds of surveys to rank predictors of dementia risk. RSF variable importance was used to assess the rank order of the potential predictors, according to the corresponding reduction of predictive accuracy when the predictor is replaced with its random permutation value risk using data from the Prospective Registry for Persons with Memory Symptoms of the Cognitive Neurosciences Clinic at the University of Calgary (N = 273; 26 potential predictors).ResultAccording to experts, the SEE revealed age and cerebrospinal fluid profile patterns consistent with Alzheimer’s disease (AD) as the two most important predictors of dementia risk in persons with MCI. In contrast, data‐driven RSF approach, using information from routine clinical practice without AD biomarkers, identified the Consortium to Establish a Registry for AD total score and the Montreal cognitive assessment (MoCA) total score as the most important predictors. Both approaches identified four common variables (among the top 10 predictors) included age, signs of parkinsonism, MoCA total score, and behaviour impairment.ConclusionOur findings revealed discrepancies between a data‐driven approach and SEE in identifying significant predictors of dementia in people with MCI. The SEE identified some crucial predictors, such as AD biomarker status, that are not routinely collected in registries and observational studies or available in widespread practice. Most published risk scores are not used in practice. This study offers a possible explanation: what is important to clinicians may be not included in the risk scores.