Therapy For Older Adults Research Articles

Cognitive effects of lamotrigine versus topiramate as adjunctive therapy in older adults with epilepsy

Older individuals may be more susceptible to cognitive side effects of antiepileptic drugs than are younger adults. This randomized, double-blind study compared the cognitive effects of lamotrigine (median maintenance dosage, 500.0 mg/d) and topiramate (median maintenance dosage, 300.0 mg/d) as adjunctive therapy for 16 weeks in patients ≥50 years of age. Fifty-one patients (lamotrigine, n=25; topiramate, n=26) were enrolled, and 28 patients (lamotrigine, n=15; topiramate, n=13) completed the study. In a combined analysis of all cognitive tests performed, no significant differences between treatment groups were noted. However, analyses of individual cognitive test results revealed that lamotrigine-treated patients had significantly better results on the Controlled Oral Word Association Test and the Symbol-Digit Modalities Test, whereas topiramate-treated patients had significantly more favorable results on the Digit Cancellation Test and the Rey Auditory-Verbal Learning Test. Larger studies are needed to further clarify the differences in the cognitive effects of lamotrigine and topiramate in older patients.

Toward Holistic Care: Integrating Spirituality and Cognitive Behavioral Therapy for Older Adults

Based on the particular mental health needs of older adults, this article formulates a theoretical approach integrating spirituality and cognitive behavioral therapy (CBT) for counseling older adults. CBT is easily applicable and highly appropriate for use with the older adult cohort. Its efficacy is well documented, specifically for disorders commonly experienced by older adults. However, as presenting problems of older adults frequently include spiritual and existential concerns, the incorporation of spirituality and meaning-making with CBT is ideal for serving this cohort. This article presents a theoretical approach to spiritually integrated CBT by formulating a modified style of assessment, formulation, beginning therapy, cognitive restructuring, behavior modification, and termination.

Recommendation of adjuvant chemotherapy and trastuzumab in older adults with HER2-positive breast cancer: A survey of oncologists

9547 Background: Though substantial evidence supports the use of adjuvant trastuzumab in patients with HER2-positive breast cancer, a lesser amount of data is available to guide use of this therapy in older adults. The objective of the current study is to understand how patient age and health status impact the oncologists' decision to recommend adjuvant therapy in older women with HER2-positive breast cancer. Methods: Medical oncologists (n=151) participated in an online survey comprised of case scenarios with patients of varying age (70, 75, 80, 85) and health status (good, average, poor) with a T2(4 cm) N2(4+ LN) ER(-), HER2(+) breast cancer. Oncologists could offer the hypothetical patient treatment with chemotherapy and trastuzumab, chemotherapy alone, trastuzumab alone, or no therapy. The influence of age and health status on treatment recommendations was assessed using a generalized linear mixed-effects model. Results: With increasing age and deterioration of health status, the recommendation for chemotherapy with trastuzumab decreased (P<0.0001 for both). In contrast, recommendation for trastuzumab alone or no therapy increased with advancing age (P<0.0001 for both) and deteriorating health status (P<0.0035 and P=0.059, respectively). Chemotherapy alone was not frequently recommended, irrespective of age or health status. Conclusions: Given the relative dearth of evidence-based data for adjuvant treatment of HER2-positive breast cancer in older adults of varying health, oncologists recommend a diverse array of therapeutic approaches for this subgroup. Increasing age and declining health status lead to more frequent recommendation of trastuzumab alone or no therapy, and less frequent recommendation of chemotherapy with trastuzumab. [Table: see text] [Table: see text]

Adjuvant Systemic Therapy for Older Adults with Early-Stage Breast Cancer

There is a relative paucity of evidence to guide the adjuvant therapy of breast cancer in older adults. Herein, we review data from relevant clinical trials and retrospective analyses that assess systemic therapies in older adults. Chemotherapy, endocrine therapy, HER2-directed agents and bisphosphonates in the adjuvant setting are discussed. Meta-analyses, such as the Oxford overview, suggest a decreasing benefit of chemotherapy with age. However, prospective trials do support a benefit from the addition of chemotherapy to endocrine therapy in older adults. In contrast to chemotherapy, the value of endocrine therapy appears to increase with age. In addition, available subset analyses suggest that the benefit from aromatase inhibitors relative to tamoxifen is independent of age. The use of HER2-directed therapy in older adults is challenged by the relatively low enrollment of this subset in prospective clinical trials. Nonetheless, the extent of enrollment may be proportional to the frequency of HER2 overexpression in this population. Finally, there are little data to support the use of adjuvant bisphosphonate therapy in older adults--ongoing prospective trials may address this issue. Each of the aforementioned therapeutic strategies will be augmented by efforts to personalize therapy for older adults. Clinical tools such as the geriatric assessment and biologic assays, such as the 21-gene recurrence score, may ultimately play a role in treatment algorithms for this unique demographic.

Dehydroepiandrosterone replacement therapy in older adults: 1- and 2-y effects on bone

BackgroundAge-related reductions in serum dehydroepiandrosterone (DHEA) concentrations may be involved in bone mineral density (BMD) losses. Objective:The objective was to determine whether DHEA supplementation in older adults improves BMD when co-administered with vitamin D and calcium. Design:In year 1, a randomized trial was conducted in which men (n = 55) and women (n = 58) aged 65–75 y took 50 mg/d oral DHEA supplements or placebo. In year 2, all participants took open-label DHEA (50 mg/d). During both years, all participants received vitamin D (16 μg/d) and calcium (700 mg/d) supplements. BMD was measured by using dual-energy X-ray absorptiometry. Concentrations of hormones and bone turnover markers were measured in serum. Results:In men, no difference between groups occurred in any BMD measures or in bone turnover markers during year 1 or year 2. The free testosterone index and estradiol increased in the DHEA group only. In women, spine BMD increased by 1.7 ± 0.6% (P = 0.0003) during year 1 and by 3.6 ± 0.7% after 2 y of supplementation in the DHEA group; however, in the placebo group, spine BMD was unchanged during year 1 but increased to 2.6 ± 0.9% above baseline during year 2 after the crossover to DHEA. Hip BMD did not change. Testosterone, estradiol, and insulin-like growth factor 1 increased in the DHEA group only. In both groups, serum concentrations of bone turnover markers decreased during year 1 and remained low during year 2, but did not differ between groups. Conclusion:DHEA supplementation in older women, but not in men, improves spine BMD when co-administered with vitamin D and calcium. This trial was registered at clinicaltrials.gov as NCT00182975.

Cognitive-Behavioral therapy for older adults with chronic pain

Cognitive-Behavioral therapy for older adults with chronic pain

Group therapy in older adults

Group therapy is a well-established therapeutic modality for older individuals often conducted in combination with individual psychotherapy and pharmacotherapy. Group leaders must be aware of age-specific factors when working with older cohorts, including the presence of cognitive impairment, physical disability, and loss of independence. A limited number of outcome studies have found that various forms of group therapy in late life are generally efficacious for depression and other symptoms and compare favorably with individual psychotherapy.

Preventing coronary heart disease and stroke with aggressive statin therapy in older adults using a team management model

The purposes of this review were to highlight recent clinical trial results on the safety and efficacy of statin therapy in adults aged 65 years and older and to examine how nurse practitioners (NPs) and physician assistants (PAs) working together with physicians as a team can better serve the needs of this fastest growing subset of the U.S. population who are at high risk for cardiovascular events including stroke. This report was compiled by reviewing the scientific literature on the safety and efficacy of statin therapy, including effects on cardiovascular, coronary, and stroke endpoints, with particular reference to clinical trial results in older patients. Recent guidelines emphasize that age alone is not a reason to withhold treatment with statin therapy in older adults. However, despite the evidence highlighted in this review demonstrating that older patients can safely achieve substantial benefit from statin therapy, studies have consistently shown an inverse relationship between age and treatment propensity. Often, older patients have multiple risk factors and many chronic comorbid conditions that seem to complicate and hinder treatment in many busy clinic practices. More extensive guidelines for the use of statin therapy in older patients, incorporating recommendations for treatment targets and developing a framework for the use of statins in stroke prevention, would assist care providers in the management of this high-risk population. Finally, NPs and PAs are both well educated and well placed to manage patients with chronic stable cardiovascular disease (CVD). The implementation of a multidisciplinary team approach to identify at-risk individuals and provide them with education, counseling, and effective statin treatment will aid efforts to reduce the increased risk for morbidity and mortality associated with CVD in older adults.

Treating Hypertension in Older Adults

This article discusses the efficacy, use and adverse effects of antihypertensive drug therapy in older adults. Numerous double-blind, randomized, placebo-controlled studies have demonstrated that antihypertensive drug therapy reduces cardiovascular events in older adults. All antihypertensive drugs may predispose older patients to the development of symptomatic orthostatic hypotension and postprandial hypotension, and syncope or falls. Adverse effects of diuretics, beta-adrenergic receptor antagonists, ACE inhibitors, angiotensin receptor antagonists, calcium channel antagonists, alpha-adrenergic receptor antagonists, centrally acting drugs and direct vasodilators are discussed. The adverse effects depend on the antihypertensive drugs used, the doses used, the co-morbidities present in older patients taking these drugs and drug-drug interactions.

Adjuvant Chemotherapy and Hormonal Therapy for Older Adults With Breast Cancer

As the US population ages over the next quarter century, the number of older adults with breast cancer is expected to grow. The challenge in providing care for older adults with breast and other cancers is that there is less evidence-based data about the risks and benefits of therapy, since older adults have been under-represented in clinical trials. However, several recent studies have contributed to our knowledge about the optimal care for these patients. This article will highlight the studies that are beginning to shed some light on the specific risks and benefits of adjuvant breast cancer therapy in older adults and review the physiologic changes with aging that can affect tolerance to cancer therapy.

Cognitive Effects of Hormonal Therapy in Older Adults

There is ample preclinical evidence that gonadal steroids (estrogens and androgens) play an important role in central nervous system development and function. The abrupt decline of estrogen levels in women after menopause, and the slower, subtler decline in total and bioavailable testosterone serum levels that occurs in aging men ("andropause," "male menopause," partial androgen deficiency in ageing males [PADAM]), have been implicated in the pathogenesis of cognitive dysfunction prevalent in elderly adults. However, the current clinical evidence supporting hormonal replacement as a neuroprotective therapy is at best inconclusive. Anti-estrogen and anti-androgen hormonal therapies are used in the treatment of breast and prostate carcinomas, respectively. Although generally considered less toxic than conventional cytotoxic chemotherapy, these hormonal manipulations have side effects that are not trivial. This review will summarize the available evidence regarding the impact of these hormonal therapies on cognitive function in older adults. Additional clinical research in this field is needed to confirm the existence and severity of such a possible cognitive impact, which may then need to be considered prior to initiating hormonal therapies in the elderly, as many patients may be in the prodromal phase or early stages of a neurodegenerative disorder, such as Alzheimer's disease, and this information may influence treatment decision-making and subsequent management.

Occupational Therapy for Older Adults: Investments for Progress

A keynote address given at the Council of Occupational Therapists for the European Countries' (COTEC's) 8th European Congress of Occupational Therapy, Hamburg, 22–25 May 2008, hosted by the Deutscher Verband der Ergotherapeuten e.V. (German Association of Occupational Therapists).

Antipsychotics Linked to Serious Adverse Events in Some Elderly

Antipsychotics Linked to Serious Adverse Events in Some Elderly

Mentoring Junior Faculty in Geriatric Oncology: Report From the Cancer and Aging Research Group

Mentoring Junior Faculty in Geriatric Oncology: Report From the Cancer and Aging Research Group

Effect of an intervention to increase statin use in medicare members who qualified for a medication therapy management program.

The cardiovascular (CV) benefits of lipid-lowering therapy in older adults with hypercholesterolemia and underlying risk factors for coronary artery disease (CAD) have been well documented. Significant reductions in the risk of myocardial infarction (MI) and coronary death have been demonstrated with statin therapy, benefits that are of particular relevance in patients with diabetes. Managed care interventions with prescribers have increased the use of selected drugs such as statins. To (1) measure the increase in new users of statins associated with the implementation of a statin initiation intervention aimed at prescribers for Medicare Part D Medication Therapy Management Program (MTMP) members with diabetes or CAD and (2) estimate the potential cost savings associated with the projected reduction in CV events based on published controlled trials. Medicare Advantage Prescription Drug (MA-PD) and prescription drug plan (PDP) members of a pharmacy benefits manager (PBM) were identified for the intervention who (1) met the criteria for MTMP (expected to incur at least dollars 4,000 in annual pharmacy expenditures for Part D-covered medications, filled at least 10 distinct Part D-covered medications, and had at least 3 of 5 chronic diseases of interest); (2) were identified as having diabetes or CAD (patients with a history of MI were considered to have CAD); and (3) had no pharmacy claims for a statin between January and June 2006. In August 2006, the primary prescribers for antidiabetic or CV medications of 1,144 identified members were sent educational materials and a report listing their patients with diabetes or CAD who were not receiving statin therapy. A comparison group of MA-PD members (N = 700) with diabetes or CAD was identified who did not receive the intervention but who met all of the MTMP criteria except the presence of at least 3 of 5 chronic diseases of interest. Logistic regression was conducted to evaluate the intervention effectiveness after adjusting for age, gender, geography, and chronic disease score. To determine the implications of this intervention for routine practice, outcome measures included estimates of (1) the number of patient interventions necessary to prevent 1 major CV event and (2) the coronary event costs avoided by the intervention. The number of interventions necessary to prevent 1 major CV event was estimated by (1) calculating the number of members requiring interventions in order for 1 member to initiate statin therapy, based on the present study's findings, and then (2) calculating the number of statin initiations necessary to avoid a major CV event, based on clinical trial estimates of the effect of statin treatment on CV event rates. During the 4-month period following the intervention, 12.1% (n = 138) of the intervention members started a statin medication compared with 7.3% (n =51) of comparison members (P = 0.001). After covariate adjustment, the odds of initiating a statin medication were 65% higher (adjusted odds ratio [OR] = 1.65; 95% confidence interval [CI] = 1.15-2.36; P = 0.006) in the intervention than in the comparison group. The estimated number of members requiring interventions to prevent 1 major CV event was 220. The estimated coronary event cost avoidance is dollars 12,323 per 220 members who received the intervention, after subtraction of program administrative costs and the cost of statin drug therapy. A statin initiation intervention aimed at prescribers for MA-PD and PDP members with diabetes or CAD who qualified for MTMP services was successful in increasing statin use among this group of members at high risk for CV events.

A Review of the Cognitive Effects of Electroconvulsive Therapy in Older Adults

To review studies that examined the impact of electroconvulsive therapy (ECT) on cognitive functioning in depressed older people. Studies were systematically retrieved using PsychINFO and MEDLINE, with additional articles sourced from lists of references. Given our aged-care focus, study participants had a minimum mean age of 60 years, with no single participant younger than 50 years. Twenty-seven studies met our criteria. Apart from evidence of interictal slowing of information processing speed, there were mixed results with regard to the impact of ECT on other cognitive domains. Factors contributing to this variability in results include the lack of discrimination between unilateral, bilateral, or mixed electrode placement; the inclusion of patients with dementia; the small sample sizes; and the use of tests insensitive to subtle cognitive changes. The effect of ECT in elderly recipients' cognition remains unclear, and further research with more critically selected methods is required. In the meantime, we recommend that clinicians regularly administer brief focused cognitive tests before, during, and after treatment to monitor progress.

Clinical pharmacology of cancer therapies in older adults

This abbreviated review outlines the physiologic changes associated with aging, and examines how these changes may affect the pharmacokinetics and pharmacodynamics of anticancer therapies. We also provide an overview of studies that have been conducted evaluating the pharmacology of anticancer therapies in older adults, and issue a call for further research.

Pharmacokinetics in geriatric psychiatry

Safe, effective drug therapy in older adults requires an understanding of drug disposition and response in this population. Evidence suggests that physiologic changes during aging, including hepatic or renal function changes, contribute to pharmacokinetic differences. A major issue surrounding the study of older adults relates to the ability to study a large number of people in a minimally invasive way. Population pharmacokinetics provides a potential means of addressing this issue and a tool to evaluate drug exposure's magnitude and consistency. This article highlights examples of pharmacokinetic studies in psychiatry, in particular those conducted in older adults. It also reviews new drugs approved for treatment in psychiatry or neurology, many of which were developed as novel formulations (eg, extended-release transdermal film) with improved pharmacokinetic profiles or developed with regard to the actions of a specific enantiomer or metabolite.

Results of a randomized controlled trial to examine the efficacy of a chronic pain self-management group for older adults [ISRCTN11899548

Chronic pain is a common, disabling problem in older adults. Pain self-management training is a multimodal therapy that has been found to be effective in young to middle-aged adult samples; however, few studies have examined the effectiveness of this therapy in older adults. In this randomized, controlled trial, we evaluated a pain self-management training group (SMG) intervention as compared with an education-only (BOOK) control condition. Participants, 65 years of age or older who experienced persistent, noncancer pain that limited their activities, were recruited from 43 retirement communities in the Pacific Northwest of the United States. The primary outcome was physical disability, as measured by the Roland-Morris Disability Questionnaire. Secondary outcomes were depression (Geriatric Depression Scale), pain intensity (Brief Pain Inventory), and pain-related interference with activities (Brief Pain Inventory). Randomization occurred by facility to minimize cross-contamination between groups. Two-hundred and fifty-six individuals, mean age = 81.8 (SD: 6.5), enrolled and 218 completed the study. No significant differences in outcomes were found between groups at post-intervention, 6-month follow-up, or 12-month follow-up. The SMG group showed a significantly greater increase over time, relative to the BOOK group, in two process measures, as measured by the Chronic Pain Coping Inventory: use of relaxation and use of exercise/stretching. In both cases, the increase was greatest from baseline to the post-intervention assessment. Study findings indicate that additional research is needed to determine the most effective content and delivery methods for self-management therapies targeted at older adults with chronic pain.

Cognitive Errors, Symptom Severity, and Response to Cognitive Behavior Therapy in Older Adults With Generalized Anxiety Disorder

Recent research by Wetherell et al. investigating the differential response to group-administered cognitive behavior therapy (CBT) for generalized anxiety disorder (GAD) in older adults found that GAD severity, homework adherence, and psychiatric comorbidity predicted statistically significant improvement. The current study investigated whether the presence/absence of cognitive errors on separate domains of the Mini-Mental State Exam (MMSE) predicted baseline differences in symptom severity and improvement following CBT, above and beyond already established predictors. Baseline characteristics were investigated in a sample of 208 older patients diagnosed with GAD. Predictors of treatment response were examined in a subsample of 65 patients who completed CBT and were included in a prior study by Wetherell et al. of response predictors. Results from the baseline sample indicated that only subjects who committed an error on the MMSE Working Memory domain exhibited increased severity in anxiety and depressive symptoms. Results from the treatment sample indicated that an error on the MMSE Orientation domain was a significant predictor of outcome at 6-month follow-up, while controlling for previously established predictors. Patients who committed at least one error in this domain showed decreased response relative to patients who committed no errors. In this sample of older adults diagnosed with GAD, poor performance on the MMSE Working Memory domain was associated with increased baseline anxiety and depression, while baseline performance differences on the MMSE Orientation domain predicted outcome six months after CBT intervention.