Karen Blank

Position Statement of the American Association for Geriatric Psychiatry Regarding Principles of Care for Patients With Dementia Resulting From Alzheimer Disease

There exists currently an effective, systematic care/treatment model for patients with dementia resulting from Alzheimer disease (AD). This consists of a series of therapeutic interventions—pharmacologic and nonpharmacologic—targeted at patients with AD and their caregivers. Although these interventions do not produce a cure of the underlying disease and do not appear to stop its progression, they have been shown to produce benefits for patients and their caregivers. The aims of this care model, often referred to as “Dementia Care,” are to delay disease progression, delay functional decline, improve quality of life, support dignity, control symptoms, and provide comfort at all stages of AD. This evolving model is based on scientific evidence of beneficial outcomes, with acceptable risks, and is increasingly targeted at an improving pathophysiological understanding of the biology of AD. Although the evidence is limited, the existing evidence, coupled with clinical experience and common sense, is adequate to produce a minimal set of care principles. In this context, the American Association for Geriatric Psychiatry (AAGP) affirms that there now exists a minimal set of care principles for patients with AD and their caregivers. Consequently, the detection and treatment of AD must now be considered part of the typical care practices for any physician and other licensed clinicians who interact with patients with this disease. This document articulates these principles of care.

Schizophrenia and Older Adults: An Overview: Directions for Research and Policy

The Group for the Advancement of Psychiatry, Committee on Aging, believes that a crisis has emerged with respect to the understanding of the nature and treatment of schizophrenia in older persons. Moreover, critical gaps exist in clinical services for this population. In this article, we examine the epidemiology of aging and schizophrenia; life-course changes in psychopathology, cognitive function, social functioning, and physical health; and various concerns regarding treatment, services, and financing. Finally, we propose six research and policy recommendations and suggest methods for addressing the research questions that we have posed.

Life‐Sustaining Treatment and Assisted Death Choices in Depressed Older Patients

OBJECTIVES: The major purpose of this study was to examine the effect of depressed mood in older, medically ill, hospitalized patients on their preferences regarding life‐sustaining treatments, physician‐assisted suicide (PAS), and euthanasia and to determine the degree to which financial constraints affected their choices.

Anxiety Disorders in Older Puerto Rican Primary Care Patients

OBJECTIVE Authors examined the frequency and comorbidity of anxiety disorders among aging Puerto Ricans seen in primary care. METHODS A group of 303 middle-aged and older low-socioeconomic-status Puerto Ricans attending primary-care clinics were surveyed, using a Spanish-language diagnostic interview. RESULTS Twenty-four percent of participants met probable DSM criteria for at least one anxiety disorder in the previous year, especially generalized anxiety disorder, specific phobia, and panic attacks. Psychiatric comorbidity was common; the occurrence of most anxiety disorders increased the conditional risk of a comorbid disorder from 5- to 30-fold. CONCLUSIONS The present results suggest a need to screen at-risk patients in primary care settings serving this population.

Depression in Later-Life Puerto Rican Primary Care Patients: The Role of Illness, Stress, Social Integration, and Religiosity

BACKGROUND Older Puerto Ricans belong to two rapidly growing demographic groups known to have high rates of depression: the aging and Hispanic populations. Studies of depression in Puerto Ricans have primarily focused on the impact of demographic factors and health. This study expands previous research, examining the relationships between depression and social stressors, social support, and religiosity, for Puerto Rican primary care patients aged 50 and older. PATIENTS Participants included 303 Puerto Ricans from six primary care clinics in a northeastern city. METHODS Patients completed in-person interview in Spanish. The Composite International Diagnostic Interview indicated depressive disorders meeting DSM-IV criteria. Bivariate and multivariate relationships between depression and demographics, health, social stress and support, and religiosity were explored. RESULTS One fifth of participants met DSM-IV criteria for major depression or dysthymia. Participants with the lowest income, more recent migration, and poor subjective health were significantly more likely to be depressed. In addition, rates of depression increased steeply for patients caring for grandchildren and those with personal or family legal problems. Seeing few relatives each month and needing more instrumental, emotional, or financial support were also related to higher rates of depression. Unexpectedly, low objective illness severity correlated with increased depression, whereas religiosity and religious participation had no relationship to depression. CONCLUSIONS The findings presented here indicate the potential for social stressors and inadequate supports to substantially increase the risk of depression in older Puerto Ricans in primary care settings. Further studies should explore incorporating these social risk factors into improved prevention, clinical detection, and culturally sensitive treatment of older depressed Puerto Ricans.

Instability of attitudes about euthanasia and physician assisted suicide in depressed older hospitalized patients

The objective of this study was to examine the interest of non-terminally ill hospitalized elderly patients in euthanasia and physician assisted suicide (PAS) and to determine the stability of these interests over time. Patients age 60 or older (n=158), including both a depressed sample and non-depressed control sample, underwent a structured interview evaluating their interest in euthanasia and PAS in the event of a series of hypothetical outcome scenarios. Substantial proportions of subjects (varying from 13.3%-42% depending on the scenario) expressed hypothetical acceptance of euthanasia and PAS. After six months a subset of patients changed their minds about euthanasia and PAS (8% - 26% depending on the scenario), most often in the direction of initial acceptance to later rejection. Patients depressed in the hospital and interested in PAS for the outcome of their current (non-terminal) condition were significantly more likely express unstable opinions, with most rejecting it six months later. Other correlations of instability, in specific scenarios, included being male, experiencing higher baseline suffering, poorer subjective health and lower instrumental support. Because euthanasia and PAS actions are irreversible, findings of instability have important implications both clinically and for design of PAS legislation.

Determinants of geropsychiatric inpatient length of stay.

Despite efforts to decrease lengths of acute psychiatric hospital stays, some geriatric inpatients continue to have extended stays. This research examined factors related to length of stay (LOS), including legal and administrative factors not traditionally included in prior studies. The charts of 384 patients, representing all 464 discharges from an inpatient geropsychiatric unit over a one-year period, were evaluated retrospectively and analyzed using logistic regression and logarithmic transformation. The LOS of over 12% of the inpatients was 26 days or more (average LOS 14.1). Factors significantly associated with longer LOS were: receiving electroconvulsive therapy (ECT), higher Brief Psychiatric Rating Scale (BPRS) positive symptoms scores, falling, pharmacology complications, multiple prior psychiatric hospitalizations, requiring court proceedings to continue hospitalization or medicate against will, consultation delays and not performing ECT on weekends. Neither demographics nor diagnoses alone had influence on length of stay. Incorporation of LOS predictors into Medicare Inpatient Prospective Payment System (IPPS) would more accurately account for the complexity in the cost of caring for geropsychiatry patients.

Ataques de Nervios and Psychiatric Disorders in Older Puerto Rican Primary Care Patients

The present study aimed to examine the phenomenon of ataques de nervios (ataques) among a primary care sample of Puerto Ricans age 50 years and older living in the mainland United States. The sample included 303 participants who were asked whether they had ever experienced an ataque and to describe the episode and the situation that provoked it. Participants were administered a Spanish-language version of the Composite International Diagnostic Interview—Short Form. Ataques occurred in 26% of participants and were a strong risk factor for current psychiatric disorders. Of participants with ataques, 84% met criteria for at least one anxiety, mood, suicidal, psychotic, or substance use problem. Ataques were most commonly elicited by interpersonal conflict. Factor analysis suggested three possible constellations of ataques symptoms that appeared to map onto anxious, angry, and depressive symptomatology. Ataques were associated with poorer subjective health status but not with other proposed vulnerability factors.

Could adequate palliative care obviate assisted suicide

Physician views regarding the relationship between palliative care and physician-assisted suicide (PAS) are poorly understood. This survey of Connecticut physicians (n = 2,805; 40% response rate) found physicians nearly evenly divided on the question of whether there is a role for PAS in systems where adequate palliative care is available (42% no, 41% yes, 17% uncertain). These groups differ significantly on numerous personal and practice characteristics (all p < .001), as well as perceptions of various risks of PAS (p < .001). Written comments by 152 respondents provide further insights. Views on the respective roles of palliative care and PAS are highly discordant, challenging the development of clinical standards for end-of-life care.