Kirsten M. Wilkins

Use of gabapentin in the treatment of behavioural and psychological symptoms of dementia: a review of the evidence.

Behavioural and psychological symptoms of dementia (BPSD) have been defined as a heterogeneous range of psychological reactions, psychiatric symptoms and behaviours that may be unsafe, disruptive and impair the care of a patient in a given environment. To date, there are no US FDA-approved drugs or clear standards of pharmacological care for the treatment of BPSD. The novel antiepileptic agent gabapentin is being increasingly considered for use in the geriatric population because of its relatively favourable safety profile compared with other classes of psychiatric medications. Gabapentin has been administered to several geriatric patients with bipolar disorder and patients with dementia. It has also been reported to be successful in the treatment of a 13-year-old boy with behavioural dyscontrol, a finding that suggested a possible role for gabapentin in the treatment of other behavioural disorders. The purpose of this review was to find evidence for the use of gabapentin in the treatment of BPSD. To this end, a search was performed for case reports, case series, controlled trials and reviews of gabapentin in the treatment of this condition. The key words ‘dementia’, ‘Alzheimer’s disease’ and ‘gabapentin’ were used. Searches were performed in PubMed, PsycINFO, Ovid MEDLINE, Cochrane Library and ClinicalTrials.gov. The search revealed that there are limited data on the efficacy of gabapentin for BPSD in the form of 11 case reports, 3 case series and 1 retrospective chart review; no controlled studies appear to have been published to date on this topic. In most of the reviewed cases, gabapentin was reported to be a well tolerated and effective treatment for BPSD. However, two case reports in which gabapentin was used in the context of agitation in dementia with Lewy bodies questioned the appropriateness of gabapentin for all types of dementia-related agitation. The dearth of available data limits support for the off-label use of gabapentin for the treatment of BPSD. Furthermore, controlled studies should be conducted before gabapentin can be clinically indicated for the successful treatment of BPSD.

Pharmacotherapy for Inappropriate Sexual Behaviors in Dementia: A Systematic Review of Literature

The aim of this study is to systematically review the published literature on pharmacotherapy for inappropriate sexual behaviors in dementia. Literature search of the 5 databases (PubMed, MEDLINE, EMBASE, PsychINFO, and COCHRANE collaboration) and the analysis of the data available for the pharmacotherapeutic treatments of inappropriate sexual behaviors in dementia were carried out.There are no published randomized controlled trials of pharmacotherapy for inappropriate sexual behaviors in dementia, but available data from uncontrolled trials, case series, and individual case reports suggest efficacy for antidepressants, antipsychotics, mood stabilizers, hormonal agents, cimetidine, and pindolol for the treatment of these behaviors. Although there are no controlled data for the treatment of inappropriate sexual behaviors in dementia, available data suggest efficacy for some commonly used pharmacotherapeutic agents.

Efficacy of Electroconvulsive Therapy in the Treatment of Nondepressed Psychiatric Illness in Elderly Patients: A Review of the Literature

Electroconvulsive therapy (ECT) is well established as a safe and effective treatment for several psychiatric disorders. Responsiveness to ECT does not abate with age, and data indicate that the use of ECT in the treatment of psychiatric disorders in the elderly persons has increased in recent decades. Special consideration must be given to the baseline cognitive abilities of an elderly patient prior to treatment with ECT. Much of the literature on the use of ECT in the elderly persons has focused on the treatment of mood disorders, whereas less research has been devoted to its use in the treatment of other psychiatric conditions. Although depressive syndromes remain the most common indication for ECT in the elderly persons, clinicians treating elderly patients should remain aware of the safety and efficacy of this treatment modality with other psychiatric disorders. This review examines the literature on the use of ECT in elderly patients with some common neuropsychiatric disorders including catatonia, bipolar mania, schizophrenia, dementia with behavioral disturbance, and Parkinsons disease.

Fostering Medical Student Interest in Geriatrics and Geriatric Psychiatry.

To the Editor: The need for medical professionals with knowledge and training to care for geriatric patients is projected to increase [1], and training and exposure in geriatric medicine have positively influenced medical trainees to choose careers in geriatrics [2]. Recruitment of psychiatry residents into geriatric psychiatry fellowship programs has remained difficult in the USA [3]; however, experience in geriatric psychiatry is highly variable for medical students and may be absent in some training programs. We conducted a survey to determine the impact of an experience in geriatric psychiatry during medical student psychiatry clerkships on students’ interests in geriatrics and geriatric psychiatry. The institutional review board at the University of Arkansas for Medical Sciences approved our study. We invited all thirdand fourth-year students completing the required 6week clerkship from November 2012 to November 2013 to participate. Participants completed a 5-point Likert-scale survey of five questions preand post-clerkship specifically about their interest in a career in geriatrics and geriatric psychiatry. For example, students ranked their agreement with the statement “In the future, I would consider a career in geriatric medicine (e.g., palliative care, geriatric internal medicine).” Participation was voluntary and students could opt out anytime. Before the clerkship, students ranked five site options and may or may not have known details about exposure to geriatrics at the individual sites. Clerkship directors made student assignments on the basis of resource availability and student preference before we asked students to participate in the study. Geriatric exposure varied across the sites and stratified students into distinct groups for data analysis: Group 1 (n=34): combination of outpatient and inpatient psychiatric experiences, including a week of inpatient geriatric psychiatry; Group 2 (n=70): consultation services that typically include exposure to geriatric patients; and Group 3 (n=41): adult inpatient services with age requirements, minimizing exposure to geriatric patients. All students received a required formal didactic session in geriatric psychiatry. We compared the mean scores of the preand postclerkship surveys between students with exposure to a formal geriatric psychiatry unit (Group 1) and geriatrics (Groups 1 and 2) and students without exposure to geriatrics (Group 3) using a paired t test with significance set at p<0.05. Power analyses estimated 90 % power with a sample size of 48 to detect a 0.5 change with alpha of 0.5 and standard deviation of 2. We used STATA to complete all statistical analyses. A total of 141 students participated, but we excluded 30 surveys from the analyses due to incomplete data. For the 111 remaining survey pairs, the average age of participants was 26 years; 64 % (n=71) were male and 36 % (n=40) female. Students were equally distributed among the groups. All participants reported a significant increase in “understanding the role of a geriatric psychiatrist,” but only students with a formal experience in geriatric psychiatry (Group 1) or exposure to geriatric psychiatry (Group 1 and 2) reported a significant increase in their interest in a career in geriatrics and geriatric psychiatry. Definitive conclusions are limited by the potential selection bias because student preferences were not incorporated in the analyses. Further limitations include no quantification or operationalization of exposure to geriatric patients across the different groups, and we did not record the overall survey response rate. * Shona L. Ray-Griffith slray@uams.edu

Development of Geriatric Mental Health Learning Objectives for Medical Students: A Response to the Institute of Medicine 2012 Report

America is aging as the population of older adults increases. The shortage of geriatric mental health specialists means that most geriatric mental healthcare will be provided by physicians who do not have specialty training in geriatrics. The Institute of Medicine Report of 2012 highlighted the urgent need for development of national competencies and curricula in geriatric mental health for all clinicians. Virtually all physicians can expect to treat older patients with mental health symptoms, yet currently there are no widely accepted learning objectives in geriatric mental health specific for medical students. The authors describe the development of a set of such learning objectives that all medical students should achieve by graduation. The iterative process included initial drafting by content experts from five medical schools with input and feedback from a wider group of geriatric psychiatrists, geriatricians, internists, and medical educators. The final document builds upon previously published work and includes specific knowledge, attitudes and skills in six key domains: Normal Aging, Mental Health Assessment of the Geriatric Patient, Psychopharmacology, Delirium, Depression, and Dementia. These objectives address a pressing need, providing a framework for national standards and curriculum development.

Integration of Basic and Clinical Science in the Psychiatry Clerkship

ObjectiveIntegration of basic and clinical science is a key component of medical education reform, yet best practices have not been identified. The authors compared two methods of basic and clinical science integration in the psychiatry clerkship.MethodsTwo interventions aimed at integrating basic and clinical science were implemented and compared in a dementia conference: flipped curriculum and coteaching by clinician and physician-scientist. The authors surveyed students following each intervention. Likert-scale responses were compared.ResultsParticipants in both groups responded favorably to the integration format and would recommend integration be implemented elsewhere in the curriculum. Survey response rates differed significantly between the groups and student engagement with the flipped curriculum video was limited.ConclusionsFlipped curriculum and co-teaching by clinician and physician-scientist are two methods of integrating basic and clinical science in the psychiatry clerkship. Student learning preferences may influence engagement with a particular teaching format.

Six Things All Medical Students Need to Know about Geriatric Psychiatry (and How to Teach Them)

Given the demographics of aging and the prevalence of psychiatric disorders, virtually all physicians can expect to care for older adults whose mental health merits professional attention. According to the World Health Organization, by 2050, individuals 65 or older will comprise 20% of the US population, and approximately 15% of this population will have mental health needs [1]. Despite this anticipated “Silver Tsunami,” the pipeline of geriatric specialty-trained physicians, including geriatric psychiatrists, remains woefully inadequate [2]. In 2012, the Institute of Medicine (IOM) issued a report entitled The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? [3]. Emphasizing changing demographics, the prevalence of psychiatric disorders, and the critical shortage of specialty-trained clinicians, the IOM recommended development of core competencies in geriatric mental health and substance use for all healthcare providers. Our responsibility as psychiatric educators is to ensure that physicians in training for any specialty are prepared to assess and manage the mental health concerns of older adult patients. Despite this compelling mandate, many medical students receive little geriatric psychiatry education. After surveying psychiatry clerkship directors from 110 US medical schools, Lehmann, Blazek, and Popeo reported that 21% of responding psychiatric clerkships lacked any specific instruction or clinical experience focused on the mental health needs of older patients [4]. They recommended the development of competence-based learning objectives in geriatric psychiatry, which could be implemented by educators across the medical school curriculum, including those who are not geriatric specialists. In 2012, five medical student educators/geriatric psychiatrists formed a workgroup of the Teaching and Training Committee of the American Association for Geriatric Psychiatry with the purpose of developing geriatric psychiatry learning objectives for all medical students to attain prior to graduation. The workgroup reviewed the literature on geriatric learning objectives and sought input from content experts in psychiatry, neurology, geriatric medicine, and medical education. The iterative development process included solicitation of local and national feedback with ongoing revisions through oral presentations at the annual meeting of the American Association for Geriatric Psychiatry in 2014 [5] and the annual meeting of the Association of American Medical Colleges Medical Education meeting in 2014 [6]. The resulting document identifies six domains of geriatric psychiatry essential in preparing medical students to deliver competent and safe care to their older patients in residency and beyond: normal aging, mental health assessment of the older adult, psychopharmacology, depression, dementia, and delirium (Table 1). The set of learning objectives is endorsed by the American Association for Geriatric Psychiatry’s Teaching and Training Committee and is featured as an educational resource on its website [7]. * Kirsten M. Wilkins kirsten.wilkins@yale.edu

When patients hurt us

Abstract In this thoughtful article, medical educators in various stages of their careers (resident, mid-career clinician-educators, medical school deans) reflect upon increasing reports of harassment and mistreatment of trainees by patients. In addition to providing a general overview of the limited literature on this topic, the authors describe their own experience collecting information on trainee mistreatment by patients at their institution. They explore the universal difficulty that educators face regarding how to best address this mistreatment and support both faculty and trainees. Given the current sociopolitical climate, there has never been a more urgent need to critically examine this issue. The authors call on the greater medical education community to join them in these important conversations.

Integration of Primary Care and Psychiatry: A New Paradigm for Medical Student Clerkships

BackgroundPublic health crises in primary care and psychiatry have prompted development of innovative, integrated care models, yet undergraduate medical education is not currently designed to prepare future physicians to work within such systems.AimTo implement an integrated primary care–psychiatry clerkship for third-year medical students.SettingUndergraduate medical education, amid institutional curriculum reform.ParticipantsTwo hundred thirty-seven medical students participated in the clerkship in academic years 2015–2017.Program DescriptionEducators in psychiatry, internal medicine, and pediatrics developed a 12-week integrated Biopsychosocial Approach to Health (BAH)/Primary Care–Psychiatry Clerkship. The clerkship provides students clinical experience in primary care, psychiatry, and integrated care settings, and a longitudinal, integrated didactic series covering key areas of interface between the two disciplines.Program EvaluationStudents reported satisfaction with the clerkship overall, rating it 3.9–4.3 on a 1–5 Likert scale, but many found its clinical curriculum and administrative organization disorienting. Students appreciated the conceptual rationale integrating primary care and psychiatry more in the classroom setting than in the clinical setting.ConclusionsWhile preliminary clerkship outcomes are promising, further optimization and evaluation of clinical and classroom curricula are ongoing. This novel educational paradigm is one model for preparing students for the integrated healthcare system of the twenty-first century.

Treatment Approaches to Sexual Dysfunction in Late Life

Purpose of reviewThis review provides an overview of the latest treatment options for sexual dysfunction in the elderly, specifically the DSM-5 male and female sexual disorders, medication-induced sexual dysfunction, and inappropriate sexual behaviors in dementia. Despite the increasing prevalence of sexual dysfunction with age, various factors including ageism, misconceptions about sexual behavior in the elderly, and discomfort discussing these issues can lead to under-recognition and under-treatment. This review highlights the importance of sexual health at any age and the available pharmacologic and non-pharmacologic treatments for these conditions.Recent findingsResearch is robust for some disorders, like erectile dysfunction, but overall lacking for most disorders of sexual function in the elderly. Few FDA-approved treatments exist, but multiple treatments have been studied with varying results. A thorough evaluation of biological, psychological, and social factors should be completed prior to treatment. Psychiatrists should keep in mind that these conditions may be influenced by psychological factors, secondary to psychiatric illness, worsened or improved with psychotropic medications, and may be responsive to psychotherapy. Inappropriate sexual behaviors in dementia that are unresponsive to behavioral interventions may also respond to a number of psychotropic medications.SummarySexual dysfunction in the elderly remains understudied. However, several pharmacological and non-pharmacological options are available that may be of benefit.