Mary Blazek

The Role of the Occupational Therapist in the Management of Neuropsychiatric Symptoms of Dementia in Clinical Settings

ABSTRACT Neuropsychiatric symptoms (NPS) of dementia include aggression, agitation, depression, anxiety, delusions, hallucinations, apathy, and disinhibition. NPS affect dementia patients nearly universally across dementia stages and etiologies. They are associated with poor patient and caregiver outcomes, including increased health care utilization, excess morbidity and mortality, and earlier nursing home placement, as well as caregiver stress, depression and reduced employment. There are no FDA-approved medications for NPS, but it is a common clinical practice to use psychotropic medications such as antipsychotics, to control symptoms; however, antipsychotics show only modest efficacy in improving NPS and have significant risks for patients, including side effects and mortality. Nonpharmacologic treatments are considered first-line by multiple medical bodies and expert consensus, as they show evidence for efficacy and have limited potential for adverse effects. Ideally, nonpharmacological management of NPS in clinical settings occurs in multidisciplinary teams, where occupational therapists play an important collaborative role in the care of the person with dementia. Our group has articulated an evidence-informed structured approach to the management of NPS that can be integrated into diverse practice settings and used by providers of various disciplines. The “DICE” (Describe, Investigate, Create, and Evaluate) approach is inherently patient- and caregiver-centered, as patient and caregiver concerns are integral to each step of the process. DICE offers a clinical reasoning approach through which providers can more efficiently and effectively choose optimal treatment plans. The purpose of this paper is to describe the role of the occupational therapy in using the DICE approach for NPS management.

Later-Life Depression and Heart Failure

Using a case history to illustrate key points, this article (1) highlights depression criteria, prevalence, and later-life depression presentations; (2) discusses factors contributing to later-life depression; (3) reviews the interplay between heart failure and later-life depression; and (4) suggests screening and treatment recommendations for depression in patients with heart failure.

The ADMSEP Milestones Project

ObjectiveCredentialing bodies mandate that a medical school’s curriculum be based upon recognized guidelines. Within the field of psychiatry, the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) has previously published recommended guidelines for the pre-clinical and clerkship curriculum. Ongoing changes within the Liaison Committee on Medical Education’s requirements for medical school curricula, and the publication of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, necessitated review of these guidelines.MethodsADMSEP convened a task force of psychiatric educators to develop a consensus report outlining new guidelines. The ADMSEP membership reviewed and approved this final document.ResultsThe guidelines outline six core learning objectives with corresponding competencies. Each of these competencies specifies accompanying milestones to be achieved through the course of medical school.ConclusionsADMSEP believes these guidelines will aid educators in crafting a school’s psychiatric curriculum. Clearly articulated milestones may foster the further development of validated educational and assessment tools by ADMSEP and other organizations.

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.

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

Spaced learning using emails to integrate psychiatry into general medical curriculum: Keep psychiatry in mind

Abstract Objectives: Traditionally, medical students on clinical rotations receive instruction on principles of mental health only during the psychiatry clerkship. We used emails to insert teaching of psychiatric concepts beyond the psychiatry clerkship into other rotations using the method of spaced learning, the delivery of brief morsels of information repeated over time intervals. We predicted that the intervention would improve attitudes and confidence towards the integration of psychiatry and knowledge retention. Methods: We developed and distributed a series of emails relating key psychiatric concepts targeted to the other core clerkships. Results: In a cluster-randomized trial over one academic year (intervention group n = 71, control group n = 61), scores on the Attitudes and Confidence in the Integration of Psychiatry scale and on the knowledge quiz did not differ significantly. Students who actively engaged with the emails demonstrated significantly higher scores on the knowledge test. Email users valued the timing, format of delivery and application of psychiatric principles outside the psychiatric setting. Participants recommended simplifying the format and previewing the benefits of spaced learning to increase utilization. Conclusion: Delivering spaced learning through emails, within a curriculum designed to foster engagement, may provide an efficient means of addressing the widely-recognized but elusive goal of integrating teaching across medical disciplines.

The Short-Answer Vignette Examination (SAVE): an assessment tool for the core psychiatry clerkship.

ObjectiveThis study aims to develop a vignette-based assessment tool for medical students on the psychiatry clerkship, with the goal of capturing knowledge and clinical reasoning.MethodsThe Short-Answer Vignette Exam (SAVE), four case vignettes with open-ended questions regarding assessment, differential diagnosis, management, and treatment, was developed for and administered to medical students rotating through psychiatry at a university medical school over one academic year (n = 169). The correlation of SAVE scores to resident/faculty evaluations (clinical rating) and Shelf exam scores were analyzed.ResultsSAVE scores were significantly correlated with scores on both the Shelf and Clinical Rating. By contrast, Shelf scores were not significantly related to Clinical Rating.ConclusionThe SAVE may measure aspects of clinical decision making not measured by the Shelf, without being redundant in what is assessed by the Clinical Rating. The SAVE provides an additional potentially useful assessment tool to evaluate medical students on the psychiatry clerkship.

Person-Centered Primary Care Strategies for Assessment of and Intervention for Aggressive Behaviors in Dementia

With an increase in the number of individuals affected by dementia, it is imperative for health care providers to be well versed in the most effective ways to manage neuropsychiatric symptoms, such as aggression. Aggression can be particularly hard to manage because it creates risk of harm for formal and informal caregivers, and options for medical intervention are complex and situation dependent. Although multiple guidelines for management of aggression in dementia are available in the literature, their scope is widespread and suggested treatments often vary, making decision making difficult to navigate for busy clinicians. Using a composite case as a model, the current article provides guidelines that take outpatient providers through the steps needed to provide effective treatment for aggression in individuals with dementia. Shifting the current focal point of health care for aggressive dementia patients toward a more person-centered approach will have a positive impact on patient care. [Journal of Gerontological Nursing, 43(2), 9-17.].

Managing behavioral disturbances in a patient with dementia.

A 92-year-old patient with Parkinson disease and dementia provides an opportunity for the advanced practice registered nurse to shift thinking about behavioral disturbances in dementia, away from controlling behavior with pharmacologic approaches, such as antipsychotics, toward understanding behavior by applying the nonpharmacologic Describe, Investigate, Create, and Evaluate method.

Medical Students in a Dementia Care Facility: an Enhanced Geriatric Psychiatry Experience

The 2012 Institute of Medicine report “The Mental Health and SubstanceUseWorkforce For Older Adults: InWhoseHands?” describes the burgeoning population of elderly in the USA and the critical shortage of clinicians trained to meet their mental health-care needs [1]. The report makes specific recommendations for strengthening the nation’s geriatric mental health workforce and urges development of model curricula for the entire spectrum of health-care providers who care for older adults. With the current shortage of specialist physicians in this field, in the future most geriatric mental health care will be provided by non-specialists. It is imperative that medical school education include an enhanced focus on preparing future physicians to address the mental health needs of older patients. Negative attitudes and stigma toward older patients with dementia are pervasive among medical students and other health professions [2]. Despite the tremendous demand for geropsychiatric care for people with dementia, the number of medical school graduates choosing to enter the field of geriatric psychiatry is woefully inadequate [3]. Studies document that clinical encounters with older patients have a positive effect on students’ sensitivity to geriatric issues and attitudes toward older people [2, 4]. In one study, researchers suggest that geriatric psychiatry programs create exemplary initiatives in the early years of medical education [5]. We developed an educational innovation, the Enhanced Geropsychiatric Experience (EGE) for third yearmedical students in a dementia care facility, which exposed students to patients with dementia with behavioral and psychological symptoms. Goals included increasing student participation and comfort, changing negative attitudes towards patients with dementia, and piquing student interest in the field of geriatric psychiatry.