Shilpa Srinivasan

Antipsychotic use in dementia: a systematic review of benefits and risks from meta-analyses:

Background: The purpose of this review is to evaluate the data on the use of antipsychotics in individuals with dementia from meta-analyses. Methods: We performed a literature search of PubMed, MEDLINE, EMBASE, PsycINFO and Cochrane collaboration databases through 30 November, 2015 using the following keywords: ‘antipsychotics’, ‘dementia’ and ‘meta-analysis’. The search was not restricted by the age of the patients or the language of the study. However, in the final analysis we only included studies involving patients that were published in English language journals or had official English translations. In addition, we reviewed the bibliographic databases of published articles for additional studies. Results: This systematic review of the literature identified a total of 16 meta-analyses that evaluated the use of antipsychotics in individuals with dementia. Overall, 12 meta-analyses evaluated the efficacy of antipsychotics among individuals with dementia. Of these, eight also assessed adverse effects. A further two studies evaluated the adverse effects of antipsychotics (i.e. death). A total of two meta-analyses evaluated the discontinuation of antipsychotics in individuals with dementia. Overall, three meta-analyses were conducted in individuals with Alzheimer’s disease (AD) whereas one focused on individuals with Lewy Body Dementia (LBD). The rest of the 12 meta-analyses included individuals with dementia. Conclusions: Antipsychotics have demonstrated modest efficacy in treating psychosis, aggression and agitation in individuals with dementia. Their use in individuals with dementia is often limited by their adverse effect profile. The use of antipsychotics should be reserved for severe symptoms that have failed to respond adequately to nonpharmacological management strategies.

Assessment of the person with late-life depression.

This article discusses characteristic factors in the presentation of depressive disorders in persons older than age 65 years. Clinical presentation is discussed along with risk and protective factors. Detailed descriptions of tests useful for screening and diagnosis of depression in the elderly are presented. Each test is reviewed according to time to administer, sensitivity and specificity, outcomes, advantages, and disadvantages. The importance of clinical history and the diagnostic interview, as well as the role of laboratory studies and neuroimaging in the clinical evaluation are discussed.

Profile of paliperidone extended release: review of efficacy and safety data

Paliperidone, an active metabolite of risperidone, is the most recent second-generation antipsychotic to become available on the market. This article addresses the pharmacology, clinical efficacy and tolerability of paliperidone. A comprehensive review of studies on MEDLINE using terms, such as paliperidone, 9-hydroxy risperidone, efficacy and tolerability, was conducted. Paliperidone, a 9-hydroxy derivative of risperidone is an antagonist at the dopamine and serotonin receptor sites. As paliperidone is an active metabolite of the parent compound risperidone, it is not metabolized hepatically, has minimal drug–drug interactions and is largely excreted unchanged by the kidneys. It follows linear pharmacokinetics. Evidence from short- and long-term trials supports the efficacy and tolerability of paliperidone extended release (ER) in the treatment of schizophrenia. Randomized, double-blind, placebo-controlled, multicenter studies have demonstrated both paliperidone 6 and 12 mg result in symptom improvement, increase in time of first recurrence of psychotic symptoms as well as significant improvements in personal and social performance. Studies demonstrated increases in plasma prolactin levels and extrapyramidal symptoms with paliperidone ER treatment compared with placebo. Changes in blood glucose and lipid levels with paliperidone ER were comparable to placebo. Overall, paliperidone is an efficacious, well-tolerated addition to the treatment armamentarium for schizophrenia.

Suvorexant for insomnia in older adults: a perspective review

The aim of this review was to identify published randomized control trials (RCTs) that evaluated the efficacy and tolerability of suvorexant for the treatment of insomnia among older adults (≥65 years). A literature search was conducted of PubMed, MEDLINE, EMBASE, PsycINFO and Cochrane collaboration databases for RCTs in any language evaluating suvorexant for the treatment of insomnia in older adults. Additionally, references of full-text articles that were included in this review were searched for further studies. Data from three RCTs of suvorexant were included in this review. All the three studies fulfilled the criteria for being of good quality based on the items listed by the Center for Evidence Based Medicine (CEBM) for the assessment of RCTs. None of the three studies were conducted exclusively among older adults. However, they also included older individuals diagnosed with primary insomnia. These studies included a total of 1298 participants aged ≥65 years in age. Trial durations ranged from 3 months to 1 year. Available data from these studies indicate that suvorexant improves multiple subjective and polysomnographic sleep parameters for sleep onset and maintenance among older individuals with a diagnosis of primary insomnia and is generally well tolerated. Current evidence, although limited, indicates that suvorexant benefits older adults with primary insomnia and is generally well tolerated.

Geriatric Telepsychiatry in Academic Settings

The growing older adult demographic in the USA and the concomitant increase in older adults with mental illness highlights the critical need for expanding access to mental health care in this population. Older adults with mental illness and/or substance use disorders often first receive clinical attention in the context of primary care settings, which are under-resourced, both in terms of time and professional training. Stigma in seeking mental health care, lack of information about services, and limited transportation to services remain major barriers to mental health care access and utilization among older adults. However, the volume of the current geriatric psychiatry workforce is insufficient to meet the mental healthcare needs of the aging population. Telepsychiatry, the provision of mental health/psychiatric care via live-two way videoconferencing, is one way to bridge the looming gap between available specialty trained providers and the population in need of services. While recognizing that healthcare providers of various specialties and disciplines play a vital role in providing mental health care to older adults, this chapter will primarily focus on academic implications of geriatric telepsychiatry within psychiatric (graduate medical) training programs.

Mental Health Consequences of Disaster Exposure in Older Adults

Older adults represent the fastest growing demographic of the United States population. However, the elderly are insufficiently represented in studies examining the mental health impact of natural and man-made disasters. Social, cultural, and economic variables influence disaster-related mental health sequelae with a higher risk for morbidity and mortality among older adults due to physiologic factors, associated cognitive underpinnings, and chronic disease burden. Post-disaster mental health symptoms in elderly include sleep disturbance, irritability, acute stress reactions, depression, generalized anxiety disorder (GAD), substance use, and post-traumatic stress disorder (PTSD).

Treatment Approaches for Opioid Use Disorders in Late Life

Purpose of reviewThe use of opioids and opioid-related deaths in the USA has risen to epidemic proportions. Until recently, the impact of this public health crisis in older adults has not been adequately emphasized. This paper reviews the extant literature for the management of opioid use disorder (OUD) in older adults, with a focus on both pharmacologic and non-pharmacologic interventions for OUD in older adults.Recent findingsOpioid prescriptions for older adults have dramatically increased since the 1990s. OUD in older adults is under recognized and under treated in clinical settings. Once identified, appropriate treatments for OUD should be offered to older adults. These include a combination of psychosocial and pharmacologic approaches. Pharmacologic treatments include antagonist and agonist therapies. Antagonist agents, such as naloxone for acute overdoses and naltrexone for maintenance treatment, and agonists, such as buprenorphine and methadone, have been used. Psychosocial treatments include motivational interviewing (MI) and motivational enhancement treatment (MET) approaches, as well as family support and community resource linkage.SummaryIn order to optimally address OUD in older adults, a multi-dimensional approach involving pharmacotherapy in combination with psychosocial treatments is recommended. Directions for future research include studies aimed at evaluating the efficacy of such treatments specifically in older adults including those with chronic pain and other comorbidities for which opioid use presents both benefits and challenges.

Introduction to Telepsychiatry

Technological advances have been applied to the practice of medicine including psychiatry. One such application is the growth of telepsychiatry. Telepsychiatry can be defined as the use of two-way interactive videoconferencing technology to provide mental health and substance abuse services remotely. Telepsychiatry falls under the umbrella terms such as telemedicine and telehealth. Telepsychiatric implementations date back to the 1950s when closed circuit television was utilized as a teaching tool. This technology was subsequently applied to the provision of group psychotherapy. In 1973, the term telepsychiatry was coined. While it improved access to care, it was costly to implement. With continued technological advancements in the 1980s and on, not only did cost begin to decrease but also the quality of the audiovisual technology improved. Since then, this treatment modality has been applied to a variety of populations from children to geriatric patients. It has been applied in various settings including hospitals, outpatient clinics, long term care facilities, and correctional settings. Lastly, it can be utilized for education of staff and trainees, coordination of the treatment team, and direct patient care.

PSYCHIATRIC FACE TIME: TELEHEALTH FOR TECHNOLOGY-DRIVEN INNOVATIONS IN DEMENTIA CARE

this information two methodologies will be used: a semistructured interview and a participant observation. The interview will be administered to those people in the early stages of the dementia at home. Interviewees will be asked to explain the compensations they are using to carry out instrumental activities of daily living where they have limitations. Information will be retrieved on for how long they have been using them, the satisfaction these strategies provide and where they got it from. Demand of additional help will be asked. Several sociodemographic and type of dementia and severity variables will be retrieved. In the participant observation carried out at the individuals’ home, information will be retrieved on the sequence in whichthe actions aredeveloped; technical aids used influence of the home environment on the process and its outcome. Up to now, the observational stage has started and some results have been collected. The collection of this information will allow the professionals to: (1) understand the real needs and difficulties of the people with dementia; (2) design and validate more ecological interventions based on the concept of everyday live and which will be able to maximize their capacities to meetthechallenges of their lives.