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•What is the primary question addressed by this study?We aim to clarify and update the information on the efficacy and tolerability of long-acting antipsychotics in geriatric patients.•What is the main finding of this study?Compared to oral antipsychotics, long-acting antipsychotic use resulted in reduced hospitalization rates and reduced no-show rates, suggesting better engagement in treatment. Female patients had increased discontinuation rates of long-acting antipsychotics and patients with neurocognitive disorder trended in that direction.•What is the meaning of the finding?Long-acting antipsychotics appear to have good efficacy and tolerability in geriatric patients; some patients, however, particularly female patients and possibly patients with neurocognitive disorders, may not tolerate LAI as well as other patients, but more studies are needed on this topic.

The case of a 91-year-old woman is used to discuss the administration of tacrine therapy for enhancing cognitive functions in patients with Alzheimer's disease. Tacrine, an inhibitor of acetylcholinesterase, is generally given to patients with no history of liver disease. Patients who receive the drug, which causes increased liver transaminases and gastrointestinal effects, usually require a follow-up cognitive test and weekly blood tests to assess liver function., Mrs. L, age 91, has resided in a nursing home since she was diagnosed with Alzheimer's disease 7 years ago. Based on her medical history and the results of mental [...]

Objective: The authors investigated the relationships between concentrations of two acute-phase proteins, [[Alpha].sub.1]-antichymotrypsin (ACT) and [[Alpha].sub.2]-macroglobulin (MAC), and cognitive impairment in the very old. Method: Concentrations of ACT and MAC were determined in a prospective study using sera from medically stable elderly nursing home residents. Cognitive impairment was assessed with the Mini-Mental State. Results: Concentrations of ACT were associated with greater cognitive impairment, as reflected by lower Mini-Mental State scores. This relationship did not exist for MAC. Conclusions: These data extend previous reports that patients with Alzheimer's disease have greater concentrations of ACT in their blood by demonstrating in a diagnostically diverse nursing home population a relationship between serum ACT and mental status. Elevated serum ACT in patients with compromised mental status may reflect a cerebral acute-phase response.

The results of previous studies have indicated that psychotropic drugs, medications used for the treatment of mental illness, are frequently prescribed for the elderly in nursing homes. Estimates of psychotropic drug prescriptions among this group range from 11 to 74 percent. These results require further investigation because of this wide range of variability, and also to further examine the patterns of drug prescribing over time. This longitudinal study consisted of 91 residents of a 200-bed nursing home that was also a geriatric and psychiatric teaching facility affiliated with a medical college. The patients ranged in ages between 54 and 103, and the average age was 85 years old. Data on prescription frequency, the number of prescriptions, and individual doses were collected over a five-year period. All psychiatric diagnoses which accompanied the psychotropic medications were also reviewed. The results of the five-year analysis revealed that 70 percent of the patients were given a psychotropic drug, but fewer than 25 percent received continuous medication during this period. Episodic administration of psychotropic drugs was more common than continuous use among those who received these drugs. It is believed that this report represents the first longitudinal study of psychotropic drug prescribing and usage patterns among elderly nursing home residents. Other factors that may be indicative of the quality of treatment among nursing home residents which require more research include the incidence of drug reactions, drug efficacy, and the association of these drugs with adverse events, such as falls, fractures, and fainting. (Consumer Summary produced by Reliance Medical Information, Inc.)

A study to assess the effect of a multicomponent advance care planning intervention directed at nursing homes social workers in identifying and documenting preferences for medical treatments and on patient outcomes is presented. The results indicate that generalized interventions brought out desired results in documenting and identifying patient's wishes regarding simple treatments.

There is an increasing prevalence of substance use disorders among the geriatric population, particularly among the baby boomer generation (Yarnell et al, 2020). This places a heavy burden on our healthcare system that traditionally minimized the need for substance use treatment for older adults. The increased prevalence of comorbid medical and psychiatric illness among older adults increases the risks associated with substance use in later life. Evidence of an increasing number of psychiatric admissions and adverse health outcomes related to substance use in the elderly demonstrates that current screening and treatment modalities are struggling to adequately address substance use in this population. The geriatric population poses unique challenges for clinicians when attempting to utilize traditional motivational interviewing (MI) techniques, as common motivators such as negative health, loss and isolation do not appear to be as influential in incentivizing change. There is substantial research evaluating the efficacy of MI for substance use in general adult and pregnant populations (Frost et al, 2018). There is a lack of evidence regarding MI for substance use with older adults. The majority of studies involving older adults and MI have focused on outcomes related to lifestyle modification, reducing risk of cardiovascular disease, and recovery post hip fracture. We have identified a group of older adults with substance use disorders and applied MI principles as a key focus of their care.

Case presentation A 78-year-old widow presents to her primary care physician with complaints of severe anxiety, insomnia, overwhelming fearfulness, and an unrelenting feeling that 'something terrible is going to happen.' [...]

Case presentation An 80-year-old woman is brought in by her husband and daughters for a psychiatric evaluation. They want a second opinion about the treatments the patient is receiving for [...]

Case presentation An 85-year-old woman with vascular dementia and multiple behavioral problems including wandering, physical aggression, and refusal to bathe or change clothing was admitted to a nursing home. One [...]

Case presentation An 87-year-old widowed white man was brought in by his daughter for psychiatric evaluation. The patient had been living alone for the past 2 years following the death [...]

Case presentation Mrs. K, an 81-year-old widow who is experiencing forgetfulness, is brought by her daughter for psychiatric evaluation. During the past 6 months the patient has lost her house [...]

Case presentation A 75-year-old man presents with a request for 'something to make me stop smoking.' He has no prior psychiatric history but has multiple medical problems, including a history [...]

Case presentation A 76-year-old man with subjective complaints of memory problems over the past 2 years is referred by a psychiatrist for neuropsychological evaluation as part of a dementia assessment. [...]

Case presentation A 75-year-old widow was brought to the office by her family because of increased frequency of episodes of restlessness, irritability, cursing and yelling, and poor self-care. Of serious [...]

Case presentation A 68-year-old woman has a history of depression and anxiety that began at age 22. She has been treated with a variety of antidepressants and anxiolytics but has [...]

Advance directives (AD) are a legal document that give a voice to an individual's opinion in matters of their desired healthcare at a time when their capacity is compromised. Ideally, preceded by a thoughtful advance care planning (ACP) process, they reduce negative emotions in the surviving loved ones, avoid unnecessary use of healthcare resources and expenses, and improve the satisfaction of the quality of care provided, as many studies have shown. Despite the benefits of ACP and AD, there is a lack of awareness in their knowledge that may partially explain why few patients are engaged in it. In 1991, as part of an initiative to improve this gap, the Patient Self-Determination Act (PSDA) was created, and though reimbursements through Medicare are provided for specified providers, the ACP prevalence completion rate remains below 7.5%. Several factors have been shown to impact this outcome and are associated with those involved in the process including the patient, loved ones, agents, providers, as well as the environment under which it takes place. The inherent complexity of this process demands a higher level not only of technical knowledge, but of the complex dynamics of older adults and those in their support systems. Given the nature of Psychiatry itself, which equips its specialists in gathering their patients’ personal information, as well as exhibiting the needed skills to handle complex situations, the ACP process and the completion of AD with patients have met their ideal facilitator. We are seeking to engage Psychiatry trainees in the process of ACP with patients and empower their ability to assist in promotion and completion of these vital documents.

Long-acting injectable (LAI) antipsychotics, an alternative to oral (PO) antipsychotics are effective in increasing medication adherence and decreasing re-hospitalization rates in adult patient with psychotic disorders. LAIs are among the most effective treatments for chronic psychotic disorders with favorable outcomes including reduced relapse risk and overall reduction in mortality. The impact of LAIs in improving outcomes in the geriatric population is less certain with studies often involving first-generation LAIs which are less widely used in older adults. LAIs in the geriatric population are often avoided by clinicians due to concerns of adverse events, tolerability, and questions regarding appropriate dosing in older adults. This ongoing study aims to clarify if LAI antipsychotic use as opposed to PO has any correlation to better outcomes in older adults. Clinicians should use a patient-centered approach with individual risk-benefit assessment in offering LAIs to older adults.

The treatment of anxiety, panic, depression, and insomnia symptoms in late life pose many challenges. The use of benzodiazepines for these symptoms offers often rapid relief in some domains but clearly poses risks.  Second only to opioids, benzodiazepine prescriptions have become a major focus of public health concern and scrutiny. The use of electronic data base reporting and FDA warnings regarding abuse potential and withdrawal have lead to a movement to both deprescribe and not initiate benzodiazepine treatment in older adults. It is clear that concerns regarding side effects of falls, fractures, acute and chronic confusional states, abuse potential and drug-drug interactions are of great concern to clinicians. Patients often cite concerns regarding tapering of these agents including fear of relapse of anxiety and panic and a wish to maintain feelings of comfort with what is percieved as a stable medication regime in their advanced years of life. A challenge to clinicians is to work with aging patients over a treatment plan which balances medication safety with the therapuetic benefits of these agents. Management of older adults who have been treated chronically, often for many decades, with benzodiazepines poses a significant challenge. Many community providers no longer want to care for these patients and as a result, they present to hospital based clinics with stigma and disappointment over prior treatment.

Personality disorders persist into late life and pose complex care needs for patients who have difficulty navigating the health care system. As chronic maladaptive patterns of coping are part of the landscape of care for these patients, stressors related to COVID-19 including isolation, lonliness, boredom, access to care and transitions to telepsychiatry and remote medical care created unique challenges for these patients. While many patients adapted well to telephone and video visits, the lack of face to face contact, fears of infection and coping with the loss of family and friends created more needs and often demands for increase in services. Help seeking and help rejecting behaviors often increased over time. The goal of treatment of personality disorders in late life is not to cure the disorder but to decrease the frequency and intensity of symptoms. The COVID-19 global pandemic placed unique stressors on these vulnerable patients with limited coping skills.

Post-acute withdrawal, also described as protracted, extended or persistent withdrawal, refers to a syndrome that includes anxiety, irritability, hostility, mood instability, fatigue, insomnia and increased physical complaints often related to gastrointestinal symptoms, pain and weakness. Unlike acute withdrawal, where treatment guidelines and practices are highly predictable and protocol driven; post-acute interventions are highly symptom driven and individualized. Attention to co-occurring medical and psychiatric disorders is vital as well.

This symposium addresses a critical need to grow the field of geriatric expertise by creating multiple learning options that reach clinicians at all phases of practice. The AAGP Strategic Planning meeting of September 2019 articulated several future goals including 1) Develop our own competency-based certificate program and 2) Offering a pathway to clinical expertise for clinicians (Tampi R, et al 2020). The strategic plan also strongly emphasized partnerships with like-minded organizations. This symposium highlights the success of the AMDA Certified Medical Director (CMD) Program. Dr Meenakshi Patel will discuss how AMDA developed the certification; she will review the core curriculum, the development of the initial certification and the subsequent recertification procedures. She will also discuss the advantages of the certification for other providers (e.g., PCPs, NPs). Discussion will address how new geriatric certification programs may supplement training conducted in traditional post-graduate settings and allow for critical workforce growth. Association-based certifications permit inclusivity for providers who are not able to avail themselves of post-graduate fellowships but wish to gain geriatric expertise. The value of “clinical pathways” to expertise will be discussed and stakeholders will be invited to explore ways for the AAGP to help create more diverse learning pathways in geriatric psychiatry

Personality is defined by the unigue set of attributes, qualities and characteristics that shape how we cope with our lives. These emotional patterns, degree of reactivity and common behaviors define us over our lifespan. While a great deal of personality style is attributed to inherited traits; environmental and cultural influences clearly shape how we cope with life stressors and manage interpersonal relationships over time. Personality disorders emerge in early adulthood and persist into later life. Older adults who present with chronic and maladaptive patterns of coping pose unique challenges across a variety of clinical settings. The prevalence of these disorders in late life ranges from 5% to 13%, indicating that most clinicians will encounter these patients on a daily basis.

Personality refers to the unique characteristics and qualities that define an individual's ability to form relationships, cope with life stressors, and approach the tasks of daily living. However, when these patterns become debilitating or interfere with interpersonal relationships or overall functioning, the result is referred to as a disorder. Personality disorders persist into late life and pose complex challenges in patients across various medical and psychiatric settings. Many older adults with personality disorders can easily become overwhelmed by age-associated losses and stresses, largely because they lack appropriate coping skills and the personal, social, or financial resources to buffer their losses. Personality disorders persist into late life and pose complex challenges in patients across various medical and psychiatric settings. Most studies estimate that 10% of older adults have personality symptoms that rise to the level of a clear disorder, the most common include Borderline, Narcissistic and Dependent traits.

There is increasing interest in and use of the herbal preparation St. John's wort. Hypericin, the major active ingre dient, has many psychoactive properties. The agent is sold in the US as a nutritional supplement and is recommended for numerous conditions, including depression, anxiety, insomnia, and inflammation. We report a series of five cases of clinically diagnosed central serotonergic syndrome among elderly patients who combined prescription antide pressants with St. John's wort. Older adults are large consumers of both over-the-counter and prescription medications. They are particularly vulnerable to interactions between medications and products sold as nutritional or herbal supplements. St. John's wort requires further evaluation due to potential for drug interactions with central ner vous system agents and for more definitive therapeutic indications. (J Geriatr Psychiatry Neurol1999; 12:7-10).

OBJECTIVE: To examine the validity of the family history method for identifying Alzheimer disease (AD) by comparing family history and neuropathological diagnoses. METHODS: Seventy-seven former residents of the Jewish Home and Hospital for the Aged, New York, NY, with neuropathological evaluations on record were blindly assessed for the presence of dementia and, if present, the type of dementia through family informants by telephone interviews. The Alzheimer's Disease Risk Questionnaire was used to collect demographic information and screen for possible dementia. If dementia was suspected, the Dementia Questionnaire was administered to assess the course and type of dementia, ie, primary progressive dementia (PPD, likely AD), multiple infarct dementia, mixed dementia (ie, PPD and multiple infarct dementia), and other dementias based on the modified Diagnostic and Statistical Manual of Mental Disorders, Third Edition, criteria. RESULTS: Sixty (77.9%) of 77 elderly subjects were classified as having dementia and 17 (22.1%) were without dementia by family history evaluation. Of the 60 elderly subjects with dementia, 57 (95%) were found at autopsy to have had neuropathological changes related to dementia. The sensitivity of the family history diagnosis for dementia with related neuropathological change was 0.84 (57 of 68) and the specificity was 0.67 (6 of 9). Using family history information to differentiate the type of dementia, the sensitivity for definite or probable AD (with or without another condition) was 0.69 (36 of 51) and the specificity was 0.73 (19 of 26). The majority (9 of 15) of patients testing false negative for PPD had a history of stroke associated with onset of memory changes, excluding a diagnosis of PPD. CONCLUSIONS: Identifying dementia, in general, and AD, in particular, has an acceptable sensitivity and specificity. As is true for direct clinical diagnosis, the major issue associated with misclassifying AD in a family history assessment is the masking effects of a coexisting non—AD dementia or dementia-related disorders, such as stroke. Including mixed cases, ie, PPD and multiple infarct dementia in estimates of the familial risk for AD can reduce the extent of underestimation of PPD.

Agitated behaviors are a common and nearly universal occurrence among patients suffering from dementing illnesses. The pharmacologic treatments available for this troubling syndrome are varied, but treatment studies are limited. Clinicians are frequently faced with the challenging management of patients with disruptive behavior who fail to respond to trials with multiple agents. This review summarizes available treatment studies of agitation in dementia and offers a guide to therapy and management. Reports of therapies for agitation in dementia are limited by lack of controlled studies, variability of diagnostic criteria and outcome measures, and small sample size. The need for carefully designed, well-controlled studies of outcome in this growing population is formidable. It is imperative to identify effective and well-tolerated treatment strategies to reduce the morbidity of these distressing and burdensome symptoms.

Emergency Departments (ED) have seen an increasing number of mental health visits over the past decade, resulting in increasing strain on health care resources. With an aging population the general consensus is that this demand is expected to rise dramatically. Appropriate resource allocation by the national health care system will be a key part of preparing for this upcoming crisis. This study seeks to assess the financial strain that geriatric high utilizers place on the system, and whether their needs are met in the psychiatric ED.

The use of complementary and integrative methods in the care of older adults is increasingly popular. Elderly persons who suffer from chronic, persistent or severe mental illness are less likely to be offered or encouraged to utilize these interventions. Engagement in treatment is an issue that plagues the mental health system and is associated with better outcomes and less use of costly inpatient hospital stays when involvement and empowerment of patients is integrated into care. Aromatherapy is a popular cultural and spiritual intervention. Many elderly people utilize components of aromatherapy as part of developmental and family rituals with strong historical roots. Individualized music is one of the most powerful forms of complementary interventions being utilized as part of treatment regimes for disorders ranging from acute psychosis to anxiety to dementia. Compliance with medications and treatment regimes is considerably higher when patients are allowed to make choices regarding care. This project describes the use of aromatherapy with and without individualized music to enhance patient engagement in therapeutic sessions and treatment discussions.