Search

In recognition of the challenges faced by older persons deprived of their liberty, a call was made for input into the 2022 report to the United Nations Human Rights Council (HRC) on older persons. This Position Statement outlines the views of two global organizations, the International Psychogeriatric Association (IPA) and the World Psychiatric Association Section of Old Age Psychiatry (WPA-SOAP), working together to provide rights and dignity-based mental health services to older persons and it was sent to the Independent Expert on the enjoyment of all human rights by older persons at HRC.

The increasing number of older adults in countries across the world is a huge challenge to those that are in charge of promoting, protecting, and implementing their human rights. This task is particularly difficult in the absence of a strong international framework addressing the principles required to guide the actions to combat all human rights violations. The existence of such a specific framework for older adults with mental health conditions is justified in view of the particular vulnerability of this section of the population by virtue of societal ageism, stigmatization, exclusion, as well as the disability and dependency which mental health conditions in old age may confer. The present article is a development of a previous statement by the International Psychogeriatric Association and the World Psychiatric Association Section of Old Age Psychiatry. As there is a call to all organizations to support efforts to combat Human Rights violations among older adults, a text will be submitted to the Executive Committee of the World Psychiatric Association to approve an official position statement on Human Rights of Older Persons with Mental Health Conditions., Competing Interests: Conflict of interest: the author has no conflicts of interest to declare., (© Authors, 2022.)

Background: Suicide among older adults is a multifactorial problem with several interrelated factors involved that vary with age, gender and culture. The number of suicides is highest in those aged 70 years or older in almost all regions of the world. With the increase in life expectancy, and the decrease in mortality due to other causes of death, we could expect the absolute number of older adults' suicide continue increasing., Methods: Review of the literature on suicide protective factors of suicide among older adults., Results: Improvements on social determinants of health and the timely detection and early treatment of affective disorders are key interventions. Prevention based on community actions and training of gatekeepers may have positive impact. Community programs that promote a sense of usefulness, belonging and that contribute to preserve social integration should be encouraged. Governments should develop the improvement of retirement programs and the development of support systems. The access to general health and mental health services should be facilitated and Primary Care professionals should receive proper training to detect and manage older persons at risk. Actively promoting a culture of coping to different stages of life and to the changes imposed by the advancing of age should form the essential part of a process bringing to better successful aging avenues., Conclusions: Suicide prevention in older adults should broaden its focus and pay attention to the many socio-environmental conditions that may be relevant in older age, especially social isolation, financial security and physical health., (© 2021 John Wiley & Sons Australia, Ltd.)

Objective: The authors systematically reviewed the management of treatment-refractory depression in older people (defined as age 55 or older)., Method: The authors conducted an electronic database search and reviewed the 14 articles that fit predetermined criteria. Refractory depression was defined as failure to respond to at least one course of treatment for depression during the current illness episode. The authors rated the validity of studies using a standard checklist and calculated the pooled proportion of response to any treatment reported by at least three studies., Results: All the studies that met inclusion criteria investigated pharmacological treatment. Most were open-label studies, and the authors found no double-blind randomized placebo-controlled trials. The overall response rate for all active treatments investigated was 52% (95% CI=42-62; N=381). Only lithium augmentation was assessed in more than two trials, and the response rate was 42% (95% CI=21-65; N=57). Only two studies included comparison groups receiving no additional treatment, and none of the participants in these groups responded. In single randomized studies, extended-release venlafaxine was more efficacious than paroxetine, lithium augmentation more than phenelzine, and selegiline more than placebo., Conclusions: Half of the participants responded to pharmacological treatments, indicating the importance of managing treatment-refractory depression actively in older people. The only treatment for which there was replicated evidence was lithium augmentation. Double-blind randomized controlled trials for management of treatment-refractory depression in older people, encompassing pharmacological and nonpharmacological therapies and populations that reflect the levels of physical and cognitive impairment present in the general older population with depression, are needed.

The effect of aging on steady-state plasma concentrations of citalopram (CIT) and desmethylcitalopram (DCIT) was investigated in 128 depressive patients treated with 10-80 mg/day CIT. They were separated into three groups, with age up to 64 years (mean age+/-S.D.: 47+/-12 years; n=48), between 65 and 79 years (72+/-1 years; n=57), and from 80 years or older (84+/-1 years; n=23). Body mass index (BMI), renal and hepatic functions were similar in the three groups. A large interindividual variability of plasma levels of CIT (16-fold) and DCIT (12-fold) was measured for a given dose. The mean plasma levels of CIT corrected for a 20 mg daily dose were 55% higher in the very elderly (>=80 years) patients (65+/-30 ng/ml; p<0.001) and 38% higher in the elderly (65-79 years) patients (58+/-24 ng/ml; p<0.001) when compared to the adult patients (42+/-17 ng/ml). DCIT mean plasma level was 38% higher (p<0.05) in the group of very elderly patients (22+/-10 ng/ml) when compared to the adult patients (16+/-9 ng/ml). As a consequence, the mean plasma concentration of CIT+DCIT was 48% higher in the very elderly patients (86+/-36 ng/ml; p<0.001) and 33% higher in the elderly patients (77+/-28 ng/ml; p<0.001) when compared to the adult patients (58+/-21 ng/ml). Age correlated significantly with CIT (r=0.43, p<0.001), DCIT (r=0.28, p<0.01), and CIT+DCIT plasma levels (r=0.44, p<0.001), and thus accounts for 18% of the variability of CIT plasma levels, with no influence of gender. The recommended dose reduction of CIT in elderly patients seems therefore justified.

Aging of the world population risks to be accompanied by an increase of chronic health problems, and most particularly of mental health problems. To face these problems the organization of care and education in old age psychiatry is still quite low. If at inter -national level the body of knowledge and skills of the psychiatry of the elderly is today enough recognized it is very difficult to convince authorities at national and local level to recognize this discipline as a sub-specialty of psychiatry. Even when some resources exist at local level to support old people with mental disorders, very often these old persons do not look for care as consequence of the prevailing double stigma attached to mental disorders in general and to the end of life in particular. In order to promote changes of this situation, the World Health Organization (WHO) Collaborating Centre of Lausanne realized a WHO-World Psychiatric Association (WPA) consensus meeting and statement on how to reduce the stigma and the discrimination against old persons with mental disorders, as well it has realized a survey in Europe on this specific subject of stigma and discrimination against these old persons. As education is one of the most important components of the strategy to reduce stigma and discrimination, 3 recent developments were done to promote this. The first one is a survey conducted by the section of old age psychiatry of WPA. The second one is the consensus statement on education in psychiatry of the elderly jointly published by WHO and WPA, and finally was the recent publication of a skill -based objectives for the training in the discipline. These efforts will be completed by some actions to strengthen the impact of all these documents.

Objective: One of the main goals of the World Psychiatric Association (WPA) section on old age psychiatry is to promote its discipline and consequently to help member societies to promote and develop locally specific medical education programmes in old age psychiatry. In order to target its support to the needs expressed by the member societies, the section conducted a survey within the WPA during the year 2001., Method: A questionnaire was sent to each of the 116 WPA member societies in 93 countries. It assessed the level of development of medical education in old age psychiatry in each country, as well as the perceived needs in educational material., Results: Answers were obtained from 50 WPA member societies (response rate 54%) from 48 countries (response rate 52%). The existence of specific old age psychiatry services was reported in 40 (83%) countries, but the discipline is recognized as a subspecialty in only 13 (27%). Formal teaching in old age psychiatry was reported at the undergraduate level in 44 (92%) countries. Specific learning objectives for postgraduate training were reported in 30 (86%) of the countries where the discipline is not yet recognized as a subspecialty. Specific Continuing Medical Education (CME) programs were however reported in only 50% of the countries. Support for the development of educational material was mostly thought to be useful at the postgraduate level. Depression, dementia, psychopharmacology and psychotherapy were among the most frequently cited areas in which educational material might be usefully provided., Conclusion: Support for the development of postgraduate training is seen as the most pressing need by WPA member societies. Such support could help to increase the level of recognition of the discipline locally and hence provide more effective support to older people with mental disorders., (Copyright 2003 John Wiley & Sons, Ltd.)

Background and Objectives: The European Office of the World Health Organization (WHO/EURO) has established a Task Force On Destigmatization. Upon the release of the Technical Statement on Old Age Psychiatry 'Reducing stigma and discrimination against older people with mental disorders', the Task Force run a small survey in two European subregions to investigate the extent of stigma and discrimination with reference to the elderly person affected from a psychiatric disorder in the countries of those subregions., Methods: WHO/EURO mental health counterparts completed a short questionnaire inquiring on the inclusion of epidemiological studies on the elderly in their country's research program; the time devoted to the teaching to old age psychiatry during psychiatric residence; the degree of coverage of services for the elderly person and their caregivers; and the extent of stigma present in society with regard to three psychiatric disorders., Results: Stigma and discrimination seem to be present both in the health sector and among the public at large., Conclusion: The development of effective health and social facilities to support older persons with mental disorders should be a high priority of any strategy to reduce stigma and discrimination. These facilities should coordinate their efforts with those of other sectors of society to reach the highest possible impact., (Copyright 2003 John Wiley & Sons, Ltd.)

This technical consensus statement is jointly produced by the Old Age Psychiatry section of the World Psychiatric Association and the World Health Organization, with the collaboration of several NGOs and the participation of experts from different Regions. It is intended to be a tool for (i) promoting debate at all levels on the stigmatisation of older people with mental disorders; (ii) outlining the nature, causes and consequences of this stigmatisation; and (iii) promoting and suggesting policies, programmes and actions to combat this stigmatisation., (Copyright 2003 John Wiley & Sons, Ltd.)

Objective: To compare levels of stress and burnout among staff caregivers in nursing homes and acute geriatric wards of general hospitals., Methods: A cross-sectional survey was conducted in three nursing homes (total of 522 beds, 270 caregivers) and nine geriatric sections of general hospitals (total of 371 beds, 280 caregivers). Staff caregivers were asked to answer a four-part questionnaire made up of socio-demographic data, the General Health Questionnaire (GHQ-12), the Maslach Burnout Inventory (MBI) and the Stressful Events Questionnaire (SEQ)., Results: 355 carers (172 from nursing homes, 183 from acute geriatric wards) answered the questionnaire (response rate 66%). Bivariate analysis reveals that general hospital carers show higher GHQ scores, higher MBI-Depersonalisation (DP) and Emotional Exhaustion (EE) sub-scores and lower MBI-Personal Accomplishment sub-scores. Stressful Events (as revealed by the SEQ) are more frequently reported by general hospital carers, particularly events related to patients' behavioural disorders. Multivariate analysis shows that general hospital work-setting, professional role, female gender and patient/carer ratio are significant explanatory variables of a high MBI-EE sub-score, while general work setting and disability are the best explanatory variables of a high MBI-DP sub-score. Professional role and general hospital work-setting are independent factors in a low MBI-Personal Accomplishment (PA) sub-score., Conclusion: These results appear to show that levels of stress and burnout among staff caregivers are moderate in acute geriatric wards, but significantly higher than in nursing homes. This suggests that increasing the rate of trained staff and improving staff support-for instance by the implementation of Consultation-Liaison (C-L) Psychiatry and/or continuing education programmes-could be needed mostly in acute geriatric wards., (Copyright 2002 John Wiley & Sons, Ltd.)

This preliminary study evaluates the prevalence of personality disorders (PD) in a sample of 37 elderly recovered depressed and non-demented patients, using the French version of the Vragenlijst voor Kenmezken van de Persoonlijkheid (VKP) or Questionnaire on Personality Traits (QPT). The prevalence of definite personality disorder was 65% with predominance of Cluster C and particularly dependent and avoidant PD. The rate of PDs was higher in early onset (73%) than in late onset (45%) geriatric depression, even though there is only a trend towards statistical significance (Chi square = 2.588, p = 0.107). These results are consistent with those of previous reports using different PD assessment methods, supporting evidence that the QPT could be useful in PD assessment of elderly French speaking patients.

Rapid cycling is a relatively unusual presentation of bipolar affective disorder in the elderly. Four cases or rapid-cycling affective disorder (RCAD) in elderly women (aged 78-86 yr) are presented. Two patients began their bipolar illness in adulthood (aged 30 and 49 yr), and rapid cycles appeared secondarily in their elderly years (82 and 76 yr). The other two began their illness immediately with rapid cycles respectively at the age of 62 and 66. Added to the nine cases of RCAD in the elderly previously reported in the literature, a meta-analysis conducted on this small sample suggests that immediate entry in rapid cycles seems more likely to be associated with a late occurrence of bipolar illness (after 60 years of age)(P = .0035, Fisher's Exact Test, two-tailed), and that very short cycles (< 2 weeks each) are more likely to be associated with female gender (P = .0047, Fisher's Exact Test, two-tailed). Despite the small size of the sample, these results give some arguments to the hypothesis that RCAD is not a homogeneous syndrome but could be considered as a pattern of evolution, as well as clinical subtype, of the bipolar illness.

The TRH test has been used in psychiatry these last 20 years. One of the most promising results is that concerning the possibility to use it to identify the best moment to stop a treatment after clinical recovery of the depressive episode. For that it is necessary to demonstrate an absence of intrinsic action of antidepressants on the HPT axis physiology. This overt, randomized study has compared the actions on T3, T4, basal TSH and its response to the TRH test after 75 mg/day of maprotiline and 100 mg/day of fluvoxamine, both administrated in depressed patients during 28 days. Forty patients (20 men and 20 women) were studied, 20 patients per treatment. The inclusion criteria were those of DSM III-R for major depression and dysthymia as well a minimum score of 25 at MADRS scale. Blood samples for T3, T4 and basal TSH dosages were made before TRH intranasal administration (2 mg) at days 1 and 28 of the treatment. We haven't observed any difference before treatment between the 2 groups for clinical and biological studied parameters. After treatment both antidepressants produced equivalent improvement of depression evaluated by MADRS (fluvoxamine:dMADRS = 16.95 +/- 7.11; maprotiline: dMADRS = 17.10 +/- 6.84. t = 0.07, NS). T3 and T4 variations between the beginning and the end of the study weren't also significantly different between the 2 groups. Basal TSH was increased in the maprotiline group but decreased in the fluvoxamine group resulting in a significant difference (fluvoxamine: dTSH = 0.31 +/- 0.76 mUI/l. Maprotiline : dTSH = -0.23 +/- 0.66 mUI/l. t = 2.40, p < 0.02). The TSH response to TRH was decreased in the fluvoxamine group (ddTSH = 0.24 +/- 6.65 mUI/l. dAUC = 103.98 +/- 596.84 mUI/l) while it was increased in the maprotiline group (ddTSH = -3.59 +/- 5.88 mUI/l. dAUC = -355.80 +/- 505.67 mUI.min/l). The difference between the 2 treatments was not significant when evaluated by ddTSH (t = 1.53, NS) but it became significant if evaluated by dAUC (t = 2.63, p < 0.01). As we could demonstrate an absence of influence of the clinical evolution between both groups in the hormonal variations observed, we concluded to a intrinsic difference action on HPT axis between fluvoxamine and maprotiline. This difference could be linked to the different aminergic action of these 2 antidepressants.

This preliminary report compares the FT3, FT4, TSH basal levels and FT4/FT3 ration of depressed patients (DSM III-R criteria) with those of a healthy control group. Authors have also studied thyroid parameters in function of some clinical depression data (polarity, intensity and endogenous character) and other factors as age and sex. 81 depressed patients (31 men, 50 women), with mean age of 44.85 years were studied. 44 patients suffered of an endogenous depression and 37 of a non endogenous depression (Newcastle criteria). 60 patients had an unipolar depression while 21 patients had a bipolar depression. The control group was constituted of 36 healthy subjects (20 men, 16 women), with mean age of 40.94 years. There is no significant difference between the two groups for sex and age, besides the different size of the two groups. FT3 mean of depressed patients was 4.39 pmol/l. There was a significant difference between unipolar group FT3 mean (4.51 +/- 1.01 pmol/l) and bipolar FT3 mean (4.03 +/- 0.91 pmol/l; t = 2.02, p < 0.05). Depression intensity was correlated negatively to FT3 mean (r = -0.23; t = 2.10, p < 0.005). FT4 mean in the depressed group was 12.62 +/- 4.14 pmol/l. The only significative result for FT4 was its correlation to TSH levels (r = -0.36; t = 3.43, p < 0.001). TSH mean in depressed patients was 1.43 +/- 0.85 microIU/ml. When we have compared these results with those of control group we concluded that FT3 and TSH levels were significantly lower in the depressed group (FT3: t = 4.83, p < 0.0001; TSH; t = 2.44 p < 0.02) and that FT4 was slightly but not significantly increased in the depressed group. FT3 decrease and the slight FT4 increase in depression may be the consequence of a metabolic deviation of FT4 transformation into FT3. Its link with intensity and polarity of depression suggests that it can be considered as a biological marker of this disease.