Geriatric Mental Healthcare Training: A Mini-Fellowship Approach to Interprofessional Assessment and Management of Geriatric Mental Health Issues

IntroductionThe population in United States aged 65 and older has rapidly grown and is projected to grow faster than any other segment of the population. Despite this demographic shift, the nation's geriatric workforce is shrinking.AimThe primary goal of the fellowship was to form a learning collaborative that would help trainees in medicine, nursing, social work, pharmacy and occupational/physical therapy understand the roles of each discipline involved in the provision of geriatric mental healthcare and to enhance basic knowledge of common geriatric syndromes.MethodsFaculty from the University of Pittsburgh developed a format for the mini-fellowship. Trainees from five disciplines were recruited for participation in the mini-fellowship. This was offered annually over four-year period, hosted by the John A. Hartford Foundation Centers of Excellence in Geriatric Psychiatry at the University of Pittsburgh and University of California at San Diego.ResultsEighty-one participants across five schools of the health sciences completed the mini-fellowship. Feedback was positive: most participants appreciated learning from other team members, endorsed appreciation of the contributions of other disciplines to patient care, and reported improved understanding of three major geriatric syndromes.ConclusionConducting an interdisciplinary mini-fellowship in geriatric mental health was feasible and well received by trainees. The fellowship enabled better appreciation for the provision of geriatric mental health care within the context of an interprofessional team. However, decanal and faculty leadership across the schools needs to place greater emphasis on the importance of interprofessional team-based learning and to free up time for such activity.     

Training the Next Generation of Geriatric-Focused Clinical Neuroscientists

It remains challenging to integrate clinical neuroscience into clinical practice. Hindrances at the training level (e.g., lack of qualified faculty and curriculum) contribute to this impasse. To help address this, we present a model of training in clinical neuroscience. We expand on a growing literature on incorporating neuroscience into psychiatry training by emphasizing two points. That is, 1) we propose a training model designed for the geriatric-minded clinician; and 2) that extends across several phases of education and career development. Considering the relevance of dementia to our population of interest, and the potential impact expertise in clinical neuroscience can have in elders with cognitive impairment, we provide relevant curriculum examples at various training stages. Clinical research, both as a practitioner and consumer, figures prominently into our training model. We discuss two mentoring programs, T32 fellowships and Research Career Institute in the Mental Health of Aging, as ways to engage geriatric psychiatrists early in their training and transition them successfully to post-residency clinical investigator positions. Although there is increasing opportunity for geriatric psychiatrists and other clinicians to become leaders in the field of neuroscience, this remains a work in progress; ours and others’ training programs continue to evolve based on input from trainers and trainees alike, as well as from the increasing literature on this important topic.     

Perspectives on Training Needs for Geriatric Mental Health Providers: Preparing to Serve a Diverse Older Adult Population

An increasingly diverse population of older adults requires a diverse workforce trained to address the problem of differential healthcare access and quality of care. This article describes specific areas of training focused on addressing health disparities based on ethnic differences. Culturally competent care by mental health providers, innovative models of mental health service delivery such as collaborative care, and expansion of the mental health workforce through integration of lay health workers into professional healthcare teams, offer potential solutions and require training. Cultural competency, defined as respect and responsiveness to diverse older adults' health beliefs, should be an integral part of clinical training in mental health. Clinicians can be trained in avoidance of stereotyping, communication and development of attitudes that convey cultural humility when caring for diverse older adults. Additionally, mental health clinicians can benefit from inter-professional education that moves beyond professional silos to facilitate learning about working collaboratively in interdisciplinary, team-based models of mental health care. Finally, familiarity with how lay health workers can be integrated into professional teams, and training to work and supervise them are needed. A growing and diversifying population of older adults and the emergence of innovative models of healthcare delivery present opportunities to alleviate mental health disparities that will require relevant training for the mental health workforce.     

Risk Aversion and Alzheimer Disease in Old Age

Objective: To test the hypothesis that late-life risk aversion is partly a prodromal sign of dementia. Methods: The authors’ design was a longitudinal clinical-pathologic cohort study. The setting included participants’ residences in the Chicago area, and a total of 874 older persons without dementia were enrolled. At baseline, risk aversion was assessed with questions involving choices between certain smaller rewards and uncertain larger rewards. At annual intervals thereafter, participants underwent evaluations that included cognitive testing and diagnosis of mild cognitive impairment (MCI) and dementia. At death, a neuropathologic examination was done to quantify common pathologies linked to dementia. Results: Risk aversion at study onset ranged from 0.05–0.91 (mean: 0.32, standard deviation: 0.31). During a mean of 4.6 years of follow-up, 123 (of 874) developed dementia. Higher risk aversion was associated with higher dementia incidence (hazard ratio [HR]: 2.08; 95% confidence interval: 1.18, 3.65) and more rapid decline in episodic (estimate: –0.062; standard error [SE]: 0.019; t [3677]: –3.33; p < 0.001) and semantic (estimate: –0.039; SE: 0.015; t [3655]: –2.61; p = 0.009) memory but not in other cognitive systems. Of 702 people without cognitive impairment at baseline, 223 developed incident MCI. Higher risk aversion was associated with higher incidence of MCI (HR: 2.10; 95% confidence interval: 1.34, 3.29) and more rapid episodic memory decline. In 181 neuropathologically examined individuals, higher risk aversion was associated with higher levels of plaques, tangles, and cerebral amyloid angiopathy. Conclusion: The results support the hypothesis that high risk aversion in old age is partly an early sign of the pathology of Alzheimer disease.     

Relationships Between Executive Control Circuit Activity,Amyloid Burden,and Education in Cognitively Healthy Older Adults

IntroductionIn cognitively healthy older adults, amyloid-beta (Aβ) burden is associated with greater activity on task-based functional magnetic resonance imaging. Higher levels of functional activation are associated with other factors along with amyloid and the authors investigated these relationships as well as how they relate to Aβ in cognitively healthy older adults.MethodsThe authors recruited cognitive healthy older adults (N = 50) from the Pittsburgh community that underwent extensive cognitive batteries, activation during a working memory (digit symbol substitution task, DSST), positron emission tomography scan for Pittsburgh Compound B (PiB, measuring amyloid), and other demographic measures. The authors tested the association between DSST activation and global PiB, neurocognitive batteries, and education.ResultsThe authors found that the DSST robustly activated expected structures involved in working memory. The authors found that greater global Aβ deposition was associated with greater DSST activation in the right calcarine, precuneus, middle temporal as well as the left insula and inferior frontal gyrus. The authors also found that greater education was associated with lower DSST activation – however this was not significant after adjusting for Aβ.DiscussionGreater amyloid was associated with greater activation, which may represent compensatory activation. Greater education was associated with lower activation, which may represent more efficient activation (i.e., less activation for the same task). After adjusting for amyloid, education was not significantly associated with activation suggesting that during the preclinical stage amyloid is the primary determinant of activation. Further, activation was not associated with cognitive function. Compensatory activation in the preclinical stage may help maintain cognitive function.     

Changes in Moderate Intensity Physical Activity Are Associated With Better Cognition in the Multilevel Intervention for Physical Activity in Retirement Communities (MIPARC) Study

ObjectiveThe authors investigated if the physical activity increases observed in the Multilevel Intervention for Physical Activity in Retirement Communities (MIPARC) improved cognitive functions in older adults. The authors also examined if within-person changes in moderate to vigorous physical activity (MVPA), as opposed to low-light and high-light physical activity, were related to cognitive improvements in the entire sample.MethodsThis was a cluster randomized control trial set in retirement communities in San Diego County, CA. A total of 307 older adults without a formal diagnosis of dementia (mean age: 83 years; age range: 67–100; standard deviation: 6.4 years; 72% women) were assigned to the physical activity (N = 151) or healthy education control (N = 156) groups. Interventions were led by study staff for the first 6 months and sustained by peer leaders for the next 6 months. Components included individual counseling and self-monitoring with pedometers, group education sessions, and printed materials. Measurements occurred at baseline, 6 months, and 12 months. Triaxial accelerometers measured physical activity for 1 week. The Trail Making Test (TMT) Parts A and B and a Symbol Search Test measured cognitive functions.ResultsThere were no significant differences in cognitive functions between the MIPARC intervention and control groups at 6 or 12 months. Within-person increases in MVPA, and not low-light or high-light physical activity, were associated with improvements in TMT Parts B, B-A, and Symbol Search scores in the entire sample.ConclusionFindings suggest that MVPA may have a stronger impact on cognitive functions than lower intensity physical activity within retirement community samples of highly educated older adults without dementia.     

Effectiveness of Shared Decision-Making for Elderly Depressed Minority Primary Care Patients

Objective: The authors assessed the impact of a shared decision-making (SDM) intervention among elderly depressed minority primary care patients not currently receiving treatment. Methods: A total of 202 English and Spanish-speaking primary care participants aged 65 and older who scored positive on the Patient Health Questionnaire-9 (≥10) were randomized at the physician level to receive a brief SDM intervention or usual care (UC). Primary analyses focused on patient adherence to either psychotherapy or antidepressant medication, and reduction in depression severity (Hamilton Depression Rating Scale) over 12 weeks. Results: Patients randomized to physicians in the SDM condition were significantly more likely than patients of physicians randomized to UC to receive a mental health evaluation or initiate some form of treatment (39% versus 21%), and to adhere to psychotherapy visits over 12 weeks. There were no differences between groups in adherence to antidepressant medication or in reduction of depressive symptoms. Conclusion: Among untreated elderly depressed minority patients from an inner-city municipal hospital, a brief SDM intervention was associated with greater initiation and adherence to psychotherapy. However, low treatment adherence rates across both groups and the intervention's lack of impact on clinical outcomes highlight the need to provide focused and accessible mental health services to patients choosing active treatments.     

Mind-Body Interventions in Late-Life Mental Illnesses and Cognitive Disorders: A Narrative Review

Background

Current pharmacological treatments and psychotherapeutic approaches often have adverse effects or are ineffective in late-life cognitive and mental illnesses. Mind-body interventions offer a holistic approach and are of interest because of potential patient acceptability and scalability.

Improving Everyday Functioning in the Old-Old with Working Memory Training

ObjectiveThe aim of this study was to assess gains related to working memory (WM) training, in the short and long term (9 months after the training), in abilities required in everyday life, and in cognitive measures in old-old adults (aged ≥ 75 years).MethodsThirty-two community-dwelling older adults (aged 75–85 years) were randomly assigned to a training or an active control group. In addition to testing for any specific gains in a WM task similar to the one used in the training (criterion task), we sought transfer effects to: 1) abilities involved in everyday life using objective performance-based tasks (the Everyday Problem Test [EPT] and the Timed Instrumental Activities of Daily Living [TIADL] scale; 2) tasks demanding the comprehension and recall of spatial information and pairing names with faces; and 3) a measure of inhibitory control, that is, recall errors (intrusion errors).ResultsOnly the trained group showed specific gains in the criterion task, and in the TIADL in the short term. At follow-up, the trained group maintained gains in the criterion task, and showed transfer effects to everyday problem-solving (in the EPT), and in constructing spatial representations of an environment. The trained group also improved in a cognitive inhibition measure (intrusion errors) at follow-up. No such improvements were seen in the active control group.ConclusionWM training may be a valid way to help old-old adults preserve at least some abilities related to everyday functioning.     

The Construction and Evaluation of Executive Attention Training to Improve Selective Attention,Focused Attention,and Divided Attention for Older Adults With Mild Cognitive Impairment: A Randomized Controlled Trial

ObjectivesTo examine the immediate and long-term effects of executive attention training on selective attention, focused attention, and divided attention in older adults with mild cognitive impairment.MethodsA double-blind, multisite randomized controlled trial at five sites. Seventy participants (mean age: 78.19 ± 7.22 years) were assigned to an experimental group (executive attention training, n = 35) or an active control group (n = 35). The training duration was the same for both groups (45 minutes per session, 3 times per week, 18 sessions in total). Primary outcome measure was selective attention (Digit Span Task). Secondary outcome measures included focused attention (Stroop Color Word Test) and divided attention (Trail-Making Test Part B). Data were collected at pretest, post-test, 3-month follow-up, and 6-month follow-up.ResultsIn GEE analysis, findings indicated a significant improvement in selective attention at post-test, whereas divided attention showed significant reducing omission error at 3-month follow-up. There was no significant effect of group in focused attention associated with the executive attention training compared with active control group.ConclusionThe executive attention training significantly improved selective attention and divided attention performance. Future studies should identify transfer effects of attention training, and that can employ early screening to provide integrated attention training, and decrease its relevant risks on competency in performing daily activities, such as falling and driving.     

Metabolic Syndrome,Mild Cognitive Impairment,and Dementia: A Meta-Analysis of Longitudinal Studies

ObjectiveA systematic review and a meta-analysis of both clinical and population-based studies was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to clarify whether Metabolic Syndrome (MetS) is a risk or a protective factor for incident dementia, Alzheimer disease (AD), and vascular dementia (VaD), and whether it's involved in progression to dementia in patients affected by mild cognitive impairment (MCI).MethodsSearch terms included (“metabolic syndrome” OR “syndrome x” OR “plurimetabolic syndrome”) AND (“dementia” OR “Alzheimer disease” OR “vascular dementia” OR “mild cognitive impairment” OR “MCI”). Research was restricted to articles published in English between January 1, 2000 and August 31, 2018. No age limit was set.ResultsAt the end of the selection procedure, nine longitudinal studies were selected for the meta-analysis: six studies enrolled cognitively well-functioning participants and three studies involved MCI patients. A total of 18,313 participants aged older than 40 years with mean MetS prevalence of 22.7% were followed on average for 9.41years. A fixed model was used to estimate pooled hazard ratios and 95% confidence intervals.ConclusionNo statistically significant pooled association emerged between MetS and incident dementia and AD. MetS increased the incidence of pure VaD. MetS increased the risk of progression from MCI to dementia. Follow-up length might be a key factor in investigating these associations further. Because MetS is constituted by a set of potentially modifiable factors, further studies with longer follow-up and repeated assessment of both MetS and cognitive status are desirable to draw definite conclusions.