Purpose of Review
We review non-pharmacological and pharmacological approaches to managing behavioral and psychological symptoms of dementia (BPSD). We examine methods for assessment and evidence for ...interventions, focusing on recent findings and innovations. Finally, we recommend an algorithm for management of BPSD.
Recent Findings
Training of formal caregivers is the most effective intervention for BPSD; other non-pharmacological interventions are also beneficial. Antidepressants and antipsychotics remain a mainstay of pharmacological treatment for BPSD. There is limited evidence supporting the use of stimulants, cognitive enhancers, dextromethorphan/quinidine, benzodiazepines, anticonvulsants, and pimavanserin.
Summary
The management of BPSD is highly individualized. Following thorough assessment, the initial step is addressing contributing medical problems. Non-pharmacological interventions should be tried prior to pharmacological interventions. Antipsychotics should be prescribed only when behaviors pose a significant safety risk or if the person with dementia is very distressed. New approaches will be needed to address an increasing population of people with dementia.
This book empowers health care professionals to accurately identify and diagnose anxiety and depression in older adult patients and help them find relief, stay independent, and lower their risk of ...suicide.Specialized material covers the unique factors facing older adults, including cognitive impairment, functional independence, and living near the end of life.
The book provides readers with evidence-based, pragmatic, and clear recommendations regarding the care of patients with behavioral and psychological symptoms of dementia.
Ishtiak-Ahmed et al advance an understanding of how to select an anti-depressant in previously untreated older adults with depression. The authors used data from two national registers in Denmark to ...identify patterns of older adults' antidepressant use for the indication of depression. This group has previously reported a high rate of possible off-label use of antidepressants among older adults in Denmark; they also found that 73% of older adults in Denmark who received antidepressant prescriptions had polypharmacy, most commonly with other agents acting on the nervous system. In this study, the authors associated the use of specific antidepressants with treatment outcomes: discontinuation, switching, augmentation, psychiatric care, suicide attempts, falls, cardiovascular events, and all-cause mortality. Ishtiak-Ahmed et al highlight the importance of careful selection of the first antidepressant for LLD.
Psychiatrists face a number of ethical challenges when caring for older adults and their families. Of paramount importance is ensuring that older adults have the capacity to make decisions about ...their medical care and their overall welfare. Psychiatrists must remain alert for the possibility of incapacity, which, if suspected, should prompt a thorough evaluation of decisional capacities. There is a robust literature guiding clinicians conducting such evaluations. Geriatric care focuses on maintaining or improving quality of life, which is especially relevant in end-of-life situations. With the aging of the United States population, discussion must take place at a societal level regarding a fair and just distribution of medical resources. Psychiatrists must be vigilant that the mental health needs of older adults, including access to effective therapies, are addressed adequately in such discussions.
In psychiatry, several converging factors are impacting the recruitment of residents: the increased competitiveness of the specialty, the national trend to take active steps to improve diversity and ...inclusion, and the decision from USMLE to change Step 1 to a pass/fail result.
We developed a workshop for psychiatry residency program directors to meet these challenges and transition into using a holistic review model during recruitment. The workshop included (1) a didactic session providing background on the AAMC holistic review model; (2) a small-group exercise to determine and prioritize experiences, attributes, competencies, and metrics (EACMs) aligned with the program's mission and aims; (3) a review of the rankings from the previous exercise, selection of two "very important" criteria for each of the four domains of the EACM model, and operationalization of these criteria based on the recruitment process; and (4) a discussion focused on application of program criteria with example applicants.
The holistic review workshop was conducted at the American Association of Psychiatry Residency Directors conference in 2021 with 48 self-selected attendees. Following the workshop, 74% of attendees reported a likelihood of implementing holistic applications during their next application cycle, 78% were able to leave with at least one actionable item, 100% thought that the session was interactive, and 78% felt that the session met their expectations.
Implementing a holistic review for psychiatry residency recruitment can assist programs in responding to the rapidly changing landscape and achieve aims for improving diversity and inclusion.
Residencies may also have to train residents to attain somewhat different skillsets than in the past, including a greater ability to work with healthcare professionals from other specialties and ...disciplines, facility with technologies to improve access to mental health care (e.g., telepsychiatry), competence to provide care to an increasingly diverse population, comfort with medical complexity (as our population ages), and knowledge of how health care systems work and how to change them. USMG = US medical graduates, IMG = International medical graduates 39 In fact, residency positions have grown at a faster rate than expected, with funding for new positions coming from the Veterans Health Administration, the Affordable Care Act, the Teaching Health Center program, state governments, and hospitals sponsoring residencies 1. Perhaps I would have developed a different attitude if I had been exposed to a curriculum such as the Child and Adolescent Mental Health Studies (CAMS) program for undergraduates at New York University, which appears to have positively influenced students’ career choices: 41.4% of students in the program reported planning to pursue a career working in mental health 13. After college, the next temporal step is the selection of new medical students. Since 2002, the AAMC has advocated for a holistic approach to medical school admissions.
Introduction
By age 60, 60% of adults with Down syndrome (DS) have dementia. Detecting dementia in persons with intellectual disability (ID) can be challenging because their underlying cognitive ...impairment can confound presentation of dementia symptoms and because adults with ID may have difficulty reporting symptoms. The National Task Group Early Detection Screen for Dementia (NTG‐EDSD) was developed to aid detection of report of cognitive impairment in adults with ID. We implemented an educational curriculum using the NTG‐EDSD and evaluated the impact of the intervention on professional caregivers’ self‐assessed capacity to identify persons with ID and dementia.
Methods
We held five in‐person training sessions for professional caregivers of persons with ID, partnering with various managed care organizations and social services agencies. We assessed knowledge and attitudes at baseline; immediately after training; and 1 week, 1 month, and 6 months after training.
Results
A total of 154 direct care workers, case managers, health‐care providers, and other social services staff attended the trainings. Satisfaction with the NTG‐EDSD training was high; 94% of attendees agreed or strongly agreed that they could use the NTG‐EDSD with their clients. After training, attendees reported a marked increase in confidence in their ability to track various health circumstances and detect functional decline in their clients, although some gains were not sustained over time. As a result of the training, one managed care organization made the NTG‐EDSD a standard part of its assessment of adults with DS starting at age 40.
Discussion
Social services and health‐care professionals can learn to document signs of cognitive decline in adults with ID using the NTG‐EDSD. Attendees were highly satisfied with the training, experienced an increase in confidence in their care of persons with ID, and found the NTG‐ EDSD feasible to use. Because not all gains were sustained over time, booster trainings may be necessary.
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