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PURPOSE OF REVIEW: This article will provide clinicians with guidance on helping older adult patients make lifestyle changes to enhance brain health and well-being. RECENT FINDINGS: Evidence suggests that physical activity might be helpful in improving cognitive functioning. The data on the benefits of cognitive activity is inconsistent and not as robust. The MediDiet, DASH, and MIND diets have been associated with better cognitive health. Sleep hygiene and cognitive behavioral therapies are considered first line evidence-based treatments for insomnia and the maintenance of healthy sleep patterns. Mindfulness based interventions have been shown to reduce anxiety, depression, and stress, and can help some older adults manage pain more constructively. Evidence-based information regarding the four topics of exercise, nutrition, sleep, and mindfulness is reviewed, so that clinicians may be better able to optimize care for their older adult patients.
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OBJECTIVE: To assess the safety and tolerability of folinic acid as an augmentation agent among geriatric inpatients with depression and to determine whether this augmentation was associated with decreased days of clinically needed hospitalization. METHODS: A retrospective chart review was conducted of the medical records of patients > 60 years of age discharged from a geriatric psychiatry unit between June 1, 2014, and February 1, 2016. Two groups were compared: those with depression who received folinic acid (leucovorin) supplementation (n = 35) and those with depression who did not receive leucovorin (n = 80). The primary outcome measure was number of clinically needed days of hospitalization. RESULTS: The mean ± SD number of days (logged) of clinically needed hospitalization in the leucovorin group was 2.0 ± 0.7 compared with 2.4 ± 0.6 in the nonintervention group. Unpaired t group analysis yielded the following: t115 = 3.47, P < .0001 (2-tailed). CONCLUSIONS: The patients who received leucovorin had a significantly reduced requirement of days of hospitalization, which translates to reduced cumulative cost of treatment during hospitalization. Further studies, including randomized controlled trials, are recommended to explore this treatment option.
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Depressão , Pacientes Internados , Idoso , Antidepressivos , Humanos , Leucovorina , Estudos RetrospectivosRESUMO
Professional and advocacy organizations have long urged that dementia should be recognized and properly diagnosed. With the passage of the National Alzheimer's Project Act in 2011, an Advisory Council for Alzheimer's Research, Care, and Services was convened to advise the Department of Health and Human Services. In May 2012, the Council produced the first National Plan to address Alzheimer's disease, and prominent in its recommendations is a call for quality measures suitable for evaluating and tracking dementia care in clinical settings. Although other efforts have been made to set dementia care quality standards, such as those pioneered by RAND in its series Assessing Care of Vulnerable Elders (ACOVE), practitioners, healthcare systems, and insurers have not widely embraced implementation. This executive summary (full manuscript available at www.neurology.org) reports on a new measurement set for dementia management developed by an interdisciplinary Dementia Measures Work Group (DWG) representing the major national organizations and advocacy organizations concerned with the care of individuals with dementia. The American Academy of Neurology (AAN), the American Geriatrics Society, the American Medical Directors Association, the American Psychiatric Association, and the American Medical Association-convened Physician Consortium for Performance Improvement led this effort. The ACOVE measures and the measurement set described here apply to individuals whose dementia has already been identified and properly diagnosed. Although similar in concept to ACOVE, the DWG measurement set differs in several important ways; it includes all stages of dementia in a single measure set, calls for the use of functional staging in planning care, prompts the use of validated instruments in patient and caregiver assessment and intervention, highlights the relevance of using palliative care concepts to guide care before the advanced stages of illness, and provides evidence-based support for its recommendations and guidance on the selection of instruments useful in tracking patient-centered outcomes. It also specifies annual reassessment and updating of interventions and care plans for dementia-related problems that affect families and other caregivers as well as individuals with dementia. Here, a brief synopsis of why major reforms in healthcare design and delivery are needed to achieve substantive improvements in the quality of care is first provided, and then the final measures approved for publication, dissemination, and implementation are listed.
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Demência/terapia , Gerenciamento Clínico , Neurologia/normas , Melhoria de Qualidade , Idoso , HumanosRESUMO
This article represents the efforts of an interdisciplinary work group, the Dementia Measures Work Group (DWG), composed of representatives of diverse national organizations who convened specifically to define optimal standards of dementia care for individual practitioners as well as multidisciplinary teams. The DWG measurement set includes all stages of dementia in a single measure set, calls for the use of functional staging in planning care, prompts the use of validated instruments in patient and caregiver assessment and intervention, highlights the relevance of using palliative care concepts to guide care prior to the advanced stages of illness, and provides evidence-based support for its recommendations and guidance on the selection of instruments for tracking patient-centered outcomes. In addition, it specifies annual reassessment and updating of interventions and care plans for dementia-related problems that affect families and other caregivers as well as patients.
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Demência/terapia , Terapia Ocupacional/normas , Avaliação de Resultados da Assistência ao Paciente , Melhoria de Qualidade , Assistência Ambulatorial/normas , Cuidadores , Aconselhamento/normas , Humanos , Planejamento de Assistência ao PacienteRESUMO
We have already entered a new, more exciting, and hopeful era in the treatment of late-life depression. The increasing numbers of older adults who are surviving to more advanced ages and the greater recognition of late-life depression's prevalence and impact on quality of life emphasize how important it is to detect and treat this disorder. Our increasing repertoire of evidence-based psychotherapeutic, pharmacologic, and neurotherapeutic treatment interventions offers many treatment alternatives, allowing substantial individualization of treatment approach. Demonstration of the effectiveness of depression treatment in primary care suggests the feasibility of increasing our patients' access to care. Growing appreciation of the pathophysiology of depression and its interrelationships with cognitive impairment may increase our ability to limit or delay certain aspects of cognitive impairment through more aggressive treatment of depression. Improved recognition and treatment of late-life depression holds great potential for improving physical and mental health in later life, reducing disability in later years, and improving quality of life.
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Antidepressivos/classificação , Demência/complicações , Transtorno Depressivo , Avaliação Geriátrica/métodos , Atenção Primária à Saúde , Fatores Etários , Idoso de 80 Anos ou mais , Antidepressivos/farmacologia , Antidepressivos/uso terapêutico , Transtornos Cognitivos/complicações , Transtornos Cognitivos/psicologia , Demência/psicologia , Transtorno Depressivo/complicações , Transtorno Depressivo/diagnóstico , Transtorno Depressivo/tratamento farmacológico , Diagnóstico Diferencial , Humanos , Sistema Hipotálamo-Hipofisário/fisiopatologia , Sistema Hipófise-Suprarrenal/fisiopatologia , Escalas de Graduação PsiquiátricaRESUMO
The need for adequate mental health services for older adults is an increasingly urgent issue as the life expectancy of Americans continues to extend; yet there are unresolved questions regarding the public's perception of service needs. The Group for the Advancement of Psychiatry collaborated with advice columnist Jeannie Phillips of "Dear Abby" to invite public feedback on mental health services for the elderly. Feedback was invited on access to services as well as perceived need for improvement in the quality or quantity of those services. The effort resulted in 800 responses that identified three primary issues: problems in accessing care, inadequate detection of mental health conditions by general practitioners, and a need for more psychotherapy services. It is hoped that this Open Forum will stimulate discussion throughout the country for the benefit of older persons with mental health needs as the country grapples with changes to come after the passage of health care reform.
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Serviços de Saúde para Idosos , Serviços de Saúde Mental , Opinião Pública , Idoso , Reforma dos Serviços de Saúde , Necessidades e Demandas de Serviços de Saúde , Serviços de Saúde para Idosos/provisão & distribuição , Humanos , Transtornos Mentais/epidemiologia , Transtornos Mentais/terapia , Serviços de Saúde Mental/provisão & distribuição , Psicoterapia , Estados UnidosAssuntos
Antidepressivos de Segunda Geração/uso terapêutico , Antipsicóticos/uso terapêutico , Cicloexanóis/uso terapêutico , Piperazinas/uso terapêutico , Transtornos Psicóticos/tratamento farmacológico , Quinolonas/uso terapêutico , Idoso de 80 Anos ou mais , Doença de Alzheimer/complicações , Doença de Alzheimer/diagnóstico , Doença de Alzheimer/tratamento farmacológico , Doença de Alzheimer/psicologia , Antidepressivos de Segunda Geração/efeitos adversos , Antipsicóticos/efeitos adversos , Aripiprazol , Terapia Combinada , Comorbidade , Cicloexanóis/efeitos adversos , Delírio/diagnóstico , Delírio/tratamento farmacológico , Delírio/psicologia , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/tratamento farmacológico , Transtorno Depressivo Maior/psicologia , Diagnóstico Diferencial , Relação Dose-Resposta a Droga , Interações Medicamentosas , Quimioterapia Combinada , Feminino , Humanos , Memantina/efeitos adversos , Memantina/uso terapêutico , Nootrópicos/efeitos adversos , Nootrópicos/uso terapêutico , Piperazinas/efeitos adversos , Psicoterapia , Transtornos Psicóticos/diagnóstico , Transtornos Psicóticos/psicologia , Quinolonas/efeitos adversos , Fatores de Risco , Resultado do Tratamento , Cloridrato de VenlafaxinaAssuntos
Doença de Alzheimer/tratamento farmacológico , Doença de Alzheimer/psicologia , Transtorno Bipolar/tratamento farmacológico , Transtorno Bipolar/psicologia , Nootrópicos/uso terapêutico , Piracetam/análogos & derivados , Idoso , Doença de Alzheimer/complicações , Transtorno Bipolar/etiologia , Feminino , Humanos , Levetiracetam , Masculino , Nootrópicos/efeitos adversos , Projetos Piloto , Piracetam/efeitos adversos , Piracetam/uso terapêutico , Escalas de Graduação PsiquiátricaRESUMO
OBJECTIVE: To assess the relationships among depressive signs and symptoms and left versus right temporal-parietal cerebral blood volumes (CBVs) in elderly patients with a primary complaint of memory loss. METHODS: Total Geriatric Depression Scale Short Form (GDS-SF) scores, left and right temporal-parietal cerebral blood volume values, and other prospectively recorded data were obtained via chart review of 24 patients aged >/=65 years, evaluated between 1995 and 2000 at McLean Hospital for a primary complaint of memory loss. Multivariate regression analyses were carried out with GDS-SF total scores as outcome variables, with CBV values as explanatory factors and with several patient characteristics as covariates. RESULTS: Depressive symptoms, as measured by the GDS-SF, were significantly associated with decreased left/right temporal-parietal CBV ratios (beta regression coefficient = -20.7; t [df = 22] = -2.96, p = 0.007). These findings remained statistically significant after controlling for age, sex, Mini-Mental State Exam (MMSE) score, years of education, years of memory loss, and handedness (beta regression coefficient = -16.7; t [df = 16] = -2.67, p = 0.017). CONCLUSION: In this study, severity of depressive symptoms as measured by the GDS-SF in patients >/=65 years old who presented with a primary complaint of memory loss was associated with decreased left/right temporal-parietal CBV ratios, independently of age, sex, MMSE score, years of education, years of memory loss, and handedness. These findings suggest that in the presence of cognitive decline, increased depressive signs and symptoms may be associated with decreased left/right temporal-parietal CBV ratios.
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Transtorno Depressivo Maior , Lateralidade Funcional/fisiologia , Imageamento por Ressonância Magnética , Transtornos da Memória , Lobo Parietal/irrigação sanguínea , Lobo Parietal/fisiopatologia , Lobo Temporal/irrigação sanguínea , Lobo Temporal/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Circulação Cerebrovascular/fisiologia , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/epidemiologia , Transtorno Depressivo Maior/fisiopatologia , Feminino , Humanos , Masculino , Transtornos da Memória/diagnóstico , Transtornos da Memória/epidemiologia , Transtornos da Memória/fisiopatologia , Testes Neuropsicológicos , Estudos Prospectivos , Estudos Retrospectivos , Índice de Gravidade de Doença , Inquéritos e QuestionáriosAssuntos
Anticonvulsivantes/uso terapêutico , Antimaníacos/uso terapêutico , Transtorno Bipolar/tratamento farmacológico , Piracetam/análogos & derivados , Idoso , Relação Dose-Resposta a Droga , Esquema de Medicação , Quimioterapia Combinada , Feminino , Humanos , Levetiracetam , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Piracetam/uso terapêutico , Escalas de Graduação Psiquiátrica , Resultado do TratamentoRESUMO
Initial investigations into the mechanistic basis of aggression focused on the role of testosterone (T) and a variety of studies on non-human animals found that elevated T levels promote aggression. However, many correlational studies have not detected a significant association between aggression and peripheral T levels. One reason for this inconsistency may be due to differential metabolism of T within the brain, in particular, the conversion of T to estrogen by aromatase. Thus, differences in aromatase enzyme activity, estrogen receptor expression, and related cofactors may have important effects on how steroids affect aggressive behavior. Hormone manipulation studies conducted in a wide variety of species indicate that estrogens modulate aggression. There is also growing evidence that social experience has important effects on the production of estrogen within the brain, and some cases can not be explained by androgenic regulation of aromatase. Such changes in central aromatase activity may play an important role in determining how social experiences affect the probability of whether an individual engages in aggressive behavior. Although studies have been conducted in many taxa, there has been relatively little integration between literatures examining aggression in different species. In this review, we compare and contrast studies examining aggression in birds, mammals, and humans. By taking an integrative approach to our review, we consider mechanisms that could explain species differences in how estrogen modulates aggression.
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Agressão/fisiologia , Aromatase/metabolismo , Encéfalo/enzimologia , Meio Ambiente , Estrogênios/metabolismo , Testosterona/metabolismo , Animais , Aves , Humanos , Aprendizagem/fisiologia , Mamíferos , Receptores de Estrogênio/metabolismo , Fatores Sexuais , Especificidade da EspécieRESUMO
OBJECTIVE: This study investigated the efficacy and safety of short-term estrogen therapy in decreasing noncognitive signs and symptoms of dementia in demented elderly patients. METHOD: Sixteen moderately to severely demented elderly patients with aggressive behavioral disturbances were randomly assigned to receive conjugated equine estrogens or placebo in a 4-week clinical trial. Frequency and severity of noncognitive signs and symptoms of dementia, as assessed with the Dementia Signs and Symptoms Scale, were compared between estrogen and placebo groups. Data were analyzed with intent-to-treat and regression modeling methods. RESULTS: Estrogen therapy was associated with a significantly greater improvement on the Dementia Signs and Symptoms Scale total score than placebo. All five Dementia Signs and Symptoms Scale subscale comparisons favored estrogen therapy. No adverse effects were observed. CONCLUSIONS: These preliminary data suggest that short-term estrogen therapy may safely decrease the frequency and severity of noncognitive signs and symptoms of dementia in elderly patients.