James M. Ellison, MD, MPH

FROM THE GROUP FOR ADVANCEMENT OF PSYCHIATRY

As the United States population ages, safe and effective geriatric care is needed as never before. By 2030, 20% of the population will be aged 65 years or older according to current 

s, a dramatic increase from the rate of 13% reported in the 2010 census.

 It is estimated that 14% to 20% of older adults require treatment for mental health conditions and/or substance use disorders.

 The anticipated increase in the number of older adults will place unprecedented and unrealistic burdens on our health care system, which now 

 fewer than 1400 board-certified geriatric psychiatrists.

 The current population of specialists is insufficient to meet even our present needs, and too few physicians are presently enrolled in geriatric psychiatry and geriatric medicine fellowship training to meet anticipated future needs. Because of the widening gap between the number of experts and the magnitude of patient needs, clinicians who have not had specialty training in geriatrics or geriatric psychiatry will provide the majority of mental health care for older adults.

The necessity for more geriatric mental health specialists and the urgent need to establish competencies in geriatric care for all clinicians who care for older adults were identified as national priorities in reports issued by the Institute of Medicine in 2008 and 2012.

 These goals have yet to be achieved. The Liaison Committee on Medical Education, which 

 accreditation for American medical schools, requires the undergraduate medical curriculum to “address each phase of the human life cycle,” but there is no stipulation for specific content or competencies in aging, geriatric care or geriatric mental health.

 Similarly, there are no national geriatric competency standards for nursing students, physician assistant students, or other allied health care trainees. In the absence of national competency requirements, curricula and training in aging and in geriatric care vary widely across institutions and training programs.

Inadequate recognition and management of common geriatric mental health conditions has serious consequences. Delirium, too often undetected on medical and surgical inpatient units, disproportionately affects older adults, and contributes to avoidable suffering and death.

 Aggression and other behavioral disturbances of dementias (major neurocognitive disorders) contribute to caregiver burnout and premature institutionalization.

 Late-life depression, the most frequent antecedent of suicide in older adults, is associated with potentially treatable suffering, excess disability, increased health care costs, and higher mortality.

 in older adults, is associated with falls, confusion, and preventable hospitalizations.

 Notwithstanding educational campaigns such as “

” (an initiative by the American Board of Internal Medicine Foundation

), benzodiazepines continue to be overprescribed to older adults, despite the complications associated with their excessive and chronic use.

There are 2 important reports that can help advance medical student geriatric education:

• In 2007, the American Association of Medical Colleges and John A. Hartford Foundation Consensus Conference developed the Minimum Geriatric Competencies for Medical Students. These include 26 behaviorally focused competencies nested in 8 domains: medication management; cognitive and behavioral disorders; self-care capacity; falls, balance, gait disorders; health care planning and promotion; atypical presentation of disease; palliative care, and hospital care for elders (

 Within each of these domains are listed between 2 to 5 specific skills that medical students should master before graduating medical school to ensure safe care of elders. While a number of medical schools have incorporated these competencies as objectives in creating clinical rotations for their students, wider adoption and implementation remain critical.

 a broader set of Geriatric Mental Health Learning Objectives for medical students that expands the domain of cognitive and behavioral disorders and addresses the need for specific knowledge and reasoning skills that medical students should attain in 6 key areas of normal aging, mental health assessment, psychopharmacology, depression, dementia, and delirium.

The intent of both of these reports was to establish proficiencies that delineate core material that all students should learn by the time of graduation from medical school in order to provide competent and safe care to older patients encountered during and after residency training.

 requires establishing an infrastructure of geriatric experts within key health care training organizations to dynamically and continuously build a workforce of appropriately trained clinicians, schooled and skilled in the health needs and vulnerabilities of older adults. These 2 reports support the development of that workforce by providing a framework for the creation of national curricula in geriatrics for medical students and allied health professions. They represent the consensuses of experts, derived from an evidence-based understanding of the essential and specific health care needs of older patients.

While achievement of these minimal competencies will not eliminate the need for specialty training and geriatric specialists, adoption of basic standards will improve the recognition and clinical management of key health conditions in older adults that impact quality of life and health care costs. Needed are national education mandates from accreditation organizations and congressional support to require enhanced education of all clinicians who care for older adults.

Such attention to improving education and training standards couldn’t be more pressing or timelier. We have just witnessed a United States presidential election in which both candidates were septuagenarians and we will soon inaugurate the oldest individual ever to assume the presidency. We urge the new president and members of Congress to make national standards for education in geriatric care a priority of health care reform. On local and national levels, psychiatrists have a leadership role to play in implementing effective and actionable strategies for increased geriatric mental health education in medical school and allied healthcare curricula.

Building upon existing competency guidelines to create national curricula will prepare the eldercare workforce to handle the growing health care needs of our aging population. Given the urgency of rapidly changing demographics, training the requisite workforce to care for the mental health needs of older patients must become a national priority.

is clinical director, Division of Geriatric Psychiatry and Neuropsychiatry, and associate professor of Psychiatry and Behavioral Sciences, Johns Hopkins Medicine, Baltimore, MD.

holds the Swank Foundation Endowed Chair in Memory Care and Geriatrics, Christiana Care Health System, Wilmington, DE, and is professor of Psychiatry and Human Behavior, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.

is Dr Sakauye is Emeritus Professor of Psychiatry at the University of Tennessee Health Science Center in Memphis, TN.

is clinical assistant professor at Boston University School of Medicine, adjunct clinical assistant professor at Tufts University School of Medicine and lecturer, part-time, at Harvard Medical School, Boston, MA. 

is professor of Psychiatry and Health Policy and Director, Center for Biomedical Ethics and Society at Vanderbilt University, Nashville, TN. 

 is vice chair in the Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, and chair of the American Psychiatric Association Council on Geriatric Psychiatry.

1. Ortman JM, Velkoff VA, Hogan H. An Aging Nation: The Older Population in the United States. May 2014. U.S. Census Bureau. Accessed December 3, 2020. 

https://www.census.gov/prod/2014pubs/p25-1140.pdf

2. Eden J, Maslow, K, Le M, Blazer D. The mental health and substance use workforce for older adults: In whose hands? 

Committee on the Mental Health Workforce for Geriatric Populations, Board on Health Care Services; Institute of Medicine.

 Washington, DC. National Academies Press. 2012.

3. American Board of Psychiatry and Neurology, Inc. 2019 Annual Report. Accessed December 3, 2020. 

https://www.abpn.com/wp-content/uploads/2020/05/ABPN_2019_Annual_Report.pdf

4. Institute of Medicine Committee on the Future Health Care Workforce for Older Americans. Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: National Academies Press; 2008.

5. Liaison Committee on Medical Education. Functions and structure of a medical school, 2019. Accessed December 3, 2020. 

http://www.lcme.org/publications/#standards

6. Witlox J, Eurelings LS, de Jonghe JF, et al. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. 

7. Hiyoshi-Taniguchi K, Becker CB, Kinoshita A.

 What Behavioral and Psychological Symptoms of Dementia Affect Caregiver Burnout?

8.Kales HC, Gitlin LN, Lyketsos CG, Detroit Expert Panel on Assessment and Management of Neuropsychiatric Symptoms of Dementia.

 Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel

9. Wei J, Hou R, Zhang X, et al. The association of late-life depression with all-cause and cardiovascular mortality among community-dwelling older adults: systematic review and meta-analysis. 

10. Bock JO, Hajek A, Weyerer S, et al. The impact of depressive symptoms on healthcare costs in late life: Longitudinal findings from the AgeMoodDe Study. 

Polypharmacy including falls risk-increasing medications and subsequent falls in community-dwelling middle-aged and older adults

12. Choosing Wisely. Promoting conversations between patients and clinicians. Accessed December 3, 2020. 

13. Maust DT, Kales HC, Wiechers IR, et al. No end in sight: Benzodiazepine use in older adults in the United States. 

14. Leipzig RM, Granville L, Simpson D, et al. Keeping Granny safe on July 1: A consensus on minimum geriatric competencies for graduating medical students. 

15. Lehmann SW, Brooks WB, Popeo D, et al. 

Development of geriatric mental health learning objectives for medical students: A response to the Institute of Medicine 2012 report

Articles

The authors make the case for national education mandates from accreditation organizations and congressional support to require enhanced education of all clinicians who care for older adults.

Raising the Bar on Geriatric Mental Health Competency Training

 holds the Swank Foundation Endowed Chair in Memory Care and Geriatrics, Christiana Care Health System, Wilmington, DE, and is Professor of Psychiatry and Human Behavior, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.

Did you know that FBI agents are required to retire at age 57? And that commercial pilots, national park rangers, and air traffic controllers face mandatory retirement at an age that many physicians consider prime years of professional fitness? In India, Central Health Service doctors must retire at 

 In the US, physicians are not subject to a mandatory retirement age, but public opinion and accumulating evidence of the effects of aging on professional performance have instigated development of “Late Career Practitioner Assessment” policies at many US health care institutions.

Our physician workforce is indisputably aging. At present, more than a quarter of US physicians are 65 or older.

 Unlike many other professions in which retirement is earlier, medical practitioners often wish to continue working into their later years. Medical practice in later adulthood is sometimes a consequence of financial pressure in our era of increased life expectancy. In addition, many physicians avoid relinquishing some of the rewards associated with full participation in professional life.

Age itself does not detract from the quality of a physician’s performance; in fact, age is often associated with greater stress tolerance, resilience, and wisdom. But aging has also been linked with changes in physical and cognitive functioning that can directly affect skills required to carry out clinical work.

 (ACS) has been proactive in its recognition of the effects of physical and cognitive aging on performance. Currently, the ACS recommends that surgeons undergo periodic voluntary physical examination, eye examination, and cognitive screening beginning as early as age 65.

 While the relationship of visual and motor function to the performance of medical and surgical procedures is readily appreciated, the link between cognitive aging and changes in physician performance presents more subtle challenges for assessment and elicits greater resistance among the professional community.

Physicians’ cognitive decline has been claimed to lag behind that of the general population, ostensibly because of high baseline ability and cognitive reserve reinforced through years of intellectual activity.

 Cognitive faculties known to change even with typical aging, however, are integral to excellent professional performance. Complex attention is required to sustain the intake of auditory and visual information while attending to the multiple tasks that constitute a clinical encounter. Intact working and short-term memory support the integration of novel information for use in decision-making. Executive function assists in the recognition of unexpected data, the correction of errors, and the development of an optimal treatment plan. Aging is often accompanied by greater reliance on pattern-based cognitive processing, which can lack flexibility, and decrements in working memory and processing speed that support complex attention and executive function.

Short of an actual neurocognitive disorder, the significance of age-associated changes in physician performance remains controversial, but growing evidence suggests there is reason for concern. Aging of physicians and time since graduation have been correlated with decrements in history taking, physical examination, record keeping, and problem solving

 as well as higher mortality with some complex surgical procedures.

 evaluated the relationship of quality of medical care to age or number of years in practice and showed a negative correlation in more than half of the studies reviewed.

Screening for fitness based on age represents a clear departure from the most prevalent current practice, which is to evaluate only when this is suggested by patient complaints or peer concerns. Interestingly, data from comprehensive evaluations of older physicians referred for assessment on the basis of such concerns have typically documented a high rate of cognitive performance issues among the referred individuals.

 Unfortunately, physicians are not necessarily good judges of their own performance,

 and reliance on reports from peers has not proved sufficient.

Aging, of course, is only one of many factors that affect physician performance. Patient volume and population characteristics, support resources and work environment, documentation requirements, adoption of electronic health records, and professional burnout are among other important influences on the quality of care provided.

National policies for age-based screening of physical and cognitive status of physicians are already an accepted part of medical practice in Canada, Australia, New Zealand, and other countries. In the United States, by contrast, policies are springing up locally and their requirements are inconsistent. Based on the groundbreaking work of 

California Public Protection and Physician Health, Inc.

, the typical requirements of an age-based assessment are the medical history, physical examination including motor and visual evaluation, performance review by various approaches, and cognitive examination-but there is much latitude in the performance and interpretation of these measures.

 The cognitive examination has been especially controversial. The medical staff of the 

, for example, was successful in eliminating it from the late career practitioner policy now in effect.

 A lively ongoing debate is examining the ethics and legality of age-based evaluation of clinicians, exploring whether physician age can be regarded as a “bona fide occupational requirement” subject to use as a trigger for performance assessment, as permitted under the 

, or whether the use of age in this way constitutes age discrimination.

2019 Annual Meeting of the American Psychiatric Association

, a matched pair of symposia will address the issues surrounding the development and spreading phenomenon of age-based practitioner assessment policies. Entitled “Health Care Systems, Malpractice Insurers, and Aging Physicians: Emerging Age-Based Assessment Practices Part 1/Part 2,” these sessions are scheduled for Wednesday, May 22, in Room 154 of the Upper Mezzanine at Moscone Convention Center South. Part 1 will take place from 10:00 AM to 11:30 AM, and part 2 from 1:00 PM to 2:30 PM. A diverse panel will present current information on the evolving demographics of the US physician workforce and the evidence linking age or years of practice with changes in performance issues; the ongoing issues raised by adoption of late career practitioner policies; the concerns that malpractice insurers have about performance of aging practitioners; and the characteristics of a model policy. Please plan to attend and to join in the lively discussion that is certain to occur.

Retirement age of central government doctors raised to 65 years

. September 27, 2017. https://www.hindustantimes.com/india-news/retirement-age-of-central-government-doctors-raised-to-65-years/story-nEFFoxDCLSujIyeITJ3HjN.html. Accessed April 28, 2019.

A census of actively licensed physicians in the United States, 2016

3. American College of Surgeons (ACS). Statement on the Aging Surgeon. ACS website. 

https://www.facs.org/about-acs/statements/80aging-surgeon

. Published January 1, 2016. Accessed April 28, 2019.

. Boston, MA: Harvard University Press; 1994.

The aging physician: changes in cognitive processing and their impact on medical practice

6. Caulford PG, Lamb SB, Kaigas TB, et al. 

Physician incompetence: specific problems and predictors

7. Waljee JF, Greenfield LJ, Dimick JB, et al. 

Surgeon age and operative mortality in the United States

8. Choudhry NK, Fletcher RH, Soumerai SB. 

Systematic review: the relationship between clinical experience and quality of health care

9. Korinek LL, Thompson LL, McRae C, Korinek E. 

Do physicians referred for competency evaluations have underlying cognitive problems?

10. Davis DA, Mazmanian PE, Fordis M, et al. 

Accuracy of physician self-assessment compared with observed measures of competence: a systematic review

11. DesRoches CM, Rao SR, Fromson JA, et al. 

Physicians’ perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues

12. California Public Protection and Physician Health, Inc. Assessing Late Career Practitioners: Policies and Procedures for Age-based Screening. 

https://www.cppph.org/wp-content/uploads/2015/07/assessing-late-career-practitioners-adopted-by-cppph-changes-6-10-151.pdf

. June 10, 2015. Accessed April 28, 2019.

13. Krieger LM. Stanford doctors fight age-related test of fitness to practice. 

http://www.mercurynews.com/2015/06/08/Stanford-doctors-fight-age-related-test-of-fitness-to-practice

14. U.S. Equal Employment Opportunity Commission. The Age Discrimination in Employment Act of 1967. 

https://www.eeoc.gov/laws/statutes/adea.cfm

A lively ongoing debate is examining the ethics and legality of age-based evaluation of clinicians.

Performance Assessment of Late Career Practitioners: On the Horizon? Or Already Here?

From the Group for the Advancement of Psychiatry, Committee on Aging

My 79-year-old memory clinic patient arrived with her daughter, whose first question caught me off guard: “Can you prescribe medical marijuana for my mother? I think it might help her agitation better than the medication you gave her last visit.” When I asked her why she thought that marijuana might help, she blushed and turned her eyes briefly away. “Well, the other night she was really bad . . . and we gave her a joint. She really calmed down.”

This dialogue will become familiar as baby boomers-many of whom are comfortable with marijuana use-age into caretaking roles, assisting parents who have Alzheimer disease and other conditions that combine cognitive decline with behavioral symptoms.

The spread of medical and recreational marijuana use in the US is accelerating. Medical use of marijuana is now legalized in 28 states plus Washington, DC.

 Twelve additional states allow medical use of isolated cannabidiol, one of the many active alkaloids contained in marijuana.

 Although marijuana remains a Schedule I substance and has not been legalized under federal law, the Obama administration refrained from interfering with its medical use in states where it is approved and appropriately regulated.

 Whether this federal permissiveness will continue under President-Elect Trump’s leadership is uncertain, despite his remarks regarding the benefits of medical marijuana.

Interest in medical and complementary treatments for agitation in people with dementia disorders, which are now under the umbrella of the DSM-5 major neurocognitive disorder category, has grown in part because of an increase in the prevalence of these disorders. Improved treatment of many chronic medical diseases has prolonged life expectancy. Because age is the chief risk factor for major neurocognitive disorders, greater longevity increases the prominence of cognitive impairment in the aging population. By 2050, barring significant treatment advances, nearly 14 million older adults in the US will live with Alzheimer disease-the most common of neurodegenerative disorders.

 The majority will display the behavioral disturbances that so often accompany cognitive decline, including agitation.

By 2050 nearly 14 million older adults in the US will live with Alzheimer disease-the most common of neurodegenerative disorders.

The most frequent of dementia-associated disruptive behaviors, agitation is known to increase caregiver burden and morbidity.

 Despite suggestive leads from case reports in peer-reviewed journals, no medication has yet achieved an FDA indication as a primary treatment for behavioral disturbances associated with major neurocognitive disorders.

As the desire for effective treatment grows in parallel with the increased availability of marijuana, it’s time to reconsider the evidence regarding risks and benefits of marijuana use in the care of those with cognitive decline and disruptive behaviors. In a recent review, Maust and colleagues

 tackled this question. They noted that “dementia” is a qualifying condition for medical marijuana use in 10 states, often specifically designated for treatment of agitation in Alzheimer disease, despite a lack of support for its efficacy in that usage. Their citation of the “only randomized, placebo-controlled trial of marijuana for dementia,” which did not significantly improve agitation, fails to note the difference between marijuana and the isolated alkaloid administered in that study, tetrahydrocannabinol (THC).

 A positive open-label trial of medical cannabis oil, also cited by Maust and colleagues, used a marijuana extract high in THC and low in other marijuana alkaloids.

The more commonly used forms of marijuana appear to remain untested as treatments for agitation in Alzheimer disease. Agitation associated with non-Alzheimer dementias appears not to be a qualifying condition for marijuana use-an important consideration for clinicians given that cognitive impairment in many older adults has no etiologic diagnosis.

Marijuana, although it may be requested, is not the only available treatment alternative for addressing disruptive behaviors in cognitively impaired individuals. Behavioral approaches such as the DICE (Describe, Investigate, Create, and Evaluate) protocol are widely regarded as the first-line intervention, although agitation sometimes fails to respond to this nonpharmacological approach.

While we await further evidence of marijuana’s efficacy and safety as a treatment for agitation in cognitively impaired individuals,clinicians are well-advised to consider better documented behavioral or pharmacological treatments. In federal institutions or states that do not include Alzheimer disease as a qualifying condition for marijuana use, patients and caregivers can be made aware of the regulations that govern marijuana availability. Given the variety of marijuana species that dispensaries provide and the varying ratios of active alkaloids they contain, a reasonable alternative to a request for medical marijuana might be dronabinol, which is a standardized and more predictable medication with a limited but supportive evidence base. Further research into the risks and benefits of marijuana is well worth pursuing and will guide clinicians’ treatment choices.

Citalopram and other serotonergic antidepressants are beneficial in the management of agitation, although they are not without adverse effects.

 Antiadrenergic agents, analgesics, and a smattering of other pharmacological approaches are supported by a limited evidence base and are used in the absence of a more definitive or standardized approach.

Synthetic tetrahydrocannabinol, available as dronabinol, holds a credible position among these sometimes effective pharmacological approaches, although both positive and negative results have been reported.

 Antipsychotic medications, still frequently prescribed, are recognized as potentially harmful and of limited clinical value for many agitated, cognitively impaired patients.

 The FDA-approved cognitive enhancers, memantine and the cholinesterase inhibitors, are not regarded as valuable treatments for acute agitation.

The jury is still out on medical marijuana’s role in the treatment ofAlzheimer disease and other major neurocognitive disorders. Anorexia, nausea, anxiety, depression, or pain might be reasonable indications in selected patients. The benefits of such use must be weighed against potential risks. Some research suggests that marijuana’s active alkaloids, the cannabinoids, can mitigate Alzheimer disease progression through neuroprotective blockade of microglial activation.

The more commonly used forms of marijuana appear to remain untested as treatments for agitation in Alzheimer disease.

Cannabis has been reported to have adverse acute and non-acute effects on cognitive functions, which might outweigh its therapeutic benefits.

 Furthermore, marijuana use has been associated with hallucinations and adverse effects on mood and memory as well as unpleasant physical symptoms, including blurred vision, dizziness, dry mouth and eyes, tachycardia, somnolence, urinary retention, and changes in blood pressure.

Marijuana interacts through pharmacokinetic and pharmacodynamic mechanisms with a large variety of prescribed psychiatric medications, including SSRIs, TCAs, and lithium. It has an additive effect when used in conjunction with other CNS depressants.

 One case report attributed increased bleeding risk to the combined use of marijuana and warfarin, and another case report attributed a man’s myocardial infarction to the concurrent use of marijuana with sildenafil.

 Needless to say, these potential complications could seriously complicate the treatment of a person with dementia.

Formerly Director of Geriatric Psychiatry at McLean Hospital in Belmont, Massachusetts

, I recently re-located to Wilmington, Delaware, where I am privileged to serve as the first Swank Foundation Endowed Chair in Memory Care and Geriatrics. In that capacity, I am consultant to a team of geriatricians who have helped me experience the great value of interdisciplinary and collaborative care.

I am the proud father of 2 teenage boys. I wish for them as much career satisfaction, whatever they choose to pursue, as I have found in psychiatry.

Dr. Ellison is Professor of Psychiatry and Human Behavior, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA; and Swank Foundation Endowed Chair in Memory Care and Geriatrics at Christiana Care in Wilmington, DE. He reports no conflicts of interest concerning the subject matter of this article.

This article is from the Committee on Aging of the Group for the Advancement of Psychiatry (GAP): Robert P. Roca, MD, Chair; James M. Ellison, MD; Warachal Faison, MD; Helen Kyomen, MD; Susan Lehman, MD; Ben Liptzin, MD; Marsden McGuire, MD; Keith Meador, MD; Robert Rohrbaugh, MD; and Ken Sakauye, MD. The GAP, American psychiatry’s think tank, informs and educates mental health professionals, policy makers, and the public at large.

 ProCon.org. 28 Medical Marijuana States and DC. November 2016. 

http://medicalmarijuana.procon.org/view.resource.php?resourceID=000881

 US Department of Justice. Guidance Regarding Marijuana Enforcement. August 2013. 

https://www.justice.gov/iso/opa/resources/3052013829132756857467.pdf

 Strauss M. Will the Trump Administration Weed Out Medical Marijuana? November 11, 2016. 

http://news.nationalgeographic.com/2016/11/medical-marijuana-cannabis-trump-election/

 Alzhemer Association. Changing the Trajectory of Alzheimer Disease: How a Treatment by 2015 Saved Lives and Dollars. 2015. 

https://www.alz.org/documents_custom/trajectory.pdf

 Lyketsos CG, Steinberg M, Tschanz JT, et al. Mental and behavioral disturbances in dementia: findings from the Cache County Study on Memory in Aging. 

 Maust DT, Bonar EE, Ilgen MA, et al. Agitation in Alzheimer disease as a qualifying condition for medical marijuana in the United States. 

 van den Elsen GAH, Ahmed AIA, Verkes RJ, et al. Tetrahydrocannabinol for neuropsychiatric symptoms in dementia: a randomized controlled trial. 

 Shelef A, Barak Y, Berger U, et al. Safety and efficacy of medical cannabis oil for behavioral and psychological symptoms of dementia: an open label, add-on, pilot study. 

 Kales HC, Gitlin LN, Lyketsos CG, et al. Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. 

 Leonpacher AK, Peters ME, Drye LT, et al. Effects of citalopram on neuropsychiatric symptoms in Alzheimer dementia: evidence from the CitADstudy. 

 Woodward MR, Harper DG, Stolyar A, et al. Dronabinol for the treatment of agitation and aggressive behavior in acutely hospitalized severely demented patients with noncognitive behavioral symptoms. 

 Volicer L, Stelly M, Morris J, et al. Effects of dronabinol on anorexia and disturbed behavior in patients with Alzheimer disease. 

 Antonsdottir IM, Makino KM, Porsteinsson AP. Dazed and confused: medical cannabis in Alzheimer disease. 

 Schneider LS, Tariot PN, Dagerman KS, et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer disease. 

 Ramirez BG, Blazquez C, Gomez del Pulgar T, et al. Prevention of Alzheimer disease pathology by cannabinoids: neuroprotection mediated by blockade of microglial activation. 

 Crane NA, Schuster RM, Fusar-Poli P, et al. Effects of cannabis on neurocognitive functioning: recent advances, neurodevelopmental influences, and sex differences. 

 Lindsey WT, Stewart D, Childress D. Drug interactions between common illicit drugs and prescription therapies. 

 Yamreudeewong W, Wong HK, Brausch LM, et al. Probable interaction between warfarin and marijuana smoking. 

 McLeod AL, McKenna CJ, Northridge DB. Myocardial infarction following the combined recreational use of Viagra and cannabis. 

“Doctor, will you prescribe medical marijuana for my mother? I think it might help her agitation better than the medication you gave her last visit.”

Medical Marijuana and Dementia-Associated Agitation: Stirring the Pot

Is it possible to delay or prevent the onset of cognitive impairment or the progression from mild impairment to major neurocognitive disorder? That is the question addressed at APA 2016 in a course titled “Identifying and Helping Our Older Adults with Mild Neurocognitive Disorder.”

The course was developed in order to help clinicians understand the significance of mild neurocognitive disorder (MiND), a newly defined syndrome in DSM-5. The multidisciplinary team of lecturers addresses the disorder definition of MiND, its causes and natural history, assessment using neuropsychological and advanced imaging techniques, and state-of-the-art evidence-based interventions.


	Before current biomarker studies validated the existence of this clinical syndrome, mild cognitive symptoms were often attributed to depression or anxiety. Mood disorders can indeed be accompanied by cognitive symptoms, but the nature of the relationship between these symptom categories is multifaceted.

[[{"type":"media","view_mode":"media_crop","fid":"48565","attributes":{"alt":"cognitive decline","class":"media-image media-image-right","height":"200","id":"media_crop_6282559550896","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5800","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"©NotarYES/Shutterstock","typeof":"foaf:Image","width":"306"}}]]In various individuals, signs of depression may be a prodrome of cognitive impairment, a risk factor for cognitive decline, a manifestation of a shared underlying etiology, or a reaction to progressive functional limitation. Identifying which one or more of these paradigms is most fitting can pave the way for effective intervention.


	Mild age-associated changes in cognition reflect aging of the brain, much as changes in glomerular filtration and reduced aerobic capacity can accompany aging of the kidney and heart. The aging brain does not, as once believed, lose vast amounts of neurons over time; however, changes in synaptic structure, diminished activity of key neurotransmitters, altered integrity of white matter, and global loss of volume are typical findings in older brains.

The essence of the DSM-5 definition of MiND is a limited but significant functional impairment associated with an acquired decline in one of 6 cognitive domains.

The functional manifestation of these changes is reflected in the different norms that apply to neuropsychological test performance of older subjects. The majority of older adults note subtle changes in memory or other cognitive functions, and fear of memory loss is one of the most prevalent of serious health concerns in this population. Fortunately, these changes are simply a minor nuisance for many.

“Subjective cognitive impairment,” a syndrome that has begun to attract the attention of researchers and clinicians, describes individuals-usually older adults-with more compromised cognitive functioning that still falls below the sensitivity of standardized screening tests. Subjective cognitive impairment is not yet a DSM-5 diagnosis, but it is can be a precursor to MiND. Concerns about memory may lead an older adult to seek evaluation. Others may express concern about language, executive function, or other cognitive areas.


	The essence of the DSM-5 definition of MiND is a limited but significant functional impairment associated with an acquired decline in one of 6 cognitive domains: attention, memory, language, visuospatial, executive function, or social cognition. The impairment is enough to require an individual to engage in compensatory behaviors to deal with a cognitive decline that is significant but not so severe as to cause loss of independence. New dependence on cueing, reminders, lists, assistive technology such as GPS, or the help of others can signify the presence of MiND despite relatively limited functional compromise.

Mounting evidence supports the notion that MiND can represent the prodromal stage of major neurocognitive disorder, whether associated with 

 or another etiology. Cognitive impairment that does not meet the criteria for the major disorder has been linked with biomarker changes, including hippocampal and global brain volume loss, changes in regional glucose metabolism, amyloid deposition, and deposition of amyloid plaques. Although a small percentage of people with MiND function more normally at later reexamination, a significant percentage will progress to MiND over time.


	A growing and necessary focus in the treatment of neurocognitive disorders is prevention. Thorough assessment of milder cognitive changes in older adults facilitates interventions that may in some cases delay progression. Identifiable medical causes of cognitive symptoms such as uncontrolled diabetes with hyperglycemia or hypoglycemia can sometimes be identified and addressed.

Modification of physical activity, diet, and cognitive stimulation have each been proposed to improve cognitive functioning and delay decline, although the evidence for each of these is not unmixed. Social engagement, relaxation, and adequate sleep each appear to play a role in maintaining 

These evidence-based categories of intervention are joined in the mnemonic DANCERS (

), and listed with potential areas for clinical inquiry and recommendations. As our population continues to age, clinicians will inevitably encounter more requests for advice and guidance in managing milder age-associated cognitive changes. “Identifying and Helping Our Older Adults with Mild Neurocognitive Disorder” points the way toward applying current knowledge about assessment and early intervention.

The Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) 

 score has 15 dietary components including 10 brain healthy food groups (green leafy vegetables, other vegetables, nuts, berries, beans, whole grains, fish, poultry, olive oil, and wine) and 5 unhealthy food groups (red meats, butter and stick margarine, cheese, pastries and sweets, and fried/fast food).


	Tangney CC, Wang Y, Sacks FM, et al. MIND diet associated with reduced incidence of Alzheimer's disease. 

http://www.alzheimersanddementia.com/article/S1552-5260%2815%2900017-5/abstract

D'Anna A. New Diet May Lessen Risk of Dementia Diagnosis. 

http://www.annalsoflongtermcare.com/article/new-diet-may-lessen-risk-dementia-diagnosis

Dr Ellison is the Swank Foundation Endowed Chair in Memory Care and Geriatrics at Christiana Care in Wilmington, Delaware.

Depression can be accompanied by cognitive symptoms, but the nature of the relationship between these symptom categories is multifaceted.

Identifying Mild Neurocognitive Disorder in Older Patients 

Although aging may be accompanied by stresses, losses, and illnesses we should not accept debilitating mood symptoms as a routine concomitant of aging. Mood disorders and clinically significant mood symptoms disrupt older adults’ later years.

Many depressive states go unrecognized as such in older patients. Late-life mood symptoms can be subtle, atypical, or less numerous than required for a DSM diagnosis of major depressive disorder (MDD). An older adult may display less overt sadness, cloaking depression in a disguise of irritability or withdrawal. Some older adults manifest depression as a preoccupation with bodily dysfunction or disintegration.

In order for older patients to derive greater enjoyment from their later years, clinicians must take special care during evaluation, treatment, and follow up when working with this growing population.

James M. Ellison, MD, MPH

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