James M. Ellison, MD, MPH

 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

Articles

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.

 Concerns about loss of cognitive function may lead a well-intentioned clinician to focus on ruling out dementia rather than addressing depression.

Delusions, which are much more frequent among older patients with depression, can interfere with a clinician’s recognition of a primary mood disorder. Among the especially confusing diagnostic puzzles faced by clinicians, the distinctions between depression and personality disorder or substance use disorders requires careful and methodical evaluation of the history, symptoms, and mental status findings. The interaction of mood disorders with medical illnesses, too, can befuddle a clinician who attributes the mood symptoms to physical illness or a psychological reaction to physical disease. Often, there is a reciprocal relationship between medical and mood conditions that is most effectively addressed through simultaneous treatment of both conditions. One particular medical condition, vascular disease, can be associated with a depressive syndrome, vascular depression, which conjoins mood symptoms with executive dysfunction.

Bipolar disorders, which typically begin in young adults, can present in older adults either de novo or as a recurrence of a disorder present earlier in life. Mania in late life is often characterized by increased irritability and dysphoria rather than euphoria and excitement. Secondary mania, the designation for symptoms caused by a medical illness such as cerebrovascular accident or infection, is far more common among older than younger patients. Treatment of bipolar disorder among older adults is similar to treatment of younger adults, although it requires attentive dosing, awareness of potential drug interactions, and alertness to adverse effects.

It is important to avoid overreliance on the DSM criteria for depression, since these criteria can lack adequate specificity and sensitivity in older patients. The diagnostic assessment of late-life mood disorders requires alertness to the medical burden associated with aging and the accumulation of chronic medical diseases.

 Physical examination and laboratory testing, often performed by a collaborating primary care clinician, are necessary for adequate assessment.

Suicide, often with firearms, is of particular concern when treating older, depressed patients. White men who are 85 and older commit suicide at a rate 5 times that of the general population. In many cases, the presence of depression might have been detected during a primary care visit and before a completed suicide.

The complex and mutually reinforcing relationship between depression and cognitive impairment is of great concern when treating older adults. Depression and dementia exacerbate each other symptomatically, and perhaps each promotes worsening of the other through inflammatory or other mechanisms.

In the past, the cognitive symptoms of depression were termed “pseudodementia,” in the belief that treatment of depression would cure the associated cognitive dysfunction. Longitudinal follow-up, however, has revealed that the “dementia syndrome of depression” may be a prodrome or even a risk factor for a later primary dementia.

Patients with Alzheimer disease or other dementias may express depression behaviorally, as aggression or vocalization or as resistance to care. Treatment with antidepressants is recommended when the symptoms resemble MDD, but studies questioning the superiority of antidepressants over placebo in these patients suggest that clinicians should be prepared to curtail an ineffective antidepressant trial.

For older patients with mild to moderate depression and sufficient cognitive capacity to benefit from an interactive approach, treatment of late-life depression frequently begins with psychotherapy or a combination of psychotherapy with an antidepressant. Evidence-based psychotherapies for older adults include cognitive-behavioral therapy, problem solving therapy, and interpersonal therapy.

All of the antidepressants approved by the FDA for treatment of depression have been used successfully in older patients, but clinicians often pass by the TCAs and MAOIs because the newer agents’ adverse effects are more benign.

 An SSRI such as sertraline is often chosen as the initial agent.

 Citalopram or escitalopram are also well-tested in the elderly, but controversial reports of enhanced risk for arrhythmia with these agents, when used at higher dosages, has resulted in more cautious use.

Serotonergic antidepressants are not without adverse effects in the elderly, and clinicians must remain alert to hyponatremia and bleeding, among other potential complications. Bupropion, in appropriate patients, treats apathy and depression with minimal weight gain, sedation, or sexual dysfunction. Patients at risk for seizure are not given bupropion, and those with psychosis or severe anxiety often do better with a different medication.

Mirtazapine is useful among depressed patients who can benefit from its anxiolytic, appetite-enhancing, and sedating effects. Neutropenia is a possible but infrequent complication, but sedation or appetite increase can interfere with compliance. A large number of patients fail to achieve remission with monotherapy, but many initial nonresponders benefit from use of the same augmentors helpful with younger patients.

In older patients, lithium is used carefully because of associated cognitive and renal adverse effects. Thyroid hormone is used with caution when adverse cardiac effects might be anticipated. Testosterone can be an effective augmentor in hypogonadal depressed men without contraindications, such as prostate or liver disease. Methylphenidate or other stimulants, when clinically appropriate, have helped some apathetic antidepressant nonresponders. All of these augmentors are used “off label” and require a clinician to discuss that aspect of treatment so that the patient can make an informed choice.

In contrast, aripiprazole carries an FDA indication for adjunctive treatment of MDD. The risks of using antipsychotics in older adults with mood disorders is not fully understood, although these medications are popular and effective antidepressant adjuncts in younger patients. Any pharmacotherapy for older patients must take into account the metabolic limitations of aging internal organs, the huge potential for adverse drug interactions, and the rising cost of medications for patients who typically are taking 5 concurrent medications prescribed by different clinicians who may be unaware of the full drug regimen being taken.

New enhancements to transcranial magnetic stimulation are increasing the usefulness of this treatment in later life. Electroconvulsive therapy (ECT) remains an important intervention among older patients with severe or psychotic depression, although it is often avoided as a result of concern about effects on memory or the risk of anesthesia. Newer approaches to stimulus delivery reduce the impact of ECT on cognitive functioning.

Among the evolving changes in our delivery of psychiatric services, the treatment of depression in primary care settings is a trend of great importance. Older adults often prefer to receive depression treatment from their primary care clinician, in a setting that is more convenient and less costly. Model systems such as those described in the PROSPECT, IMPACT, and PRISM-E studies have demonstrated efficacy and cost similar to treatment in specialty care settings. Treatment of depression in primary care may be especially effective and desirable with patients whose depression is complicated by substance use disorders, chronic medical illnesses, or cognitive impairment.

Mood disorders in older adults are neither inevitable nor particularly resistant to treatment. With attention to the special needs of older patients during evaluation, treatment, and follow-up, clinicians can help many patients derive greater enjoyment from their later years.

Editor's note: Dr Ellison was a presenter at this year's 

American Psychiatric Association Annual Meeting

 in Toronto, in sessions titled "Late-Life Mood Disorders: Achieving Accurate Diagnosis and Effective Treatment" and "Identifying and Helping Older Adults With Mild Neurocognitive Disorders." An interdisciplinary team addressed the recognition and management of late-life mood disorders for the 8th consecutive year at the APA. This article was updated from a previously published article by Dr Ellison.

Dr Ellison is Director of the Geriatric Psychiatry Program at McLean Hospital in Belmont, Mass.

 Ellison JM, Kyomen HH, Harper DG. Depression in later life: an overview with treatment recommendations. 

 Alexopoulos GS, Meyers BS, Young RC, et al. “Vascular depression” hypothesis. 

 Gallo JJ, Rabins PV. Depression without sadness: alternative presentations of depression in late life. 

 Mottram P, Wilson K, Strobl J. Antidepressants for depressed elderly. 

 Lyketsos CG, Sheppard JM, Steele CD, et al. Randomized, placebo-controlled, double-blind clinical trial of sertraline in the treatment of depression complicating Alzheimer’s disease: initial results from the Depression in Alzheimer’ Disease study. 

 Zubenko GS, Sunderland T. Geriatric psychopharmacology: why does age matter? 

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.

Recognizing and Treating Geriatric Mood Disorders

Mood disorders and clinically significant mood symptoms steal the pleasure and vitality from many older adults’ later years. Although aging may be accompanied by stresses, losses, and illnesses that are more common in this phase of life, we should not accept debilitating mood symptoms as a routine concomitant of aging. An interdisciplinary team addressed the recognition and management of late-life mood disorders for the seventh consecutive year at the 

 of the APA. The course was taught by co-directors James Ellison and Yusuf Sivrioglu, and additional faculty members Donald Davidoff, Brent Forester, and Joan Cook.

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 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.

Patients with Alzheimer disease or other dementias may express depression behaviorally, as aggression or vocalization or as resistance to care. Treatment with antidepressants is recommended when the symptoms resemble MDD, but studies questioning the superiority of antidepressants over placebo in these patients suggest that clinicians should be prepared to curtail an ineffective antidepressant trial.

For older patients with mild to moderate depression and sufficient cognitive capacity to benefit from an interactive approach, treatment of late-life depression frequently begins with psychotherapy or a combination of psychotherapy with an antidepressant. Evidence-based psychotherapies for older adults include cognitive-behavioral therapy, problem solving therapy, and interpersonal therapy.

This article was originally posted on 4/30/2014 and has since been updated.

Mood disorders in older adults are neither inevitable nor particularly resistant to treatment. With attention to the special needs of older patients during evaluation, treatment, and follow up, clinicians can help many patients derive greater enjoyment from their later years.

Update on Mood Disorders in Later Life

“When am I going home?”
“We’re just trying to arrange the transportation.”

“When is my husband going to visit?”
“He’s away on business for a few days.”

“Why can’t I go over there?”
“Because you will fall into a bottomless black pit.”

[[{"type":"media","view_mode":"media_crop","fid":"23938","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_6095069651","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2003","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":"width: 150px; height: 186px; float: right;","title":" ","typeof":"foaf:Image"}}]]Asked by a reader of 

 about the ethics of placing black floor mats in front of exits to deter demented nursing home residents from dangerous wandering, ethicist Chuck Klosterman

 acknowledged that this behavioral intervention is based on deception. On balance, however, he expressed support for a maneuver that might be preferable to more restrictive alternatives, such as chemical or physical restraints. From an ethical standpoint, he considered the mats a way of maximizing independence. He saw no “downside that isn’t purely theoretical.” As clinicians who work with geriatric patients, we’d like to explore the possible downside, even though it may be only theoretical.

Therapeutic lies, or fiblets, are often used to reduce stress and manage the anxieties and disruptive behaviors of demented inpatients, long-term–care residents, or the elderly who are cared for at home, who are not reassured by simple distraction or redirection. When an inpatient or long-term–care resident tries to leave a facility, sometimes with the intent of returning to a home that no longer exists, a fiblet can reduce suffering and offer comfort. An agitated widow seeking her deceased husband high and low in a nursing home may feel much less distress if told that staff will help her look for her husband later but in the meantime she is needed to help set the table for dinner. When “later” arrives, the urgency that drove the woman’s search may have waned considerably. The first two interactions at the start of this article are accepted commonplace, anxiety-reducing fiblets. The third, a verbal interpretation of the visual deception created by a black mat, is a threat rather than a distraction.

Demented patients’ avoidance of dark mats, tiles, or even lines on the floor has long been observed-and sometimes exploited clinically-although we could not locate any studies of the effectiveness and safety of this maneuver. Patients avoid the dark mat because they visually misinterpret the blackness as a drop-off, the socalled visual cliff. Experimental observations of behaviors associated with the visual cliff in infants and in animals shed light on how we might understand the experience of a demented person faced with an unexpected chasm where floor had been expected.

At 5 months of age, infants placed near a visual cliff explore it more or less boldly, but by 9 months a fear reaction is seen.

 The heart rate acceleration associated with this experience may represent fear, although alternative explanations have been proposed. Unambiguous fear reactions have been documented in animals subjected to this experience. Kittens and goats placed atop the deep side of a visual cliff displayed freezing and limb tensing.3 Rhesus monkeys placed on the deep side of the cliff showed crouching, distress vocalizations, self-clasping, and rocking behavior.

Cognitively impaired older adults are not infants or animals, of course, but in some respects their cognitive functions have retrogressed to a stage in which analytic thinking is more limited and catastrophic reactions are more likely than with cognitively intact adults. That persons with dementia might react fearfully to a visual cliff should not surprise us, when we think about the subjective experience of a disoriented person who may also have gait and balance problems and difficulty with visual contrast and interpretation. Many of our cognitively impaired patients also have had terrifying experiences with previous falls. Phobic anxiety, with or without insight, may remain as an emotional response.

In some long-term–care facilities, the concealment of doors by curtains or pictures has reduced exit-seeking behavior. Other doors, visible to patients, can lead to a garden or circular path suitable for walking. A dark mat blocking an exit, however, differs from concealment of an exit or from the technique of redirection with an arrow or a “Do Not Enter” sign on the door. The mat is a visual deception that, we might imagine, could evoke fear in a cognitively impaired person. In principle, though more gently, an apparent pit in front of a door serves the same purpose that we might have achieved by posting a holographic image of a charging rhinoceros on a door’s center panel. Why do we avoid using the ostensibly harmless rhino?

One of my colleagues, a dementia unit nurse director whose office sports a dark blue carpet, has observed the timidity and apprehension with which patients step into her room. An unsteady gait could be further destabilized in such a situation. Less likely but more frighteningly, what might happen to a demented person whose exit has been blocked by a dark floor covering in the event of a fire? Would he or she balk at taking the apparent risk required in order to exit safely?

Lies that reduce suffering and stress in patients unable to fully appreciate the cause of distress can be beneficial. Clinicians sanction their use in dementia care and see them as a manifestation of the ethical imperatives of beneficence and non-malfeasance.

 Whether the use of dark mats is a benign alternative of this sort or whether it might inadvertently invoke a fear reaction can easily be tested. Until such testing provides evidence of safety and effectiveness, the use of these mats for behavioral control should be regarded as an intervention of unproven acceptability.

Dr Ellison is Director of the Geriatric Psychiatry Program at McLean Hospital in Belmont, Mass. Dr Hsu is a Clinical Fellow in the Partners Geriatric Psychiatry Fellowship Program in Boston. They report no conflicts of interest concerning the subject matter of this article.

 Schwartz AN, Campos JJ, Baisel EJ Jr. The visual cliff: cardiac and behavioral responses on the deep and shallow sides at five and nine months of age. 

 Gibson EJ, Walk RD. The “visual cliff.” 

 Rosenblum LA, Cross HA. Performance of neo-natal monkeys in the visual cliff-situation. 

Placing black floor mats in front of exits to deter demented nursing home residents from dangerous wandering may pose ethical questions.

Author | James M. Ellison, MD, MPH

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