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The pandemic has disproportionately affected older adults. Elderly individuals with dementia and other mental health disorders are especially vulnerable, both to the virus and to the negative effects of lockdowns and social isolation. Under these conditions, their mental health can easily deteriorate.

In this Mental Health Minute, Rajesh R. Tampi, MD, MS, DFAPA previews an upcoming panel at the 

American Psychiatric Association annual meeting

: “Caring for Older Adults With Mental Health Disorders and Dementia: American Association for Geriatric Psychiatry’s Response to the Pandemic.” The panel will discuss both caring for older patients with mental health disorders and how the American Association for Geriatric Psychiatry has responded to the pandemic through its education, research, advocacy, and clinical missions. 

is professor and chairman, Department of Psychiatry & Behavioral Sciences, Cleveland Clinic Akron General, Akron, Ohio, and is the section chief for geriatric psychiatry, Cleveland Clinic, Cleveland, Ohio.

How have you cared for older patients during the pandemic? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

The  pandemic has made caring for geriatric patients more difficult, but a panel at the American Psychiatric Association Annual Meeting discusses the latest best practices.

New Approaches to Treating Dementia?

Should older physicians be required to undergo occasional screening and assessment if they want to keep practicing into their 70s? Susan Lehmann, MD, associate professor of Psychiatry and Behavioral Sciences at Johns Hopkins Medicine, proposed this question at an American Association of Geriatric Psychiatry Annual Meeting panel on aging. The online annual meeting was held March 15 to 19.

“I think age testing is going to increase in coming years,” Lehmann told her audience. The question, she continued, will be “are these programs fair to practitioners? [Or] are they examples of age discrimination?”

“In many ways,” she explained, “these are not really new concerns at all.” According to Lehmann, Sir William Osler, MD, CM, a founder of modern American medicine, told the Johns Hopkins University medical faculty that physicians should retire at age 60. He reportedly said, “We should miss the energies of some young-old men, but on the whole be of greater service to the sexagenarii themselves.”

The issue is more pressing now ever, because physicians population is aging. In 2010, 16.3% licensed physicians were aged 60 to 69, and 8.9% were aged 70 years or older. By 2016, those numbers had risen. 19.3% were aged 60 to 69, and 10.0% were 

Cognitive decline is part of aging, and Lehmann cited several troubling studies on its clinical consequences. Older physicians were found to have less factual knowledge, worse adherence to standards of care, and their patients have 

 In addition, she said older physicians are less likely to 

 and patients with older physicians had higher mortality rates than patients with 

Even more troubling, older physicians may not recognize their own impairment, Lehmann added. They may lack insight into their conditions, or they may want to minimize or deny their impairments. The stigma surrounding age-based decline may prevent them from asking for help, and colleagues may keep quiet out of fear of offending them.

Medical organizations have already broached the issue of age-based assessments, Lehmann told attendees. In 2015, the American Medical Association’s (AMA) Council on Medical Education recommended that the AMA develop voluntary screening procedures for physicians aged 70 years or older. But its proposed “guiding principles” were voted down in 2018 by a narrow margin of 282 to 222. Those who objected to the AMA’s guidelines cited ageism as a major concern. “I think it’s a really slippery slope to start doing that to any group of people, especially our colleagues,”

Similarly, Lehmann reported that the Society of Surgical Chairs (SSC) has begun developing recommendations, including mandatory cognitive and motor tests 

The SSC has recognized the need to create modified roles for senior surgeons as well as the importance of discussing career transition and retirement earlier in surgeons’ careers.

Lehmann seconded this sentiment, noting “the transition from an active and productive work life to retirement is a difficult one.” She shared the story of a colleague who lamented that after retirement he had gone from “Who’s Who” to “Who’s he”? By creating new roles for older physicians, Lehmann hopes medicine can ease the tension between ageism and the need to maintain high clinical standards.

1. Young A, Chaudhry HJ, Pei X, et al. A census of actively licensed physicians in the United States, 2016. 

2. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005 Feb 15;142(4):260-73.

3. Hawkins RE, Welcher CM, Elliott VS, Pieters RS, Puscas L, Pick PH. Ensuring competent care by senior physicians. 

4. Tsugawa Y, Newhouse JP, Zaslavsky AM, et al. Physician age and outcomes in elderly patients in hospital in the US: observational study. 

5. Firth S. How can competency be measured in older docs? AMAcouncil guidance for testing fails to win over delegates. 

. November, 14, 2018. Accessed March 23, 2021. 

https://www.medpagetoday.com/meetingcoverage/ama/76334

6. Rosengart TK, Doherty G, Higgins R, et al. Transition planning for the senior surgeon: guidance and recommendations from the society of surgical chairs. 

What do you think? Should there be mandatory testing or retirement for clinicians? 

Should clinicians of a certain be assessed to ensure competence, or does that just foster stigma and stereotypes?

Physician Assessments: Ageist or Necessary? 

General medical illness can contribute to affective disorders in elderly patients. Treating the medical illness is an integral part in treating depression in these patients.


5 Medical Comorbidities Linked to Depression in Older Patients

A new question must be added to the list that mental health clinicians ask their older patients while taking a history, regardless of age: “Have you used any cannabis products recently?”

I learned this lesson during a follow-up appointment with an 82-year-old man with Alzheimer disease. He reported some rather abrupt cognitive decline, and I asked him and his wife about recent medical changes without finding any clear precipitant. Finally, his wife sheepishly confessed that their son had sent them a grab bag of cannabis-derived products that the patient was taking. The family was desperate for anything to help his cognitive decline and they had heard that cannabis was a miracle cure for Alzheimer disease and many other conditions. Unfortunately, the patient received no benefit but did experience some mild, noticeable adverse effects. Without my probing, I never would have known. The next patient I asked explicitly about using cannabis products responded in an equally explicit manner: “No I haven’t,” he said, “but can you get me some?” It was clear that the age of cannabis had arrived.

Older individuals with psychiatric disorders are increasingly using cannabis, largely in the form of prescribed medical marijuana and cannabidiol (CBD). This trend has been driven by several factors: reduced stigma, lifted restrictions on possession and sale by most states, and the enormous proliferation of articles and ads that tout supposed benefits of 

 for many conditions that afflict the elderly, including chronic pain, peripheral neuropathy, stress, anxiety, depression, insomnia, headaches, and the adverse effects of chemotherapy.

 As a result, medical marijuana use by individuals 65 or older has increased more than 8-fold in recent years, from less than 0.5% in 2006 to 4.2% in 2018

). In a survey of 345 adults in Colorado, 16% had used medical marijuana since legalization, with half the users being 75 or older.

 CBD has seen a particularly enormous surge in interest and availability after it was exempted from federal regulations in the 2018 US Farm Bill. Since then, it is estimated that 6.4% of adults aged 45 to 55 and 3.7% of those 55 or older have used CBD at least once.

Although the cannabis sativa plant contains hundreds of chemicals known as cannabinoids, the 2 main active chemicals are Δ-٩-tetrahydrocannabinol (THC) and CBD. THC has both psychotropic and euphoric properties and confers the high associated with marijuana, while CBD is noneuphoric because it does not activate the cannabinoid 1 receptor like THC does. The same plants that produce THC also produce CBD. Both THC and CBD come in a variety of forms; they can be smoked, vaped, eaten, ingested as liquids, used as oils, and applied via creams and cosmetics.

The psychotropic effects of both THC and CBD are mainly because of their interaction with endogenous cannabinoid receptors in the brain, as well as activation of a variety of other cannabinoid and noncannabinoid receptors (ie, serotonergic, glutaminergic, µ-opioid, and α1-adrenergic) in the central nervous system and on immunologic cells. Based on their known and theorized properties, marijuana and CBD have been proposed as remedies to modulate symptoms of stress, insomnia, pain, inflammation, and cognitive impairment, particularly in older individuals. As a result, there are many unsubstantiated claims that THC and/or CBD can treat Alzheimer disease, Parkinson disease, schizophrenia, and anxiety and mood disorders.

Several small case series have suggested a tentative basis for some of these claims. For example, a study looked at the use of an oral spray containing THC and CBD for peripheral nerve pain and found that it was well tolerated and showed a trend toward improvement in pain and sleep.

 Medical marijuana use has been associated with some improvement in both movements and neuropsychiatric symptoms in individuals with Parkinson disease.

 One small case series found improvement in behavioral and psychological symptoms of dementia from cannabis oil containing THC.

 A related randomized control trial of 50 individuals with dementia and associated neuropsychiatric symptoms did not see any benefit from THC, but did find it was well tolerated and with no appreciable effect on memory.

 Despite these limited data, agitation associated with dementia is a qualifying condition for medical marijuana in several states.

Gruber and colleagues studied a sample of middle-aged individuals using medical marijuana over 3 months and found improvements in 

 and reductions in depression, insomnia, and impulsivity.

 They also saw a reduction in the use of benzodiazepines and opioids as well as a normalization of brain activation waves to states seen in normal controls. It is not clear, however, if these neurocognitive results were the direct result of the medical marijuana or an indirect benefit of decreases in pain, anxiety, and 

Although there are many other in vivo, in vitro, and animal studies of THC and CBD, it is clear that evidence is limited, and there are few randomized controlled trials to support most of their theorized clinical benefits. In addition, these studies are based on a variety of cannabis products from multiple sources and with variable contents.

 The 2 exceptions include a Food and Drug Administration (FDA)-approved form of synthetic THC known as dronabinol, which is used for treating appetite and weight loss resulting from AIDS as well as nausea and vomiting from chemotherapy, and a medication containing CBD for the treatment of 2 rare childhood seizure disorders. Dronabinol has also been studied in Alzheimer disease to treat anorexia and agitation and was found to be well tolerated with variable efficacy for both conditions.

, a CBD-THC combination, has been approved for the treatment of muscle spasms associated with multiple sclerosis.

The use of medical marijuana and CBD in older adults must be approached with caution because there are several potential adverse effects. It has been well established that heavy marijuana use in both young and middle-aged adults can cause mild functional and structural brain impairments affecting attention, 

, motor coordination, verbal memory, and executive function.

 Although these effects may be more variable with lighter use in older adults, they may be amplified by preexisting brain impairment as well as by underlying pulmonary and cardiovascular conditions, especially when medical marijuana is smoked or vaped.

 One review of 184 older patients (median age, 82) who were on medical marijuana for 6 months found that approximately 80% reported some benefit for the treated symptoms, but one-third reported adverse effects, including dizziness (12%) and sleepiness and fatigue (11.2%).

 Other reported adverse effects from a national epidemiologic survey included changes in mood and cognition, psychosis, increased heart rate and blood pressure, urinary retention, and blurred vision.

 In addition, THC has been associated with impaired driving in young adults, which could also be a problem in older drivers who may be impaired at baseline.

 of CBD use found that it is generally well tolerated with few adverse effects, the most common one being diarrhea.

 Other adverse effects associated with CBD include nausea, drowsiness, fatigue, dry mouth, and mood changes. Keep in mind that CBD is an inhibitor of several cytochrome P450 enzymes, including CYP1A2, CYP2B6, CYP2C9, CYP2D6, and CYP3A4. CBD can lead to drug-drug interactions with several commonly used medication groups in older patients, including blood thinners, antibiotics, anticonvulsants, antidepressants, and antipsychotics.

What To Ask Patients, and What To Tell Them

In this new era of medical marijuana and CBD, there are several important takeaways for clinicians working with older patients. Do not assume that because a patient is elderly and has physical or cognitive limitations that they do not fit the profile of a cannabis user. To the contrary: Every older patient along with their caregivers should be queried as to their use of cannabis, whether recreationally, from mail order or friends and family, or through a prescription. To this end, every clinical history should include questions about the use of cannabis products, including the stated reasons for use, the type of marijuana or CBD being used, and observed benefits and adverse effects. Concomitant medical conditions must be reviewed for potential vulnerabilities, such as an individual with hypertension using a product that increases blood pressure or heart rate, or an individual with chronic obstructive pulmonary disease using vaping oils. Potential 

 also need to be considered, with a focus on the categories of medications discussed in the article.

Patients and their caregivers need to understand that nearly all benefit claims are largely unsubstantiated, as they lack a rigorous scientific basis. Slick articles and ads generally exaggerate potential benefits, or they refer to in vitro or animal studies and anecdotal reports, making them sound as if they constitute direct evidence of clinical effects. They also need to understand the differences between THC and CBD, along with the fact that production is largely unregulated, so products can have many different ingredients and properties. Several studies have found wide discrepancies between labels for cannabis products and their actual contents, especially when it comes to the amount of THC or CBD.

 Thus, many products that claim only to have CBD actually have varying degrees of THC present. This lack of consistency often accounts for both inconsistent clinical effects as well as adverse effect issues, and these factors lead many older adults to discontinue use of cannabis products.

Finally, keep in mind that older patients with preexisting 

 such as in Alzheimer disease might be particularly vulnerable to adverse effects such as drowsiness, dizziness, fatigue, and mood changes, which in turn can account for significant and unpredictable fluctuations in cognition and behavior. Such unpredictability (in the amount of drug being ingested over time and the ensuing effects on brain and body) is exactly the sort of variability that can be hazardous in the older patient. Compounding these risks is the fact that many individuals will use products such as CBD oil without the knowledge and supervision of a knowledgeable clinician.

The bottom line is that more rigorous scientific study using randomized controlled trials is needed to substantiate the proposed benefits of cannabis and more fully understand the range and impact of common adverse effects.

is the chief medical officer at MIND Institute at Miami Jewish Health.

1. Gruber SA, Sagar KA, Dahlgren MK, et al. 

Splendor in the grass? A pilot study assessing the impact of medical marijuana on executive function

2. Grinspoon P. Older adults and medical marijuana: reduced stigma and increased use. 

Updated April 6, 2020. Accessed February 1, 2020. 

https://www.health.harvard.edu/blog/older-adults-and-medical-marijuana-reduced-stigma-and-increased-use-2-2020040119321

3. Han BH, Palamar JJ. Trends in cannabis use among older adults in the United States, 2015-2018. 

4. Reynolds IR, Fixen DR, Parnes BL, et al. Characteristics and patterns of marijuana use in community-dwelling older adults.

5. Oberbarnscheidt T, Miller NS. The impact of cannabidiol on psychiatric and medical conditions. 

6. Russo EB. Cannabis therapeutics and the future of neurology. 

7. Serpell M, Ratcliffe S, Hovorka J, et al. A double-blind, randomized, placebo-controlled, parallel group study of THC/CBD spray in peripheral neuropathic pain treatment. 

8. 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. 

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

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

11. Gruber SA, Sagar KA, Dahlgren MK, et al. The grass might be greener: medical marijuana patients exhibit altered brain activity and improved executive function after 3 months of treatment. 

12. Britch SC, Babalonis S, Walsh SL. Cannabidiol: pharmacology and therapeutic targets. 

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

14. Crean RD, Crane NA, Mason BJ. An evidence-based review of acute and long-term effects of cannabis use on executive cognitive functions. 

15. Nader DA, Sanchez ZM. Effects of regular cannabis use on neurocognition, brain structure, and function: a systematic review of findings in adults. 

16. DeFilippis EM, Bajaj NS, Singh A, et al. Marijuana use in patients with cardiovascular disease: JACC review topic of the week. 

17. Abuhasira R, Ron A, Sikorin I, Novack V. Medical cannabis for older patients-treatment protocol and initial results. 

18. Benitez A, Lauzon S, Nietert PJ, et al. Self-reported cognition and marijuana use in older adults: Results from the national epidemiologic survey on alcohol and related conditions-III. 

19. Arkell TR, Vinckenbosch F, Kevin RC, et al. Effect of cannabidiol and Δ9-tetrahydrocannabinol on driving performance: a randomized clinical trial. 

20. Chesney E, Oliver D, Green A, et al. 

Adverse effects of cannabidiol: a systematic review and meta-analysis of randomized clinical trials

Cannabis use has prompted symptoms such as dizziness, sleepiness, and fatigue in older patients. Are there any benevolent effects?

The Age of Cannabis Has Arrived: Issues for Older Adults

American Association for Geriatric Psychiatry

 virtual annual meeting, “Management of Geriatric Bipolar Disorder: A Case Series and Review of Current Evidence Based Treatment Guidelines,” Rana Jawish, MD, and colleague David Atkison, MD, noted the challenges of treating bipolar disorder (BD) in older patients and future possibilities for treatment.

“Compared to younger patients, older patients with bipolar disorder spend less time manic and more time depressed,” said Jawish.

A huge concern is misdiagnosis: 40% to 60% of patients with BD are misdiagnosed, often with major depressive disorder or borderline personality disorder. According to 

 Jawish reviewed, 28% of geriatric patients with a neurodegenerative disease received a psychiatric diagnosis, commonly depression.

It may be difficult to differentiate BD from depression in geriatric patients. Jawish stated these indicators might signify BD in patients with depression: family history of BD; early onset, like in early 20s; seasonality; numerous previous episodes; history of antidepressant-induced episodes, such as mania or hypomania; history of treatment-resistant depression; previous inpatient hospitalizations; and previous suicide attempts.

Also surprising, there is only 1 randomized controlled 

 in geriatric BD comparing lithium and divalproex for the treatment of mania and hypomania.

 Post-hoc analyses of mixed age trials suggest that medications effective in a younger cohort are effective for geriatric patients as well.

“Only one trial,” Jawish emphasized. “What works for everyone will work for the geriatric population with bipolar too.”

Another issue is late diagnosis. “Due to stigma about seeking mental health treatment, there could be a delay between a patient experiencing significant, distressing symptoms and presenting to care for a diagnosis,” said Atkinson.

With late diagnoses, many patients do not receive a formal diagnosis of BD until their 50s or 60s, an age range where the onset of neurodegenerative diseases is more common. BD might then be mistaken for frontal temporal dementia.

“This is an area that needs more studies,” said Atkinson.

Overall, in their synthesis of existing guidelines, geriatric principles, and case series observations, Jawish and Atkinson agreed that medications intended for general population use were also effective for geriatric populations.

1. Woolley JD, Khan BK, Murthy NK, et al. 

The diagnostic challenge of psychiatric symptoms in neurodegenerative disease: rates of and risk factors for prior psychiatric diagnosis in patients with early neurodegenerative disease

2. Young RC, Mulsant BH, Sajatovic M, et al. 

Geri-BD: A Randomized Double-Blind Controlled Trial of Lithium and Divalproex in the Treatment of Mania in Older Patients with Bipolar Disorder

Misdiagnosis and late diagnosis may be preventing older patients with bipolar disorder from getting proper care. 

Difficulties Diagnosing Geriatric Bipolar Disorder

“The problem of treatment-resistant depression in later life [TRD-LL] is increasingly recognized but remains poorly characterized,” Randall Espinoza, MD, MPH, told the audience at the American Association of Geriatric Psychiatry Annual Meeting. According to Espinoza, estimates of its prevalence run from 6% up to 40% in geriatric patients with depression, depending on how treatment-resistant depression (TRD) is defined.

At a session titled “Beyond ECT – Neuromodulation and Interventional Psychiatry for Treatment Resistant Depression in Later Life,” Espinoza and his colleagues Aaron Kaufman, MD, and Ali Ashghar-Ali, MD, discussed the challenges of identifying and treating TRD in older patients, including the latest results from clinical research.

TRD is associated with increases in morbidity and mortality, including greater levels of pain and suicide. It leads to higher health care costs, lower quality of life, and reduced workplace productivity. TRD can be chronic and recurrent: 20% to 35% of patients have continuous depression for more than 1 year, and 25% to 40% of patients experience a recurrence within 2 years, and 60% have a recurrence after 

Despite the prevalence of TRD, simply identifying it may be a challenge, Espinoza noted. He broke it down into 3 possible categories: 1) nonresponse to treatment and a high degree of functional impairment, 2) treatment resistant depression, which shows minimal to partial response to treatment, and 3) treatment refractory depression, which shows no response to treatment and 

 He noted that TRD may have a different epidemiology in older adult populations and may arise due to trauma, social adversity, and losses. Furthermore, treatment is complicated by brain aging and the fact that most clinical trials deliberately exclude older adults, which makes pharmacological options uncertain.

Espinoza also warned that TRD in older patients may be accompanied by significant comorbidities, including anxiety disorders, substance abuse, and cognitive and personality disorders.

In terms of treatment, Espinoza suggested that clinicians consider moving from the framing of “treatment-resistant” to a “difficult to treat” depression (DTD) model.

 The TRD model treats depression as a chronic rather than acute illness. To the biological emphasis of the TRD model, it would add a neurobiopsychosocial focus. Rather than judging progress according to cure or remission alone, it also emphasizes capability, recovery, and symptom management.

As Espinoza explained, “DTD captures not only acute phase treatment but also encourages a shift of focus to long-term treatment with the goals of improving overall function, quality of life, and optimization of treatment when full remission is no longer viable.”

Turning to more specific treatment options, Ashghar-Ali noted that “ECT remains [the] gold standard for neuromodulation intervention in older adults,” and noted clinicians have other options as well. He reviewed 2 studies of repetitive transcranial magnetic stimulation (RTMS)/DEEP TMS, which 

Ashghar-Ali also discussed ketamine. Although it is not approved by the US Federal Drug Administration (FDA) for treating TRD, ketamine has shown 

 Esketamine, however, is FDA approved for treating depression. Ashghar-Ali noted that esketamine plus an antidepressant demonstrated a statistically significant treatment effects in patients aged 65 to 74 years (although not for patients aged more than 75 years).

 He concluded that esketamine might play a helpful role in treating TRD in patients during the 64 to 75 age band.

Kaufman considered the possible role of lithium augmentation. He discussed 1 study in which lithium augmentation had a high remission rate (63.6%) among elderly patients with treatment resistant depression, and another in which geriatric patients responded significantly better to lithium augmentation than 

 He noted that some evidence also existed for augmenting with atypical antipsychotics and stimulants.

Psychotherapy is also an option. Kaufman presented from a meta-analysis of psychotherapy in later-life depression that found large effects, when compared with 

 The evidence is strongest for problem-solving therapy, interpersonal psychotherapy, and cognitive behavioral therapy. Exercise, meditation, acupuncture, and Tai Chi had also been shown to help in a number of cases.

During the Question and Answer period, both Kaufman and Ashghar-Ali spoke to why treatments beyond ETC may be necessary.

“These are of course really challenging cases,” Kaufman said. Some patients may have trouble recalling the details of her medication and adherence history, and many do not trust ECT. “We’ve all had patients decline ETC and want to pursue alternatives,” Kaufman said further.

Alternately, said Ashghar-Ali, “a lot of people come to ECT with the assumption that it’s the only option left.”

But, Ashghar-Ali and Kaufman concluded, ECT is in fact only 1 option, and there are many others for clinicians and patients.

1. Benson C, Szukis H, Sheehan JJ, et al. An evaluation of the clinical and economic burden among older adult Medicare-covered beneficiaries with treatment-resistant depression. 

2. Pilon D, Joshi K, Sheehan JJ, et al. Burden of treatment-resistant depression in Medicare: a retrospective claims database analysis. 

3. Rush AJ, Aaronson ST, Demyttenaere K. Difficult-to-treat depression: a clinical and research roadmap for when remission is elusive. 

4. Lisanby SH, Husain MM, Rosenquist PB, et al. Daily left prefrontal repetitive transcranial magnetic stimulation in the acute treatment of major depression: clinical predictors of outcome in a multisite, randomized controlled clinical trial. 

5. Conelea CA, Philip NS, Yip AG, et al. Transcranial magnetic stimulation for treatment-resistant depression: naturalistic treatment outcomes for younger versus older patients. 

6. Murrough JW, Perez AM, Pillemer S, et al. Rapid and longer-term antidepressant effects of repeated ketamine infusions in treatment-resistant major depression. 

7. Ochs-Ross R, Daly EJ, Zhang Y, et al. Efficacy and safety of esketamine nasal spray plus an oral antidepressant in elderly patients with treatment-resistant depression-TRANSFORM-3. 

8. Kok RM, Nolen WA, Heeren TJ. Outcome of late-life depression after 3 years of sequential treatment. 

9. Buspavanich P, Behr J, Stamm T, et al. Treatment response of lithium augmentation in geriatric compared to non-geriatric patients with treatment-resistant depression. 

10. Huang AX, Delucchi K, Dunn LB, Nelson JC. A systematic review and meta-analysis of psychotherapy for late-life depression. 

If patients decline electroconvulsive therapy, psychiatrists still have many good options. 

How to Identify and Tackle Treatment-Resistant Depression in Geriatric Patients

According to Maria I. Lapid, MD, there are shockingly only 4 geriatric psychiatrists in all of the Philippines, a country with a population of over 110 million. Lapid is a professor of psychiatry at the Mayo Clinic Department of Psychiatry and Psychology.

In the American Association for Geriatric Psychiatry 2021 Annual Meeting presentation, “International Psychogeriatric Association (IPA): Topics in Aging and Mental Health,” Lapid and her colleagues shared a number of ways geriatric mental health care is lacking and how it can—and should—be improved.

“One of the goals of the IPA is to provide for geriatric communities everywhere,” Lapid said. “The pandemic has provided a wonderful opportunity to develop and improve online courses for physicians providing geriatric care.”

She stressed the need for education, teaching communities how to care for mental health of the geriatric population. Lapid and other IPA members have worked to create educational resources to ensure there is a sustainable and appropriately trained health workforce to care for aging populations.

Another presenter, William E. Reichman, MD, discussed the importance of adequate long-term care facilities, and the cruciality of person-centric care.

“It should be less an institution than a home with health care support,” said Reichman, president and CEO of Baycrest, professor at the University of Toronto, and president of the IPA.

Reichman shared a new vision for long-term care, where there is a range of facility choices.

One of these potential choices is the Dutch Apartment for Life (AFL), or age-proof dwelling. In such a facility, inhabitants have autonomy to make choices, share meals and activities in a broad community, utilize onsite daycare, and take advantage of home care service delivery. This might be a viable option for patients with early- to mid-level dementia, according to Reichman.

The typical North American facilities, the Continuing Care Retirement Communities, are largely made for high income level patients. They provide a closed country club type of community and have stratified levels of care. AFLs, by contrast, provide supportive housing for all income levels, are open to the surrounding community, and maintain an “aging in place” style. Reichman believes this style will be the preferred aging facility for baby boomers.

Technology will also be crucial to aging in place. Smart home safety devices, such as motion-detection lighting, smart mattresses, floor sensors, movement tracking devices, smart appliances, and the like, will assist patients who wish to maintain independence.

To learn more about caring for geriatric patients, the IPA provides 12 hour-long seminars on supporting the world’s aging population, which can be accessed 

The International Psychogeriatric Association shares opportunities to improve worldwide geriatric care.

Supporting the World’s Aging Population 

“Being gay in itself was a crime,” said Hein H. Latt, MD, in a presentation on the Stonewall riot’s impact at the 2021 American Association for Geriatric Psychiatry virtual annual meeting.

In their presentation, “Stonewall Uprising: Impact on Older LGBT Adults,” Latt and colleagues William Smith, MD, and Peter Ureste, MD, broached how history has oppressed and built up the stigma around LGBTQ+ individuals. From policing gay clubs to conversion therapy, time paints a disheartening story of what it was like to be a member of the LGBTQ+ community.

 began in 1969 after police raided the Stonewall Inn, a New York City gay club, and sparked outrage among patrons, enough to cause them to take to the streets. For 6 days, protests and riots broke out outside the club. It was these riots that acted as a catalyst for the gay rights movement.

“Members of the community truly believed they were sick, and had a problem they needed to fix,” Latt said.

Ureste broke the geriatric LGBTQ+ community down into 3 cohorts: 1) the Greatest Generation, born in 1091-1924, or the Old-Old; 2) the Silent Generation, born in 1925-1945, or the Middle-Old; 3) the Pride Generation, born 1946-1964, or the Young-Old. Each of these cohorts was impacted by the sociocultural factors of their formative years, and performs their identity accordingly, as shown by the 

For example, the Young-Old have the highest right of “outness,” or public disclosure of their sexuality, but they also have experienced the highest number of lifetime victimization or discrimination events. Oppositely, the Old-Old have the lowest levels of “outness,” but the lowest rate of discrimination. The Middle-Old, generally, tended to have better mental health.

This cohort breakdown may assist in approaching geriatric LGBTQ+ patients.

“Be mindful about stigma,” Ureste said in the Q+A session post-presentation. “Older LGBTQ+ individuals might be reluctant to share. Always leave the door open, so that when they’re comfortable, they feel invited to do so.”

Smith expressed similar sentiments, even sharing a story about one of his patients who is just now beginning her gender transition in her 60s.

“She’d never been asked about her gender identity before,” Smith said. “Asking everyone about how they feel, no matter how old, is important.”

. Updated June 26, 2020. Accessed March 16, 2021. 

https://www.history.com/topics/gay-rights/the-stonewall-riots

2. National LGBTQ Health and Longevity Center. Wellness with Pride homepage. 

What socio-cultural events impacted the older LGBTQ+ generations, and how do they inform their current mental health status? 

LGBTQ+ Through the Ages: Stonewall’s Impact

It is important to monitor and alter psychotropic medications and dosages in older patients as needed. This slideshow serves as quick reference on the effects of pharmacokinetic and pharmacodynamic changes in the elderly.

10 Facts About Geriatric Pharmacotherapy

The American Psychiatric Association (APA) and the APA Foundation have selected Rajesh R. Tampi, MD, MS, DFAPA, as the recipient of the 2021 

Jack Weinberg Memorial Award in Geriatric Psychiatry

. The award, instituted in 1983, recognizes a psychiatrist who has devoted their career to geriatric psychiatry. The awardee 

 and goes above and beyond in the areas of clinical practice, educational training and mentorship, and important research.

Tampi’s passion—to promote the care of older adults with mental health disorders and to train the next generation of leaders in psychiatry and geriatric psychiatry—certainly fall within these parameters. His clinical interests focus not only on psychiatric disorders in late life but also on legal matters and ethics, neurodegenerative disorders, and integrated 

. He has been a proponent for undergraduate and postgraduate education in psychiatry and geriatric psychiatry.

“I am honored and humbled to receive the award,” Tampi told 

. “It was the support of Cleveland Clinic, the 

, the American Association of Geriatric Psychiatry (

), and the APA that has allowed me the opportunity to pursue my passion for clinical excellence, teaching, mentorship, research, writing, and advocacy,” he added.

When asked what drew Tampi to geriatric psychiatry as a specialty, he said, “It provides compassionate care for vulnerable, older adults with mental health disorders who face so many hardships in their life. In addition, the field of geriatric psychiatry offers the perfect interface between psychiatry, medicine, and neuroscience to practice the science and art of healing.”

Tampi is the chairman, Department of Psychiatry & Behavioral Sciences,

, Akron, Ohio. He is professor of medicine, 

Cleveland Clinic Learner College of Medicine

An award will go to a psychiatrist who exemplifies leadership and goes above and beyond in the areas of clinical practice, educational training and mentorship, and important research

Geriatric Psychiatry