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 is identified as an individual’s positive adaptation to life tasks under stressful and adverse social situations, or 

 that mediates rates of recovery after disruptions.

 capacity related to risk factors (eg, stressful life events such as disease, loss of social support, financial hardship).

 can be influenced by the interaction of internal factors (eg, cognitive capacity, personality, physical health) and external resources (eg, social status, financial stability).

 These can be leveraged—along with biological, psychological, social, and environmental protective and promotive factors—to shift an individual along the path from 

 to adaptation, recovery, wellness, and even growth.

 as the ability to recover from disruptions, in contrast to either preventing disruptions or allowing them to be deterministic.

 This definition is consistent with the National Academies of Science (NAS) definition of resilience in the face of 

 a framework that can be applied to resilience for aging adults with applications to psychiatry.

 The critical functions for aging adults in a resilience analysis might include the ability to live independently, or to engage meaningfully in certain activities. In a psychiatric context, these 

 can be defined by both patients and clinicians, rather than only by researchers who may not fully capture what individuals deem important.

 For psychiatric health in older adults, resilience includes acceptance that disruptions will arise over time and produce negative impacts, as well as that the effects of adversity do not have to be permanent or deterministic of future life experiences.

Resilience, as envisioned by the NAS, is composed of 4 separate phases: preparing for a disruption, absorbing a disruption by decreasing certain critical functions (such as rationing food, water, energy, and communication during a disaster), recovery, and finally, if possible, adaptation to improve critical functions. For older adults, these phases occur within an expected decline due to the normal aging process, and resilience theory aims at recovery that fits a patient’s specific aging trajectory. A patient’s decline can be accelerated by disruptions such as the death of a partner, serious accident, or a pandemic.

Among aging individuals, mental health and illness adversity may be long-term chronic, episodic, or acute, and it may require consideration of the life course. For instance, some individuals struggle with depression or bipolar disorder over many years, whereas others may face life crises, such as dementia or suicidal ideation, that arise during later life. Additionally, we can identify 2 contrasting generic resilience and aging trajectories: (1) declines in physiological and psychological resilience due to normal aging; and (2) increases in resilience due to social learning and successful coping strategies. The unique contexts of aging are incorporated into the 

The resilience matrix, originally conceived by 

 and based on system capabilities from Alberts and Hays,

 can be applied to an individual (in conjunction with a clinician) to help develop their psychiatric resilience. The 

 emphasizes 4 domains of critical functions that can help a patient identify and articulate aspirations and interventions within a resilience context (

 In the case of psychiatric evaluation, the domains also could be characterized in 4 ways (

To apply these components of psychiatric resilience and aging, the clinician will need to work with each individual patient to determine the critical function(s) most important for their recovery. Such critical components might include identity and self-image development to enhance meaning in life, relationships with family members, and the ability and desire to live independently. Clinicians can structure resilience-oriented treatment using the aforementioned matrix to prioritize critical functions before or during disruptions in order to manage the absorption, recovery, and adaption process.

For clinicians to operationalize the resilience matrix, they must differentiate 

resilience-by-design and resilience-by-intervention

 The former assumes that a system can internally reconfigure to adjust and recover following a disruption, while the latter relies on external resources.

In the case of clinicians, this resilience matrix can help frame the external support (resilience-by-intervention) that a clinician might offer their patients. In addition to supporting patients after disruptions, the resilience matrix framework can provide avenues for patients to build internal resilience (resilience-by-design) for the future, or to mobilize existing internal resilience. A clinician focused on a particular patient can tailor resilience strategies that capitalize on the patient’s unique strengths and circumstances, which for older adults, compared with young individuals, include considerable experiential contexts and learning. Similar to designing resilient systems in engineering, psychiatrists can develop strategies to enhance individuals’ mental health. Ensuring overall mental health through the use of relevant medications and treatments approximates resilience-by-intervention in broader governance (like stockpiling resources in the case of crises).

Disruptions can take many forms for patients, and a resilience-oriented treatment plan is not predicated on predicting which disruptions will arise. For clinicians, the preparation phase should establish a relationship with the patient that is characterized by trust. This relationship, and other preparation areas that can be identified in collaboration with the patient, constitute a suite of potential resilience systems that can be leveraged and enhanced before a disruption occurs. 

 might include a propensity to set conditions for rest, meditation, relaxation, restoration, and social engagement; development of mastery and self-confidence; practicing positive behaviors such as cultivating and maintaining loving, supportive relationships; and problem-solving ability.

 These constitute a patient’s resilience-by-design: meaning the internally embedded perspectives, learned coping strategies, reflexes, and management strategies that enable patients to face crises productively as they arise.

Building a patient’s resilience-by-design in the preparation phase provides the patient with the appropriate tools or learned perspectives to apply when a disruption occurs, thereby initiating the absorption process. Absorption is the process of encountering the disruption and subsequent loss of critical function, which can vary in magnitude according to resilient resources available. Such resources include collaborative work with the clinician, who can evaluate the components of the resilience matrix and identify elements or skills that may need clinical direction. The clinician can help the patient identify when the switch is made from absorption to recovery and guide the patient to the tools best suited for each stage. These resilience-by-interventions rely on the clinician’s understanding of the patient’s needs and goals, and existing foundational resources, and the clinician’s ability to supplement any resources that are missing or depleted.

Finally, adaptation asks the patient to use the disruption as an opportunity to reevaluate and potentially change habits or behaviors that were either previously deficient or have become untenable under new circumstances. This phase of resilience invites the patient to reimagine ways to support their critical functions, which should either ensure the return to the patient’s original trajectory or, possibly, their return to an improved trajectory, if they have embraced the opportunity to evaluate and carefully optimize beliefs and behaviors.

This resilience matrix framework can be empowering to older adults. At a population and public health level, the coronavirus pandemic has revealed that older adults may be 

better positioned to cope with stressful situations

, such as social isolation, than their younger counterparts.

 The reasons for this are numerous, and they likely include the confluence of more resources, previous learned experiences, and fewer responsibilities. Regardless of the reasons, the results of these studies provide a counterpoint to the idea that elderly patients are frail and helpless.

Ultimately, degradation to death remains an inevitability, but resilience can be part of the tool kit to prolong life and, equally important, to prolong the period when quality of life can be maximized. Some study results suggest that 

 could be comparable in importance with decreasing physical disability in terms of ensuring successful aging.

 A resilience framework, structured by the resilience matrix, can help clinicians support patients prior to and during disruptions to their lives, whether those disruptions are anticipated or not.

is the senior science and technology manager of the US Army Engineer Research and Development Center (ERDC) and an adjunct professor at Carnegie Mellon University. He is responsible for ERDC’s project portfolio in the areas of crises management and resilience. He has published widely on environmental and technology policy, and on risk and resilience analytics, including 25 books and more than 400 peer-reviewed papers and book chapters. 

 works with the Risk and Decision Science team within the US Army Corps Engineer Research and Development Center. Her research topics include the public health response during the 2020-2021 coronavirus pandemic, governance of synthetic biology, stakeholder engagement in water resources management, automated algorithms and artificial intelligence, and resilience applications in fields like gerontology, team behavior, and value chain analysis. Ms Klasa is a PhD candidate in health services organization and policy at the University of Michigan’s School of Public Health, Department of Health Management and Policy. She uses mixed methods to explore the intersection of health policy, risk/resilience, and politics, drawing from cross-disciplinary training in nursing, health care management, public health, economics, and political science. Dr Wister is director of the Gerontology Research Centre and a professor in the Department of Gerontology at Simon Fraser University. His work has been published often on topics such as baby boomer health dynamics; population aging and population health; resilience and aging; social isolation; and environmental adaptation among older adults. His most recent book, Resilience and Aging: Emerging Science and Future Possibilities, co-edited with Theodore D. Cosco, was published in 2021 by Springer.

The concept of resilience in OSH management: a review of approaches

Resilience and Vulnerability: Adaptation in the Context of Childhood Adversities

Resilience, vulnerability and mental health

Procedia – Social and Behavioral Sciences

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The Routledge International Handbook of Psychosocial Resilience

Resilience concepts in psychiatry demonstrated with bipolar disorder

6. Laird KT, Krause B, Funes C, Lavretsky H. 

Psychobiological factors of resilience and depression in late life

7. Ungar M, Theron L, Murphy K, Jefferies P. 

Researching multisystemic resilience: a sample methodology

Resilience and Aging: Emerging Science and Future Possibilities

9. Galaitsi SE, Keisler JM, Trump BD, Linkov I. 

The need to reconcile concepts that characterize systems facing threats

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Disaster resilience: a national imperative

Environment: Science and Policy for Sustainable Development

Conceptualising and operationalising resilience in older adults

12. Klasa K, Galaitsi S, Wister A, Linkov I. 

System models for resilience in gerontology: application to the COVID-19 pandemic

13. Linkov I, Eisenberg DA, Bates ME, et al. 

Measurable resilience for actionable policy

14. Alberts DS, Hayes RE. Power to the Edge: Command…Control…in the Information Age. Department of Defense Command and Control Research Program; 2003. Accessed May 13, 2021. 

http://edocs.nps.edu/dodpubs/org/CCRP/Alberts_Power.pdf

15. Linkov I, Trump BD, Golan M, Keisler JM. 

Enhancing resilience in post-COVID societies: by design or by intervention?

16. Vance JE. Can we prescribe resilience? Psychiatric Times. 2018;35(5). Accessed May 13, 2021. 

https://www.psychiatrictimes.com/view/can-we-prescribe-resilience

17. Carstensen LL, Shavit YZ, Barnes JT. 

Age advantages in emotional experience persist even under threat from the COVID-19 pandemic

18. Wister AV, Speechley M. Inherent tensions between population aging and health care systems: what might the Canadian health care system look like in twenty years? 

19. Vahia IV, Jeste DV, Reynolds CF 3rd. 

Older adults and the mental health effects of COVID-19

20. Jeste DV, Savla GN, Thompson WK, et al. 

Association between older age and more successful aging: critical role of resilience and depression

What does 'resilience' include for older adults? 

Resilience and Healthy Aging

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.

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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.

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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.

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

Geriatric Psychiatry

Resilience and Healthy Aging

New Approaches to Treating Dementia?

Physician Assessments: Ageist or Necessary?

5 Medical Comorbidities Linked to Depression in Older Patients

The Age of Cannabis Has Arrived: Issues for Older Adults

Difficulties Diagnosing Geriatric Bipolar Disorder

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

Supporting the World’s Aging Population

LGBTQ+ Through the Ages: Stonewall’s Impact

10 Facts About Geriatric Pharmacotherapy