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3 Must-Read Stories in Geriatric Psychiatry
Mark L. Fuerst
A research roundup about long-term prescribing guidelines, “psychogenic death,” and implications for patients with depression and pain.
The highlights of three new studies in geriatric psychiatry indicate that one-quarter of older adults prescribed benzodiazepines use them long term; “psychogenic death” is a pathology of a normal, passive coping response; and older adults with depression often feel significant arthritis pain.
Despite treatment guidelines that recommend short-term prescribing of benzodiazepines for older adults, one-quarter of these patients go on to risky long-term use. A study evaluated the transition to long-term benzodiazepine use among 576 older adults, mean age 78.4 years, by a non-psychiatric clinician from 2008 to 2016. One year after the initial prescription, 152 (26.4%) of patients met the definition for long-term use. White patients were 4 times more likely to have gone on to long-term use, those whose initial prescriptions were written for the largest amounts were also more likely to become long-term benzodiazepine users.
“This shows that we need to help providers start with the end in mind when prescribing a benzodiazepine, by beginning with a short-duration prescription and engage patients in discussions of when to reevaluate their symptoms and begin tapering the patient off. We also need to educate providers about effective non-pharmaceutical treatment alternatives, such as cognitive behavioral therapy, for these patients,” said lead author Lauren Gerlach, DO, MSc, a geriatric psychiatrist at the University of Michigan.
Gerlach LB, Maust DT, Leong SH, et al. Factors Associated With Long-term Benzodiazepine Use Among Older Adults. JAMA Intern Med. 2018 Sep 10 [Epub ahead of print].
“Psychogenic death” could stem from a change in a frontal-subcortical circuit of the brain governing how a person maintains goal-directed behavior. Psychogenic trauma, termed “give-up-itis” by Dr John Leach in a recent article, progresses from an initial withdrawal response through a spectrum that includes apathy, conditions comparable to aboulia and psychic akinesia before concluding in psychogenic death. The progressive demotivation and executive dysfunction observed have parallels suggesting frontal-subcortical dysfunction consequent upon impairment of the prefrontal cortex-basal ganglia system, particularly the dorsolateral prefrontal circuit and the anterior cingulate circuit. In general, traumatic shock causes neurochemical environments to disequilibrate.
“Psychogenic death is real. It isn’t suicide, it isn’t linked to depression, but the act of giving up on life and dying usually within days, is a very real condition often linked to severe trauma. Severe trauma might trigger some people’s anterior cingulate circuit to malfunction. Motivation is essential for coping with life and if that fails, apathy is almost inevitable,” said author Dr John Leach, a senior research fellow at the University of Portsmouth in Portsmouth, United Kingdom.
Leach J. 'Give-up-itis' revisited: Neuropathology of extremis. Med Hypotheses. 2018;120:14-21.
Older adults who are depressed show a high prevalence of arthritis pain, suggesting that depression and arthritis should be considered as co-occurring physical and psychosocial conditions. An analysis included 2483 women and 2309 men, mean age 64.5 years, who had participated in the National Health and Nutrition Examination Survey between 2011 and 2014. Nearly half (2094 participants) said they had a doctor’s diagnosis of arthritis. The prevalence of arthritis increased with the severity of depression. Prevalence was 55% in minor depression, 62.9% in moderate depression, and 67.8% in severe depression. A significant association was found between all forms of depression.
“Arthritis is commonly reported in participants with varying degrees of depression. This study highlights the importance of screening for and treating arthritisârelated pain in older adults with depressive symptoms, and the need for future geriatric psychiatry research on developing integrated biopsychosocial interventions for these common conditions,” said the researchers, led by Jessica M. Brooks, PhD, of the department of psychiatry at Dartmouth College. “It may be critical for mental health care providers to provide regular arthritis-related pain assessments and evidenceâbased treatments for coâoccurring arthritis in older adults with or at risk for depression.”
Brooks JM, Titus AJ, Polenick CA, et al. Prevalence rates of arthritis among US older adults with varying degrees of depression: Findings from the 2011 to 2014 National Health and Nutrition Examination Survey. Int J Geriatr Psychiatry. 2018 Sep 19 [Epub ahead of print].
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