World psychiatric association section of old age psychiatry consensus statement on ethics and capacity in older people with mental disorders

The World Psychiatric Association (WPA) Section of Old Age Psychiatry, since 1997, has developed Consensus Statements relevant to the practice of Old Age Psychiatry. Since 2006 the Section has worked to develop a Consensus Statement on Ethics and Capacity in older people with mental disorders, which was completed in Prague, September 2008, prior to the World Congress in Psychiatry. This Consensus meets one of the goals of the WPA Action Plan 2008-2011, "to promote the highest ethical standards in psychiatric practice and advocate the rights of persons with mental disorders in all regions of the world". This Consensus Statement offers to mental health clinicians caring for older people with mental disorders, caregivers, other health professionals and the general public the setting out of and discourse in ethical principles which can often be complex and challenging, supported by practical guidance in meeting such ethical needs and standards, and to encouraged good clinical practice.

Secrets to psychological success: why older doctors might have lower psychological distress and burnout than younger doctors

BACKGROUND

Doctors have long been exposed to situations that can induce psychological distress. Long hours, little acknowledgement, poor sleep and high-stress work environments all contribute to making doctors prone to psychological distress and burnout, which have been much studied in younger doctors, but less so in older doctors. Little is known about whether there are differences in psychological distress among different age groups of doctors.

METHODS

Doctors (n = 158) were recruited from in and around the St George Hospital, a major teaching hospital in Sydney, Australia. Participants completed a self-report questionnaire, comprising the Maslach Burnout Inventory (MBI), and Kessler 10 Psychological Distress Scale. Demographic details were collected. A subsample (n = 51) completed a semi-structured interview about issues related to burnout. These data were subjected to qualitative analysis.

RESULTS

Older doctors and doctors with more years of experience had significantly lower scores on MBI subscales of Depersonalization and Emotional exhaustion, and K-10 measured psychological distress. Aspects of working conditions such as being in private practice were associated with increased scores on MBI subscales of Personal accomplishment, and lower scores on MBI subscales of Emotional exhaustion and Depersonalization, and K-10 measured psychological distress. Older doctors more frequently worked in private practice. These quantitative findings were supported by the qualitative data that suggested that older doctors perceived that they experienced less psychological distress compared with earlier in their careers, which they attributed to the development of protective defences in their relationship with patients and the liberation afforded by accumulation of experience and changed work conditions.

CONCLUSIONS

Findings from this study suggest that older, more experienced doctors report lower psychological distress and burnout than younger doctors which the older doctors attributed to lessons learned over their years of training and practice. It may be of considerable value to find ways to more efficiently pass on these lessons to younger doctors to aid them in dealing with this challenging profession. By soliciting older doctors to aid in this transfer of knowledge, this approach may also have the added benefit of assisting older doctors in transitioning from an active clinical practice to a role of mentoring the new physician cohort.

Physician don't heal thyself: a descriptive study of impaired older doctors

BACKGROUND

The growing and welcome interest in the issues leading to distress and impairment in younger doctors has not been mirrored by a focus on the similar issues in older doctors which is surprising given the aging medical workforce.

OBJECTIVES

To improve understanding of impairment in older doctors and to facilitate the planning of primary prevention strategies.

METHOD

Consecutive case records of notifications to the Impaired Registrants Program of the New South Wales Medical Board, Australia, of doctors over 60 years from January 2000 to January 2006 (N = 41) were examined. Details of demographics, type of practice, nature of referral, medical morbidity, cognitive examination, psychiatric diagnosis and outcome of assessment were recorded.

RESULTS

Impaired older doctors suffered cognitive impairment (54%), substance abuse (29%) and depression (22%) and 17% had two comorbid psychiatric conditions. Twelve percent had frank dementia. Two work patterns--the "workhorse" and the "dabbler"--were observed, as was a culture of postponed retirement due to a sense of obligation and working "until you drop." Impaired older doctors were found to have higher chronic illness burden compared with community norms. Almost half were the subject of patient complaints or of poor performance within ten years of presentation.

CONCLUSION

To our knowledge there has been no other comprehensive examination of patterns of impairment in older doctors. Older doctors are prone to suffer "the four Ds": dementia, drugs, drink and depression. We need to encourage mature doctors to adapt to age-related changes and illness and validate their right to timely and appropriate retirement.

Investigation of Alzheimer's disease-related pathology in community dwelling older subjects who committed suicide

BACKGROUND

Older people have a higher risk of completed suicide than any other age group worldwide. The contribution of neurodegenerative disease to this risk remains controversial.

AIMS

To investigate prevalence of Alzheimer's disease-related (AD) pathology in older suicide victims.

METHODS

Ratings of AD pathology using Braak and CERAD protocols were compared in 143 community-dwelling suicide victims aged 65 years or more and 59 motor vehicle accident victims autopsied at the request of an Australian Coroner's Court.

RESULTS

There were no significant differences in plaque score or neurofibrillary tangle staging between suicide and control groups. None of the subjects with a history of dementia had neuropathologically confirmed AD.

CONCLUSIONS

Our study is the second and largest investigation of the prevalence of AD neuropathology in the elderly suicide population. Unlike the previous study, we did not find an increased prevalence of AD neuropathology despite a history of dementia in 6.3%, implicating other pathologies such as Lewy Body or Vascular dementia in the aetiology of dementia in elderly suicide victims.

Children of a cohort of depressed patients 25 years later: psychopathology and relationships

BACKGROUND

While many studies have examined cross-sectional or short-term effects of parental depression on children, few have studied such children many years later when they reach adulthood. It was hypothesised that children of patients hospitalised for depression 25 years ago would have more psychological morbidity and relationship difficulties than children of a surgical comparison group.

METHOD

Children (n=94) of depressed patients and a surgical control group (n=31) admitted to a teaching hospital 25 years ago were compared on measures of psychiatric morbidity, personality, marital and family relationships.

RESULTS

Compared with control children, children of depressed patients demonstrated trends for higher rates of non-phobic anxiety and substance disorders, but neither psychological morbidity overall nor affective disorder specifically. Compared with control children, children of depressed patients rated their relationships with fathers who were spouses of female patients more negatively. Having consciously tried to make their own intimate relationships different from that of their parents, children of depressed patients and their partners reported significantly more caring in their relationships compared with control children and their partners.

CONCLUSION

In this study of the effects of parental depression on children 25 years on, adult children of depressed patients demonstrated significant resilience as evidenced by similar rates of overall psychiatric morbidity and quality of intimate relationships to controls. They may be at risk for specific disorders such as anxiety and substance disorder and have problematic relationships with the "well" spouses of depressed patients particularly if the "well" spouse is their father.

Neuropsychological performance and dementia in depressed patients after 25-year follow-up: a controlled study

BACKGROUND

Previous research has yielded conflicting evidence regarding the long-term cognitive outcome of depression. Some studies have found evidence for a higher incidence of subsequent cognitive impairment or dementia, while others have refuted this.

METHOD

Depression, neuropsychological performance, functional ability and clinical variables were assessed in a sample of patients who had been hospitalized for depression 25 years previously.

RESULTS

Data were available on 71 depressed patients (10 of whom were deceased) and 50 surgical controls. No significant differences were found between depressed subjects and controls on any neuropsychological measure. Ten depressed patients but no controls were found to have dementia at follow-up (continuity corrected chi2 = 5.93, P < 0.01). Presence of dementia was predicted by older age at baseline. Vascular dementia was the most common type.

CONCLUSIONS

We conclude that this study did not find evidence that early onset depression is a risk factor for Alzheimer's disease, but that for a small subgroup there appears to be a link with vascular dementia. Several plausible explanations for this link, such as lifestyle factors, require further investigation.

A 25-year longitudinal, comparison study of the outcome of depression

BACKGROUND

There is still a relative paucity of information about the long-term course of depression.

METHODS

Consecutive patients admitted to a teaching hospital psychiatry unit with symptoms of depression, previously assessed at 6 months and 2, 5 and 15 years after index admission, were reviewed at 25 years (N = 49, including eight informants of deceased probands, of an original 145 with major depression (DEPs)). Prospective psychiatric (N = 22) and retrospective surgical (N = 50) control groups assessed after 25 years were used for comparison.

RESULTS

A further decade of follow-up confirmed the chronicity of depression. Of depressed patients (DEPs) followed for the full 25-year-period only 12% of the 49 original DEPs recovered and remained continuously well, 84% experienced recurrences, 2% experienced an unremitting course and another 2% died by suicide. Note that in the first 15-year-period 6% (9/145 DEPs) committed suicide, a further 38 died and 32 were lost to follow-up. They experienced an average of three episodes of depression over the 25 years. In the decade since the 15-year follow-up, 27% improved in clinical outcome (including four of five previously chronically depressed patients), 55% remained unchanged and 18% worsened; and the number of episodes per year declined. Patients initially diagnosed with neurotic or endogenous depression had similar long-term outcomes. The criteria for a current DSM-III-R disorder were met by 37% of DEPs, including 11% with depression or dysthymia. On the global assessment of functioning scale 78% of the DEPs had some impairment compared to 62% of psychiatric controls and 40% of surgical controls.

CONCLUSION

Even after 25 years, severe depressive disorders appear to have poor long-term outcomes. Patients with chronic outcomes over 15 years can improve when followed over longer periods.

Practical guidelines for the treatment of behavioural complications of dementia

A step-by-step approach to management of behavioural problems in dementia is outlined. Initial strategies include assessment of the underlying cause and consideration of non-pharmacological methods of treatment. If pharmacotherapy is required, the altered pharmacokinetics in the elderly and the variable efficacy of different psychotropic drugs should be kept in mind. Recommendations regarding drug dosage, monitoring and review are given.

Caring for the institutionalised elderly: how easy is it?

In the light of long-standing criticism of nursing homes an assessment of staff's ability to provide care was required. By creating a profile of nursing home staff it may be possible to explain and predict difficulties in providing care. One hundred and five staff from 15 nursing homes and 18 hostel staff were interviewed to examine demographic characteristics, attitudes to the job and to the elderly, as well as sources of stress in the workplace. Staff were predominantly female, with children, and had a strong sense of altruism and desire to nurture. They foster an atmosphere of care and protection and may unwittingly encourage dependence. This may preclude challenge and rehabilitation for nursing home residents. Constraints such as staff shortages, stress (35.3 per cent cases on the General Health Questionnaire), lack of training, conflict among staff and lack of support may hamper care. These problems could be addressed by additional training and incentives for staff, increased staff cooperation and communication. Medical practitioners and other health professionals have a significant role to play in assuming greater responsibility for supporting the caregivers in nursing homes.