<b><i>Background:</i></b> Research on terminal decline has widely documented that cognitive performance steeply declines with nearing death. To date, it is unclear whether these changes are normative, based on pathologies associated with (preclinical) dementia, or both. <b><i>Objectives:</i></b> We analyzed heterogeneity in trajectories of terminal cognitive change in Swiss nursing home residents with the objective of examining whether terminal change is normative or whether one or multiple subgroup(s) with relative stability exist. <b><i>Methods:</i></b> We performed a longitudinal analysis based on routine assessments with the Resident Assessment Instrument – Minimal Data Set in 341 nursing homes between 1998 and 2014. In sum, we used 143,052 observations from 30,054 residents (69% women, average age at death 87 years) in the last 3 years of life. We analyzed trajectories of the Cognitive Performance Scale (CPS) score with latent class growth curve models and examined sociodemographic factors (age at death, sex, marital status, prior living situation) as well as functional and mental health (Activities of Daily Living Index and Depression Rating Scale) and dementia diagnosis as correlates of group membership. <b><i>Results:</i></b> We identified three distinct classes based on longitudinal trajectories of the CPS score. In the first group (transition from no to mild impairment, 27%), cognitive impairment increased with time to death (linear and quadratic), but remained at relatively mild levels at all times. The trajectories of the second group (transition from moderate to severe impairment, 43%) were characterized by linear and quadratic changes across time to death. The trajectories of the third group (severe impairment, 30%) were characterized by the lowest amount of linear increase across all groups and no quadratic increase indicating no accelerated change. Better functional health and absence of a dementia diagnosis predicted less impairment. Fewer depressive symptoms were associated with low as opposed to moderate or severe, but also severe versus moderate impairment. <b><i>Conclusion:</i></b> Our findings suggest that the majority of residents experience terminal change, with the exception of those at already high levels of impairment. Furthermore, late-life cognitive change is related to functional and mental health.
We aimed to assess the efficacy of a person-centered care intervention in improving quality of life (QoL) for people with dementia in long-term care facilities.
Although psychotherapy has traditionally been an essential part of psychiatric training and practice, its role within psychiatry has become less evident in recent years. There have even been some doubts as to whether psychotherapy will remain in the armamentarium of future psychiatrists 1. Several differences have been reported among European countries concerning both training and practice of psychotherapy 2. However, few studies have explored residents' and early career psychiatrists' views and perspectives about their psychotherapy training experience and use of psychotherapy in clinical practice. The WPA, within its Action Plan 2008–2011, established an Early Career Psychiatrists Council (ECPC), with the aim to "promote the professional development of early career psychiatrists worldwide" 3. One of the goals of the ECPC Action Plan was to run a survey on training and practice of psychotherapy in European countries 4,5. This survey has been conducted online with the ECPC members in the countries of Europe I Zone (Northern, Southern and Western Europe). Respondents have been invited to complete a questionnaire on the basis of their own experience and collecting the opinions of their peers. Twelve out of the 13 ECPC members (representing Austria, Belgium, Cyprus, Estonia, France, Germany, Italy, Spain, Switzerland, Sweden, Turkey and the UK) returned the questionnaires. The 16-item questionnaire explored the following aspects: a) quality of psychotherapy training (supervision, type of psychotherapy training available, barriers in accessing training); b) organizational aspects of psychotherapy training (compulsoriness, payment and assessment); c) satisfaction with training in psychotherapy; d) self-confidence in the use of psychotherapy. Training in psychotherapy is mandatory in all countries considered in the survey except Belgium and France. Psychotherapy training is available in the public school of medicine only in four countries (Germany, Spain, Switzerland, UK). In most of the countries, in order to receive psychotherapy training, residents have to pay additional fees. Training in psychodynamic and cognitive-behavioral therapies is available in almost all countries, whereas training in systemic psychotherapy is provided in 6 countries, training in interpersonal, supportive and psychoeducational techniques in 4 countries, and training in dialectical-behavioural psychotherapy in 3 countries. The requested number of patients to be treated by the residents during the training ranges from none (Estonia) to more than 15 (Turkey). A dedicated supervisor for training in psychotherapy is not available in 5 countries out of 12, while in Austria, Cyprus and Switzerland supervision has to be self-financed. Psychotherapy competencies are evaluated differently: a logbook or a workplace-based assessment is used in 3 countries, a written or oral examination is required in 4 countries. In the remaining countries there is not a clear guidance regarding trainees' evaluation. The main barriers in accessing training in psychotherapy are difficulties to get time away from other duties, lack of supervisors, and lack of funding. Although a personal psychotherapy is mandatory in 9 countries, most European early career psychiatrists have to pay themselves for it. Despite this heterogeneity, most European early career psychiatrists (70%) are satisfied with the training they receive in psychotherapy and 80% of them feel confident to use psychotherapies. We hope this information can contribute to promote a process of harmonization of psychotherapy training within the European Union.
Hippocampal cavities (HcC) are frequent findings in brain MRIs of elderly subjects. The prevalence, evolution and impact on cognitive performance of these cavities are unclear. Our study therefore aims at providing data on prevalence, morphological evolution and clinical significance of HcC. We used a population-based sample of nondemented elderly subjects aged 75–85 and a comparison group with Alzheimer's disease for cross-sectional analysis. All nondemented subjects were included in a prospective study (mean follow-up 3.2 years). HcC numbers and volume were recorded from volumetric T1w MRI scans. Serial MRIs were performed for a subgroup of subjects. Cognitive functions were assessed by SIDAM and CDR. Hippocampal and brain volume, medial temporal lobe atrophy, white matter lesions, ApoE genotype and vascular risk factors were considered as confounders. The prevalence of HcC in our sample was approx. 60% with no differences between cognitive groups. HcC volume was found to be a predictor of short-term episodic memory performance. The effect of HcC volume was non-linear with the highest risk for decrease in short-term memory associated with the smallest HcC volumes. Mean HcC number and volume remained stable during follow-up. However, we provide anectodal evidence for both cases with increase and decrease of HcC volume over time. In conclusion, small HcC may be an independent risk factor for decline in short term episodic memory performance in elderly subjects.
Although several targets of APP intracellular domain (AICD) mediated transcriptional gene regulation have been published, the role of AICD in nuclear signaling in health and (Alzheimer's) disease remains under debate. We previously demonstrated that AICD forms nuclear complexes with two other proteins, Fe65 and Tip60, called AFT complexes. Functionally, these co-localization areas likely represent sites of transcription. However, it is currently unknown how the formation of these complexes is regulated. Bimolecular fluorescence complementation (BiFC) is a recently developped technique to visualize protein/protein interaction. We established a detection system based on BIFC to study the intracellular interaction of AICD, Fe65 and Tip60 in cell culture. By means of confocal microscopy the subcellular localization of the proteins was studied. The influence of several genetic mutations for familial Alzheimer's disease as well as for caspase cleavage and phosphorylation sites was quantified by fluorescence assisted cell sorting (FACS). Using our BiFC visualization system, we could verify known findings such as APP/APP dimerization in the membrane and the interaction of AICD, Fe65 and Tip60 in the nucleus. Our system furthermore revealed the regulatory effect of familial AD and caspase cleavage site mutations on AFT complex formation. AFT complex formation can be effectively visualized and quantified by means of our novel BiFC constructs, thus opening new insights into the functions of the amyloid precursor protein APP.
Behavioural and psychological symptoms of dementia (BPSD) such as agitation, aggressive behaviour, repetitive vocalizations, apathy, etc. are a frequent challenge in the care for patients with dementia. BPSD are furthermore associated with individual suffering, reduced quality of life and caregiver burden. This talk will provide an update on current pharmacological and non-pharmacological treatment strategies for BPSD on the basis of the relevant guidelines and a review of the current literature. For pharmacological treatment, the focus has recently shifted from antipsychotics to antidepressants due to their more favourable risk/benefit profile. Treatment algorithms that include behavioural diagnostics and both pharmacological and non-pharmacological interventions will be presented as a tool to guide clinical practice.
This presentation highlights core pharmacological aspects of opioid and non-opioid pain medications in the elderly patient. Specifically, it covers pharmakinetics, pharmacodynamics and drug-drug interactions of select pain medications. The presentation aims to promote safe use of pain medications in the elderly. Disclosure No significant relationships.
The transition from psychiatric training to independent practice is a crucial step in the professional development of every psychiatrist. For many psychiatrists, this phase also determines their choice of subspecialization and therefore has an important impact both on individual career paths as well as on the availability of psychiatrists in the various areas of our specialty. Despite its importance, this period of professional development is relatively understudied 1. In accordance with the WPA aim to "promote the professional development of early career psychiatrists worldwide" 2, the members of the WPA Early Career Psychiatrists Council (ECPC), Europe I area, conducted a survey to investigate this period in more detail 3. A 27-item online questionnaire was developed covering: a) factors influencing choice of psychiatric subspecialty and work setting, b) job availability, and c) availability of training and mentoring opportunities specific to this phase. All 60 Council members were asked to participate in the survey as experts of the situation in their countries. Forty Council members representing 35 countries from all five continents participated in the survey, resulting in a response rate of 66%. Career choice was more often reported to be strongly or very strongly influenced by personal variables, such as salary expectations (30/40), personal interests (29/40), and compatibility with private life (27/40), than by external factors such as societal expectations (13/40) and the political environment (10/40). Strikingly, gender inequalities were reported to have a strong influence on career choice in three countries. Furthermore, six of 40 respondents stated that in their countries the location of practice was decided "by somebody else" rather than the psychiatrists themselves. In 12 countries, higher salaries and access to subspecialty training are used as incentives to recruit psychiatrists into underserved regions. The risk for unemployment immediately after psychiatric specialization was judged either unlikely or very unlikely by almost all experts (37/40). However, more than half (21/40) stated it was difficult or very difficult to get the desired job. Positions in university hospitals and private psychiatric practices were most frequently cited as attractive career options. Of these, the availability of job opportunities in university hospitals was reported to be "quite bad" or "bad" in 21 of 40 countries. In addition, 14 of 40 representatives reported that it was not possible in their countries to immediately establish oneself as an independently practicing psychiatrist after completion of training. Limitations fixed by governments regarding the number of available positions and periods of mandatory service in the public sector — in one country up to nine years — were mentioned as restricting factors. Although the transition between psychiatric training and independent practice is associated with high levels of stress, anxiety, and difficulties with patient care amongst young psychiatrists 4, the survey highlighted a lack of specific support during this phase. Specific training opportunities to develop "real world" psychiatric skills, for example, in leadership or management, were reported to exist only by eight of 40 respondents. While 19 representatives stated that in their country a mentor was available during psychiatric training, that number dropped to 11 for the first years of working as a specialist. In our view, the transition from psychiatric training to independent practice should be recognized as a complex task and a crucial step toward mastery of our profession. It deserves both self-reflection by the young psychiatrist and support by psychiatric professional associations. Specific training opportunities for this transition period should be created. Furthermore, we believe that establishing incentives may be a more suitable approach than imposing restrictions in order to sustainably attract young psychiatrists to work in underserved regions of a country or neglected fields of psychiatry 5. While the latter approach may function in the short run, it can be a strain on the individual psychiatrist and a danger to recruitment in the long-term. Florian Riese1, Clare Oakley2, Marie Bendix3, Piirika Piir4, Andrea Fiorillo5 1Psychiatric University Hospital, Zurich, Switzerland; 2Institute of Psychiatry, King's College, London, UK; 3Psychiatric Clinic Southwest, Karolinska University Hospital Huddinge, Stockholm, Sweden; 4Psychiatry Clinic, University of Tartu, Estonia; 5Department of Psychiatry, University of Naples SUN, Naples, Italy
Undergraduate psychiatric education is essential for the training of medical students and for their recruitment into psychiatry. A significant shortage of graduates choosing a career in psychiatry has been recently documented, and this trend might have many causes. When medical students have positive experiences of teaching, elective placements and exposure to psychiatric patients, their attitudes towards psychiatry are significantly better. Therefore, there is a need to improve the quality of undergraduate training courses in psychiatry. Innovative teaching strategies are suggested, including the use of movies, virtual reality, simulated patients and multiprofessional training wards.
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