January 11, 2013

Paradox of aging: The older we get, the better we feel?

Presently, there are about 40 million Americans over the age of 65, with the fastest-growing segment of the population over 80 years old. Traditionally, aging has been viewed as a period of progressive decline in physical, cognitive and psychosocial functioning, and aging is viewed by many as the "number one public health problem" facing Americans today. But this negative view of aging contrasts with results of a comprehensive study of 1,006 older adults in San Diego by researchers from the University of California, San Diego School of Medicine and Stanford University. Results of the Successful Aging Evaluation (SAGE) study – comprising a 25-minute phone interview, followed by a comprehensive mail-in survey – will be published in the December 7 online issue of the American Journal of Psychiatry. "While there is a growing public health interest in understanding and promoting successful aging, until now little published research has combined measures of physical health with cognitive and psychological assessments, in a large and randomly selected sample," said principal investigator Dilip V. Jeste, MD, Estelle and Edgar Levi Chair in Aging, Distinguished Professor of Psychiatry and Neurosciences, and director of UC San Diego's Stein Institute for Research on Aging, and the current President of the American Psychiatric Association (which was not involved in this study). The SAGE study included adults between the ages of 50 and 99 years, with a mean age of just over 77 years. In addition to measures which assessed rates of chronic disease and disability, the survey looked at more subjective criteria such as social engagement and participants' self-assessment of their overall health. "Sometimes the most relevant outcomes are from the perspective of the subjects themselves," said Jeste. The study concludes that resilience and depression have significant bearing on how individuals self-rate successful aging, with effects that are comparable to that of physical health. "Even though older age was closely associated with worse physical and cognitive functioning, it was also related to better mental functioning," said co-author Colin Depp, PhD, associate professor of psychiatry at UC San Diego School of Medicine. After adjusting for age, a higher self-rating of successful aging was associated with higher education, better cognitive function, better perceived physical and mental health, less depression, and greater optimism and resilience. Participants were asked to rate the extent to which they thought they had "successfully aged," using a 10-point scale and using their own concept of the term. The study found that people with low physical functioning but high resilience, had self-ratings of successful aging similar to those of physical healthy people with low resilience. Likewise, the self-ratings of individuals with low physical functioning but no or minimal depression had scores comparable to those of physically healthy people with moderate to severe depression. "It was clear to us that, even in the midst of physical or cognitive decline, individuals in our study reported feeling that their well-being had improved with age," Jeste said. This counterintuitive increase in well-being with aging persisted even after accounting for variables like income, education and marriage. Jeste suggests there's a take-away message for clinicians, which is that an optimistic approach to the care of seniors may help reduce societal ageism. "There is considerable discussion In public forums about the financial drain on the society due to rising costs of healthcare for older adults – what some people disparagingly label the 'silver tsunami.' But, successfully aging older adults can be a great resource for younger generations," he said. The findings point to an important role for psychiatry in enhancing successful aging in older adults. "Perfect physical health is neither necessary nor sufficient," Jeste said. "There is potential for enhancing successful aging by fostering resilience and treating or preventing depression." Aging and Long Term Care (Abridged) CE Course (3 hours) ### Additional contributors to this study include Gauri N. Savla, PhD, Wesley K. Thompson, PhD, Ipsit V. Vahia, MD, Danielle K. Glorioso, MSW, A'verria Sirkin Martin, PhD, Barton W. Palmer, PhD, David Rock, BA, and Shahrokh Golshan, PhD, UC San Diego; and Helena C. Kraemer, PhD, professor of biostatistics in psychiatry at Stanford University. This work was supported, in part, by NIMH grants T32 MH-019934 and P30 MH-066248, by NIH National Center for Research Support grant UL1 RR-031980, by the John A. Hartford Foundation, and by the Sam and Rose Stein Institute for Research on Aging.

January 08, 2013

Guide Offers a Blueprint for End-of-Life Conversation With Youth

Enlisting the advice of adolescents and young adults with serious illness, researchers at the National Institutes of Health have developed a guide to help young people and their families address issues surrounding end-of-life care. Voicing My CHOICES is the first guide designed to help adolescents and young adults express how they would like to be comforted, supported, and cared for in the course of serious illness, and how they would like to be remembered if they do not survive. The guide is aimed at helping families and health professionals open difficult conversations, and was written using language and questions tailored to the particular needs and preferences of young people. A paper in the November 2012 issue of the journal Pediatrics reported on a study in which young people with serious illnesses read and commented on pages from two existing advance care planning guides. The study found that adolescents and young adults do want to be involved in end-of-life planning. Almost all of the 52 participants in the study felt that having such a guide was helpful and important. Their comments on specific questions shaped the content of Voicing My CHOICES. Lori Wiener, Ph.D., director of the pediatric psychosocial support and research program at the National Cancer Institute, is lead author of the Pediatrics study and developed the prototype for Voicing My CHOICES that the young participants evaluated. She collaborated with Maryland Pao, M.D., clinical director of the National Institute of Mental Health, whose staff provides psychiatric consultation at NIH’s research hospital for patients of all ages with serious illness. Developing Voicing My CHOICES began with focus groups in which young people with serious illness endorsed the need for an advance care planning guide for persons their age. Out of this came a study, reported in 2008, in which a group of 20 adolescents and young adults living with cancer or perinatally acquired HIV disease were asked to read and evaluate the publication Five Wishes, an advanced directive for adults, along with additional topics identified during the focus groups. The study team used their feedback to create a new guide for young people called My Thoughts, My Wishes, My Voice. In the current study, youth reviewed pages from this publication and Five Wishes. Their comments were incorporated in the final Voicing My CHOICES. “Adolescents and young adults often stay silent, not sharing their fears—as they do not want to further upset their parents,” said Wiener. “And parents don’t bring up end-of-life issues for the same reasons.” The research studies showed, however, that teens and young adults are interested in these issues and value the opportunity to express their preferences. The guide also serves a developmental purpose. “At a stage of life where they would normally be seeking identity and a way to leave their mark on the world, they are in a situation where they can’t make decisions,” said Pao. Youth are concerned, she said, with how they will be cared for and remembered and, true to their age, about peer relationships. They want to be heard. Voicing My CHOICES includes questions about making medical care decisions and the types of life support a young person would or would not want. In response to comments, changes were made to make the language in Voices My CHOICES less technical, and to offer both yes/no and open-ended questions. Participants in the study endorsed a section in which they can indicate whether they would like to donate their body to science or have an autopsy, which speaks powerfully, said Wiener, to their sense of altruism and the need to find meaning in their experience Aging and Long Term Care CE Course “Adolescents and young adults can feel very frightened and alone when their bodies are no longer responding to medical interventions and decisions are being made around them,” said Wiener. “Allowing them to be involved in decisions, and to document how they wish to be remembered, enhances the trust in parent and medical provider relationships and provides them with the opportunity to give meaning to their life.” The product of a collaboration between clinical research teams representing two different areas of focus within NIH’s research hospital—pediatric oncology and psychiatry—Voicing My CHOICES can be used to help patients, families, caregivers, and health care providers. Voicing My CHOICES is available from Aging With Dignity (www.agingwithdignity.org), a nonprofit that provides the advanced directive document for adults, Five Wishes. References Wiener L, Zadeh S, Battles H, Baird K, Ballard E, Osherow J, Pao M. Allowing adolescents and young adults to plan their end-of-life care. Pediatrics. 2012 Nov;130(5):897-905. doi: 10.1542/peds.2012-0663. Epub 2012 Oct 8. Wiener L, Ballard E, Brennan T, Battles H, Martinez P, Pao M. How I wish to be remembered: the use of an advance care planning document in adolescent and young adult populations. Journal of Palliative Medicine. 2008 Dec;11(10):1309-13.

January 06, 2013

Emergency Department Suicide Screening Tool Accurately Predicts At Risk Youth

A set of four questions that takes emergency department nurses or physicians less than 2 minutes to administer can successfully identify youth at risk for attempting suicide, reported a study by National Institute of Mental Health (NIMH) researchers that was published in the December 2012 issue of the Archives of Pediatrics and Adolescent Medicine Aspira Continuing Education Online Courses Background Each year as many as 5 to 8 percent of U.S. children and young adults attempt suicide, according to the U.S. Centers for Disease Control and Prevention. In 2010, 4867 youths between ages 10 and 24 died by suicide, making it the second leading cause of death for people in this age group. Most individuals who die by suicide have visited a health care provider 3 months to 1 year before their death. Typically these patients saw an emergency department (ED) nurse and physician for some other health concern such as abdominal pain or headaches. These at-risk individuals often go unrecognized by ED staff who either lack the time or training to properly screen patients. The Joint Commission, a leading U.S.-based nonprofit healthcare accreditation organization, and the American Academy of Pediatrics have previously recommended the creation and use of suicide screening tools for adult and pediatric patient populations. To date there are no screening instruments to assess suicide risk in children and adolescents who visit EDs for medical or surgical reasons. “Many families use the emergency department as their sole contact in the healthcare system,” said Lisa M. Horowitz, Ph.D., M.P.H., lead author of the study. “Most people don’t show up to the emergency department and say ‘I want to kill myself.’ Rather they show up with physical complaints and do not discuss their suicidal thoughts. But studies have shown that if you ask directly, the majority will tell you. Nurses and physicians need to know what questions to ask.” Horowitz, a clinician and researcher with NIMH, and her colleagues developed a quick questionnaire that ED nurses and physicians could use to assess suicide risk among youth. Their study tested 17 candidate questions in 524 patients ages 10 to 21 years who visited one of three academically-affiliated pediatric EDs and had either psychiatric problems—suicidal ideation, intense anxiety, post-traumatic stress disorder—or medical/surgical concerns—gastrointestinal diseases, sickle cell anemia, cystic fibrosis. The questions—focusing on suicidal thoughts and behavior—were reviewed and revised by a panel of mental health clinicians, health services researchers, and survey specialists. The patients also completed one of two versions of the Suicidal Ideation Questionnaire (SIQ), the “gold standard,” 30-question suicide-screening tool that is used by pediatric and adolescent psychiatrists, but which is too long for ED visits and requires additional training. As part of the study’s safety plan, individuals whose responses indicated that they were at risk for attempting suicide were referred to mental health professionals—social workers, psychiatrists, psychologists—for further evaluation Suicide Prevention CE Course Results of the Study Of the 17 candidate questions, four (used as a set) stood out as having the most accuracy for predicting suicide attempts: current thoughts of being better off dead, current wish to die, current suicidal ideation, and history of suicide attempt. Positive responses to 1 or more of these 4 questions identified 97% of the youth at risk for suicide, regardless of whether these patients came in for psychiatric or general medical concerns. Based on results from the new questionnaire, 18.7% of the ED patients (98 of the 524) screened positive for suicide risk; most of whom had come to the ED with psychiatric concerns (84 of the 524). Elevated suicide risk was detected in 4.1% of the ED patients (14 of the 344) with medical/surgical concerns. Had it not been for the new screening tool, the suicide risk in these 14 patients most likely would have gone undetected. Significance The instrument based on these 4 questions, called the Ask Suicide-Screening Questions (ASQ), is the first time such a screen has been validated for pediatric and young adult patients evaluated in EDs for medical/surgical reasons. Although the number of these patients identified as high risk for suicide is small, the screen takes less than 2 minutes to administer. The tool is freely available and accessible online (pdf). What’s Next Additional research assessing the impact of suicidal screening in pediatric EDs on referral rates to mental health services and future suicidal behavior are needed. The accuracy of the ASQ among diverse demographic populations also needs examination. Additionally, a cost-benefit analysis for the screening tool is needed, as is research studying its use in other healthcare settings such as in-patient and out-patient care. Reference Horowitz LM, Bridge JA, Teach SJ, Ballard E, Klima J, Rosenstein DL, Wharff EA, Ginnis K, Cannon E, Joshi P, Pao M. Ask Suicide-Screening Questions (ASQ). A Brief Instrument for the Pediatric Emergency Department. Archives of Pediatrics and Adolescent Medicine. December 2012. 166(12):1170–1176.