Pub Date : 2024-02-19DOI: 10.1016/j.jagp.2024.01.063
Tarek Rajji MD, FRCPC , Linda Mah MD, MHSc , Krista Lanctot PhD
Older adults with Alzheimer's Disease and Related Dementias (ADRD) and those with high risk conditions such as major depressive disorder (D) or mild cognitive impairment (MCI) are growing in numbers. Interventions to treat these conditions early and to prevent cognitive decline and ADRD are highly needed. This session will present results from new studies examining neuromodulation alone or in combination with other modalities in these populations. Dr. Linda Mah will present on deep Transcranial Magnetic Stimulation (dTMS) for older adults with treatment-resistant D or memory concerns. Dr. Krista Lanctôt will present preliminary results from a trial combining transcranial Direct Current Stimulation (tDCS) with exercise for older adults with early AD or MCI. Last, Dr. Tarek Rajji will present the results of a large 7-year randomized controlled trial (Preventing Alzheimer's dementia with cognitive remediation plus transcranial direct current stimulation in mild cognitive impairment and depression: PACt-) that aimed to prevent cognitive decline and dementia among older adults with MCI or remitted D with or without MCI using the combination of tDCS and cognitive remediation. Overall, this panel will present novel unpublished data across various neuromodulation trials of different designs with various outcomes relevant to preventing cognitive decline and ADRD.
{"title":"Advances in Neuromodulation for Older Adults with Mood and Neurocognitive Disorders","authors":"Tarek Rajji MD, FRCPC , Linda Mah MD, MHSc , Krista Lanctot PhD","doi":"10.1016/j.jagp.2024.01.063","DOIUrl":"https://doi.org/10.1016/j.jagp.2024.01.063","url":null,"abstract":"<div><p>Older adults with Alzheimer's Disease and Related Dementias (ADRD) and those with high risk conditions such as major depressive disorder (D) or mild cognitive impairment (MCI) are growing in numbers. Interventions to treat these conditions early and to prevent cognitive decline and ADRD are highly needed. This session will present results from new studies examining neuromodulation alone or in combination with other modalities in these populations. Dr. Linda Mah will present on deep Transcranial Magnetic Stimulation (dTMS) for older adults with treatment-resistant D or memory concerns. Dr. Krista Lanctôt will present preliminary results from a trial combining transcranial Direct Current Stimulation (tDCS) with exercise for older adults with early AD or MCI. Last, Dr. Tarek Rajji will present the results of a large 7-year randomized controlled trial (Preventing Alzheimer's dementia with cognitive remediation plus transcranial direct current stimulation in mild cognitive impairment and depression: PACt-) that aimed to prevent cognitive decline and dementia among older adults with MCI or remitted D with or without MCI using the combination of tDCS and cognitive remediation. Overall, this panel will present novel unpublished data across various neuromodulation trials of different designs with various outcomes relevant to preventing cognitive decline and ADRD.</p></div>","PeriodicalId":55534,"journal":{"name":"American Journal of Geriatric Psychiatry","volume":null,"pages":null},"PeriodicalIF":7.2,"publicationDate":"2024-02-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139908382","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-19DOI: 10.1016/j.jagp.2024.01.110
Alex Pena Garcia DO , Veronica Derricks PhD , Joseph Asper DO , Daniela Gonzalez BS , Miriam Rodriguez PhD , Patricia Garcia PsyD , Francine Epperson AGS , Angelina Polsinelli PhD , Andrew Saykin MS, PsyD , Sophia Wang MD
Introduction
An estimated 6.7 million people are living with Alzheimer's Disease and its related dementias (ADRD) with the disease being found in about 1 in 9 people (10.8%) age 65 and older. Secondary to being often uninformed regarding the risk factors, prevention measures, the importance of early detection and having lack of access to cognitive screening, Black and Hispanic older adults are disproportionality affected by ADRD. The EMPOWER curriculum serves to address this disparity by providing patient education emphasizing risk reduction strategies for older adults and improve ADRD health literacy.
Methods
12 curriculum modules addressing ADRD risk reduction strategies were developed. This curriculum covers relevant topics including the importance of brain health, memory changes, genetics, physical activity, social activity, diet, sleep, managing comorbidities, mental health, medication, head injuries, and cognitive screening. Additional supplementary reading materials in both English and Spanish are also provided. Qualitative interviews will then be conducted to obtain feedback from the community prior to implementing the curriculum.
Results
Currently pending upon completion of the community feedback qualitative interviews prior to curriculum implementation.
Conclusions
The EMPOWER curriculum covers several relevant topics for older adults with concerns for ADRD and its risk reduction. Community feedback via the qualitative interviewing will be utilized and analyzed to assess the relevance and applicability of the curriculum which will then be provided to the public. With its successful implementation into the community, ADRD knowledge gaps will be addressed and contribute to lowering ADRD risk within these communities.
{"title":"EMPOWER! (Brain Health Education in Minority Communities to Promote Knowledge about Early Detection of Alzheimer's Disease and Research Participation) Curriculum","authors":"Alex Pena Garcia DO , Veronica Derricks PhD , Joseph Asper DO , Daniela Gonzalez BS , Miriam Rodriguez PhD , Patricia Garcia PsyD , Francine Epperson AGS , Angelina Polsinelli PhD , Andrew Saykin MS, PsyD , Sophia Wang MD","doi":"10.1016/j.jagp.2024.01.110","DOIUrl":"https://doi.org/10.1016/j.jagp.2024.01.110","url":null,"abstract":"<div><h3>Introduction</h3><p>An estimated 6.7 million people are living with Alzheimer's Disease and its related dementias (ADRD) with the disease being found in about 1 in 9 people (10.8%) age 65 and older. Secondary to being often uninformed regarding the risk factors, prevention measures, the importance of early detection and having lack of access to cognitive screening, Black and Hispanic older adults are disproportionality affected by ADRD. The EMPOWER curriculum serves to address this disparity by providing patient education emphasizing risk reduction strategies for older adults and improve ADRD health literacy.</p></div><div><h3>Methods</h3><p>12 curriculum modules addressing ADRD risk reduction strategies were developed. This curriculum covers relevant topics including the importance of brain health, memory changes, genetics, physical activity, social activity, diet, sleep, managing comorbidities, mental health, medication, head injuries, and cognitive screening. Additional supplementary reading materials in both English and Spanish are also provided. Qualitative interviews will then be conducted to obtain feedback from the community prior to implementing the curriculum.</p></div><div><h3>Results</h3><p>Currently pending upon completion of the community feedback qualitative interviews prior to curriculum implementation.</p></div><div><h3>Conclusions</h3><p>The EMPOWER curriculum covers several relevant topics for older adults with concerns for ADRD and its risk reduction. Community feedback via the qualitative interviewing will be utilized and analyzed to assess the relevance and applicability of the curriculum which will then be provided to the public. With its successful implementation into the community, ADRD knowledge gaps will be addressed and contribute to lowering ADRD risk within these communities.</p></div>","PeriodicalId":55534,"journal":{"name":"American Journal of Geriatric Psychiatry","volume":null,"pages":null},"PeriodicalIF":7.2,"publicationDate":"2024-02-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139908386","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-19DOI: 10.1016/j.jagp.2024.01.103
Vinay Kotamarti MD
An ambiguous clinical presentation can create diagnostic uncertainty, leading to delays in effective interventions and increasing the likelihood of adverse clinical outcomes. Unfortunately, many psychiatric conditions share overlapping clinical symptoms. Psychotic depression, catatonia, neurocognitive disorders, and delirium are all examples of distinct clinical conditions with overlapping symptomatology, and all require decidedly different therapeutic interventions. While much literature is devoted to the diagnostic criteria and management of these clinical conditions, little is dedicated to the challenge of disentangling these diagnoses when faced with a complex clinical presentation.
We present here a complicated psychiatric inpatient hospitalization of a 77-year-old male who exemplified this diagnostic challenge. He primarily presented with severely depressed mood and decreased functionality, remaining in bed for much of the day with little attention to basic hygiene and oral intake. While records from a recent outside hospitalization carried a historical diagnosis of catatonia, his moderate level of engagement with providers and somatic delusion of disseminated prostate cancer suggested an alternate diagnosis of psychotic depression. However, before a diagnostic conclusion could be reached, other clinical characteristics surfaced. Following a singular administration of olanzapine shortly after his initial assessment, he developed Lilliputian hallucinations, prominent parkinsonism, and significantly altered mentation.
Neuroleptic sensitivity raised clinical suspicion for an underlying neurocognitive disorder such as dementia with Lewy bodies, and a consult was placed to the neuropsychology service. While dementia could not be fully ruled out, they did recommend additional workup to rule out herpes simplex encephalitis, autoimmune limbic encephalitis, and paraneoplastic syndromes. After his MRI imaging revealed moderate microvascular ischemic changes, a true multidisciplinary approach to care was taken, as neurology was consulted to also help narrow the differential. An EEG was unremarkable and a serum encephalitis panel was also unremarkable. Olanzapine was discontinued with significant improvement in parkinsonism and cognition; however, severe neurovegetative symptoms and somatic and nihilistic delusions persisted. While antipsychotics remained clinically indicated for a suspected depression with psychotic features, caution was taken due to established neuroleptic sensitivity, subtle catatonic features, and the related risks of neuroleptic malignant syndrome. Ultimately, low-dose quetiapine was initiated with some benefit; however, he continued to remain acutely depressed and withdrawn with prominent negativism. Trials with benzodiazepines for these catatonic features were also approached with caution to avoid potential risks of delirium.
Over time, a multidisciplinary approach to psychopharmacologic interventions a
{"title":"Disentangling the Diagnoses of Psychotic Depression, Catatonia, Neurocognitive Disorders, and Delirium: A Multidisciplinary Approach","authors":"Vinay Kotamarti MD","doi":"10.1016/j.jagp.2024.01.103","DOIUrl":"https://doi.org/10.1016/j.jagp.2024.01.103","url":null,"abstract":"<div><p>An ambiguous clinical presentation can create diagnostic uncertainty, leading to delays in effective interventions and increasing the likelihood of adverse clinical outcomes. Unfortunately, many psychiatric conditions share overlapping clinical symptoms. Psychotic depression, catatonia, neurocognitive disorders, and delirium are all examples of distinct clinical conditions with overlapping symptomatology, and all require decidedly different therapeutic interventions. While much literature is devoted to the diagnostic criteria and management of these clinical conditions, little is dedicated to the challenge of disentangling these diagnoses when faced with a complex clinical presentation.</p><p>We present here a complicated psychiatric inpatient hospitalization of a 77-year-old male who exemplified this diagnostic challenge. He primarily presented with severely depressed mood and decreased functionality, remaining in bed for much of the day with little attention to basic hygiene and oral intake. While records from a recent outside hospitalization carried a historical diagnosis of catatonia, his moderate level of engagement with providers and somatic delusion of disseminated prostate cancer suggested an alternate diagnosis of psychotic depression. However, before a diagnostic conclusion could be reached, other clinical characteristics surfaced. Following a singular administration of olanzapine shortly after his initial assessment, he developed Lilliputian hallucinations, prominent parkinsonism, and significantly altered mentation.</p><p>Neuroleptic sensitivity raised clinical suspicion for an underlying neurocognitive disorder such as dementia with Lewy bodies, and a consult was placed to the neuropsychology service. While dementia could not be fully ruled out, they did recommend additional workup to rule out herpes simplex encephalitis, autoimmune limbic encephalitis, and paraneoplastic syndromes. After his MRI imaging revealed moderate microvascular ischemic changes, a true multidisciplinary approach to care was taken, as neurology was consulted to also help narrow the differential. An EEG was unremarkable and a serum encephalitis panel was also unremarkable. Olanzapine was discontinued with significant improvement in parkinsonism and cognition; however, severe neurovegetative symptoms and somatic and nihilistic delusions persisted. While antipsychotics remained clinically indicated for a suspected depression with psychotic features, caution was taken due to established neuroleptic sensitivity, subtle catatonic features, and the related risks of neuroleptic malignant syndrome. Ultimately, low-dose quetiapine was initiated with some benefit; however, he continued to remain acutely depressed and withdrawn with prominent negativism. Trials with benzodiazepines for these catatonic features were also approached with caution to avoid potential risks of delirium.</p><p>Over time, a multidisciplinary approach to psychopharmacologic interventions a","PeriodicalId":55534,"journal":{"name":"American Journal of Geriatric Psychiatry","volume":null,"pages":null},"PeriodicalIF":7.2,"publicationDate":"2024-02-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139908414","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-19DOI: 10.1016/j.jagp.2024.01.036
Amita Patel MD , Maureen Nash MD, MS
The US population continues to age. with people over 65 years constituting 13# of the general population. By 2050, this percentage is expected to rise to nearly 25%. With the "Graying of America", the number of individuals with multiple physical and mental comorbidities requiring long-term care continues to rise sharply. Due to the deinstitutionalization of the state hospitals, the number of mentally ill patients has increased significantly in long-term care. Today, approximately 25% of newly admitted nursing home residents has mental illness (defined by schizophrenia, bipolar disorder, depression, or anxiety). With this, the need for high-quality care for these complex patients with mental illness who reside in long-term care is needed.
Centers for Medicare and Medicaid Services (CMS) has responded to this need with increasing regulations governing the use of psychoactive medications. While the intention of these regulations was undoubtedly to reduce the morbidity of overprescribing psychotropics, they too severely limit access of antipsychotics to a few diagnoses. Under the 5 star rating regulations, long-term care patients must carry a diagnosis of Huntington's Disease, schizophrenia, or Tourette's syndrome in order to meet compliance standards. Unfortunately, this excludes a huge population of patients that could stand to benefit from access to these medications. Patients particularly at risk are those with Alzheimer's with behavioral and psychological symptoms of dementia (BPSD). While the FDA approves brexpiprazole for the treatment of agitation associated with dementia due to Alzheimer's disease, access to this treatment for long-term care residents is still limited by 5-star rating regulations. Facilities also pose a unique barrier to access for patients who have antipsychotics on their medication list. Patients with severe mental illness are sometimes discriminated against because their needs cause the facilities to drop in their quality ratings/metrics, thus decreasing reimbursement.
State regulators use critical element pathways to monitor what they deem to be unnecessary psychotropic medication use. Fines and ratings are dependent on compliance with these documentation audits. Prescribers who understand the existing policies can learn how to accurately code and document for their patients and keep the facility in compliance. A special CMS audit is ongoing regarding excess/inappropriate use of schizophrenia as a diagnosis for patients on antipsychotics. It is imperative that documentation is up to date and accurate.
In order to improve access for appropriate antipsychotic use according to APA guidelines, state and federal policies require revision. Project Pause is a coalition of multidisciplinary stakeholders dedicated to this cause. This group contains psychiatrists, nursing home providers, pharmacists, National Minority Quality Forum representatives, and other relevant association members. Through discussio
{"title":"Overburdened by Regulations in Long-Term Care: A Public Health Crisis in Need of Policy Solutions to Improve Care and Access","authors":"Amita Patel MD , Maureen Nash MD, MS","doi":"10.1016/j.jagp.2024.01.036","DOIUrl":"https://doi.org/10.1016/j.jagp.2024.01.036","url":null,"abstract":"<div><p>The US population continues to age. with people over 65 years constituting 13# of the general population. By 2050, this percentage is expected to rise to nearly 25%. With the \"Graying of America\", the number of individuals with multiple physical and mental comorbidities requiring long-term care continues to rise sharply. Due to the deinstitutionalization of the state hospitals, the number of mentally ill patients has increased significantly in long-term care. Today, approximately 25% of newly admitted nursing home residents has mental illness (defined by schizophrenia, bipolar disorder, depression, or anxiety). With this, the need for high-quality care for these complex patients with mental illness who reside in long-term care is needed.</p><p>Centers for Medicare and Medicaid Services (CMS) has responded to this need with increasing regulations governing the use of psychoactive medications. While the intention of these regulations was undoubtedly to reduce the morbidity of overprescribing psychotropics, they too severely limit access of antipsychotics to a few diagnoses. Under the 5 star rating regulations, long-term care patients must carry a diagnosis of Huntington's Disease, schizophrenia, or Tourette's syndrome in order to meet compliance standards. Unfortunately, this excludes a huge population of patients that could stand to benefit from access to these medications. Patients particularly at risk are those with Alzheimer's with behavioral and psychological symptoms of dementia (BPSD). While the FDA approves brexpiprazole for the treatment of agitation associated with dementia due to Alzheimer's disease, access to this treatment for long-term care residents is still limited by 5-star rating regulations. Facilities also pose a unique barrier to access for patients who have antipsychotics on their medication list. Patients with severe mental illness are sometimes discriminated against because their needs cause the facilities to drop in their quality ratings/metrics, thus decreasing reimbursement.</p><p>State regulators use critical element pathways to monitor what they deem to be unnecessary psychotropic medication use. Fines and ratings are dependent on compliance with these documentation audits. Prescribers who understand the existing policies can learn how to accurately code and document for their patients and keep the facility in compliance. A special CMS audit is ongoing regarding excess/inappropriate use of schizophrenia as a diagnosis for patients on antipsychotics. It is imperative that documentation is up to date and accurate.</p><p>In order to improve access for appropriate antipsychotic use according to APA guidelines, state and federal policies require revision. Project Pause is a coalition of multidisciplinary stakeholders dedicated to this cause. This group contains psychiatrists, nursing home providers, pharmacists, National Minority Quality Forum representatives, and other relevant association members. Through discussio","PeriodicalId":55534,"journal":{"name":"American Journal of Geriatric Psychiatry","volume":null,"pages":null},"PeriodicalIF":7.2,"publicationDate":"2024-02-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139907340","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Grief is a common and significant human emotional experience. It has known physical, emotional, and social ramifications in patients and their families. In particular, grief is central to the dementia experience for all involved – the people living with dementia (PLWD) themselves, and for all of their caregivers: family members, staff members of assisted living facility (ALF) settings, and clinicians. Grief can ultimately take a large toll on all of these different players in the dementia experience, including medically, interpersonally, and socially, and end up at times causing significant harm if not recognized and addressed.
This presentation will describe the medical, psychological, and psychosocial manifestations of grief in general, and then specifically in the context of dementia. We will discuss ways in which grief can present through defense mechanisms in interactions between various caregivers of the PLWD, as well as in the PLWD themselves. We then will discuss a model of grief for caregivers of PLWD, and a newer extension of this model to apply to PLWD themselves, as well as approaches to management. Finally we will turn to a discussion of prolonged grief disorder, how this manifests in the dementia experience and beyond for the greater population, as well as appropriate treatment. Clinical case examples from the outpatient as well as ALF setting will be incorporated throughout the presentation.
{"title":"Not Your Average Grief: Addressing the Many Layers of Dementia-Related Loss","authors":"Caroline Bader MD , Marie Clouqueur LICSW , Danielle Glorioso LCSW","doi":"10.1016/j.jagp.2024.01.039","DOIUrl":"https://doi.org/10.1016/j.jagp.2024.01.039","url":null,"abstract":"<div><p>Grief is a common and significant human emotional experience. It has known physical, emotional, and social ramifications in patients and their families. In particular, grief is central to the dementia experience for all involved – the people living with dementia (PLWD) themselves, and for all of their caregivers: family members, staff members of assisted living facility (ALF) settings, and clinicians. Grief can ultimately take a large toll on all of these different players in the dementia experience, including medically, interpersonally, and socially, and end up at times causing significant harm if not recognized and addressed.</p><p>This presentation will describe the medical, psychological, and psychosocial manifestations of grief in general, and then specifically in the context of dementia. We will discuss ways in which grief can present through defense mechanisms in interactions between various caregivers of the PLWD, as well as in the PLWD themselves. We then will discuss a model of grief for caregivers of PLWD, and a newer extension of this model to apply to PLWD themselves, as well as approaches to management. Finally we will turn to a discussion of prolonged grief disorder, how this manifests in the dementia experience and beyond for the greater population, as well as appropriate treatment. Clinical case examples from the outpatient as well as ALF setting will be incorporated throughout the presentation.</p></div>","PeriodicalId":55534,"journal":{"name":"American Journal of Geriatric Psychiatry","volume":null,"pages":null},"PeriodicalIF":7.2,"publicationDate":"2024-02-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139907342","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-19DOI: 10.1016/j.jagp.2024.01.127
Camryn Dixon BA , Jin Joo MD, MA , Melissa Davey-Rothwell PhD , Namkee Choi PhD , Joseph Gallo MD, MPH , Ryan A. Mace PhD , Alice Xie BA, BS
Introduction
In the U.S., there are disparities between the well-being of Black and white older adults. Black older adults are more likely to develop chronic illnesses such as hypertension, heart disease, and diabetes, which can diminish their quality of life. The prevalence of chronic illness is compounded by the stressors common in aging, such as decreased income, changes in physical function, and the loss of spouses and friends. Psychological well-being contributes to an individual's overall health, along with their environment and quality of life. Despite Black older adults' burden of stressors and increased vulnerability to stress, only a few qualitative studies focus on the well-being or coping of community-dwelling Black older adults in the U.S. This mixed methods study aims to assess stressors older Black adults experience and how they cope.
Methods
We used data obtained as part of the Peer Enhanced Depression Care (PEERS) study, a randomized clinical trial testing the effectiveness of a community-based peer support intervention that provided depression care to low-income white older adults and older adults of color in an urban setting. Among 149 participants enrolled in the study, we focused on Black older adults (N=27) who completed the intervention and underwent an hour-long semi-structured interview to assess their experience of the study. We reviewed baseline survey data to describe stressors related to their medical comorbidities, social determinants of health, and the most common coping strategies they endorsed. In addition to baseline surveys, we analyzed their transcripts of semi-structured interviews, using thematic analysis as a framework to guide coding and theme generation. NVivo software was used for the organization of the data.
Results
Participants ranged in age from 54 to 90, with a mean age of 70 (SD= 8.0) years, and 89% were women. Participants had a mean income between 16,000 and 19,999 per year. 67% lived alone, and 33% were widowed. Social determinants of health needs were common; 56% experienced housing, transportation or food insecurity. The mean number of total chronic conditions was 5 (SD=1.7). Black participants in our sample, on average, were highly engaged with religion (M=7.1, SD= 1.28), planning (M= 6.2, SD= 1.6) and acceptance (M= 6.5, SD= 1.25) as coping mechanisms. In our analysis of transcripts, older adults described various stressors in their lives including limited resources, social isolation, family conflicts and grief. We found that many participants described self-reliance and emotional repression as ways in which they manage the stress in their lives.
Conclusions
Participants experienced many stressors in multiple aspects of their lives, ranging from resources to familial relationships, which was captured in the qualitative data. These stressors were compounded by high co-morbidity, resource insecurity, and
{"title":"Stress and Coping Among Community-Dwelling Black Older Adults with Depression","authors":"Camryn Dixon BA , Jin Joo MD, MA , Melissa Davey-Rothwell PhD , Namkee Choi PhD , Joseph Gallo MD, MPH , Ryan A. Mace PhD , Alice Xie BA, BS","doi":"10.1016/j.jagp.2024.01.127","DOIUrl":"https://doi.org/10.1016/j.jagp.2024.01.127","url":null,"abstract":"<div><h3>Introduction</h3><p>In the U.S., there are disparities between the well-being of Black and white older adults. Black older adults are more likely to develop chronic illnesses such as hypertension, heart disease, and diabetes, which can diminish their quality of life. The prevalence of chronic illness is compounded by the stressors common in aging, such as decreased income, changes in physical function, and the loss of spouses and friends. Psychological well-being contributes to an individual's overall health, along with their environment and quality of life. Despite Black older adults' burden of stressors and increased vulnerability to stress, only a few qualitative studies focus on the well-being or coping of community-dwelling Black older adults in the U.S. This mixed methods study aims to assess stressors older Black adults experience and how they cope.</p></div><div><h3>Methods</h3><p>We used data obtained as part of the Peer Enhanced Depression Care (PEERS) study, a randomized clinical trial testing the effectiveness of a community-based peer support intervention that provided depression care to low-income white older adults and older adults of color in an urban setting. Among 149 participants enrolled in the study, we focused on Black older adults (N=27) who completed the intervention and underwent an hour-long semi-structured interview to assess their experience of the study. We reviewed baseline survey data to describe stressors related to their medical comorbidities, social determinants of health, and the most common coping strategies they endorsed. In addition to baseline surveys, we analyzed their transcripts of semi-structured interviews, using thematic analysis as a framework to guide coding and theme generation. NVivo software was used for the organization of the data.</p></div><div><h3>Results</h3><p>Participants ranged in age from 54 to 90, with a mean age of 70 (SD= 8.0) years, and 89% were women. Participants had a mean income between 16,000 and 19,999 per year. 67% lived alone, and 33% were widowed. Social determinants of health needs were common; 56% experienced housing, transportation or food insecurity. The mean number of total chronic conditions was 5 (SD=1.7). Black participants in our sample, on average, were highly engaged with religion (M=7.1, SD= 1.28), planning (M= 6.2, SD= 1.6) and acceptance (M= 6.5, SD= 1.25) as coping mechanisms. In our analysis of transcripts, older adults described various stressors in their lives including limited resources, social isolation, family conflicts and grief. We found that many participants described self-reliance and emotional repression as ways in which they manage the stress in their lives.</p></div><div><h3>Conclusions</h3><p>Participants experienced many stressors in multiple aspects of their lives, ranging from resources to familial relationships, which was captured in the qualitative data. These stressors were compounded by high co-morbidity, resource insecurity, and ","PeriodicalId":55534,"journal":{"name":"American Journal of Geriatric Psychiatry","volume":null,"pages":null},"PeriodicalIF":7.2,"publicationDate":"2024-02-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139907763","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-19DOI: 10.1016/j.jagp.2024.01.135
Bryce Bolden BS, Mary Dozier PhD
Introduction
Hoarding Disorder (HD) occurs when an individual has difficulty discarding items due to the belief they hold value. When faced with the challenge of discarding the items, the individual experiences extreme distress which results in item accumulation and impairment of daily life functioning (Kalogeraki and Michopoulos, 2017). The implications of individuals suffering from hoarding have been extensively studied, but recent research suggests that hoarding behavior may be hard-wired in humans from our mammalian ancestors. Additionally, it can remain inactive until some form of trauma occurs (Miguel and Ligabue-Braun, 2019). In one study, shrews were used as an animal model and were found to display complex hoarding behavior during the winter months to ensure their survival, but during times of bountifulness they hoarded food items less (Ligabue-Braun, 2019). One hypothesis suggested was that during times of great stress a signaling pathway that normally lies dormant in humans can become reactivated if traumatic conditions are present (Ligabue-Braun, 2019). Individuals with a mutated form of the hoarding gene are especially susceptible to this type of behavior. By understanding the generational transmission of hoarding, preventative strategies can be employed to promote a healthier aging process. The purpose of this study was to investigate the association between reported parental hoarding status and psychiatric symptom severity in adult children. Hoarding has been shown to not only cause debilitation in individuals with HD, but it can cause impairment in their relatives as well (Drury et. al, 2014).
Methods
Participants were undergraduate students at a large state university in the United States who completed an online survey in exchange for course credit during the Fall 2022 semester (N = 363). Participants completed a self-report battery that included demographic questions, their parental history of clutter, perceptions about possible interventions for clutter, and standardized measures of hoarding severity, psychiatric symptoms, and psychosocial functioning. Hoarding severity was assessed using the Saving Inventory-Revised (SI-R), a 23-item Likert-type scale that assesses the three main symptoms of hoarding: difficulty discarding, urges to save, and impact of clutter. The Patient-Reported Outcomes Measurement Information System (PROMIS) short form measures were used to assess symptoms of Anxiety (8a) and Depression (8b).
Results
Eight percent of participants (n = 28) answered yes to the question “Would you consider your parent(s)/guardian(s) as people who hoard?” These participants reported higher hoarding severity on the SI-R Total (M = 23.86 (SD = 2.04) vs. M = 17.21 (SD = 13.11); t (359) = 2.61, p < .01) but not on the PROMIS Anxiety 8a and Depression 8b short forms (both ps > .05).
{"title":"Epigenetic Consequences of Hoarding Disorder","authors":"Bryce Bolden BS, Mary Dozier PhD","doi":"10.1016/j.jagp.2024.01.135","DOIUrl":"https://doi.org/10.1016/j.jagp.2024.01.135","url":null,"abstract":"<div><h3>Introduction</h3><p>Hoarding Disorder (HD) occurs when an individual has difficulty discarding items due to the belief they hold value. When faced with the challenge of discarding the items, the individual experiences extreme distress which results in item accumulation and impairment of daily life functioning (Kalogeraki and Michopoulos, 2017). The implications of individuals suffering from hoarding have been extensively studied, but recent research suggests that hoarding behavior may be hard-wired in humans from our mammalian ancestors. Additionally, it can remain inactive until some form of trauma occurs (Miguel and Ligabue-Braun, 2019). In one study, shrews were used as an animal model and were found to display complex hoarding behavior during the winter months to ensure their survival, but during times of bountifulness they hoarded food items less (Ligabue-Braun, 2019). One hypothesis suggested was that during times of great stress a signaling pathway that normally lies dormant in humans can become reactivated if traumatic conditions are present (Ligabue-Braun, 2019). Individuals with a mutated form of the hoarding gene are especially susceptible to this type of behavior. By understanding the generational transmission of hoarding, preventative strategies can be employed to promote a healthier aging process. The purpose of this study was to investigate the association between reported parental hoarding status and psychiatric symptom severity in adult children. Hoarding has been shown to not only cause debilitation in individuals with HD, but it can cause impairment in their relatives as well (Drury et. al, 2014).</p></div><div><h3>Methods</h3><p>Participants were undergraduate students at a large state university in the United States who completed an online survey in exchange for course credit during the Fall 2022 semester (N = 363). Participants completed a self-report battery that included demographic questions, their parental history of clutter, perceptions about possible interventions for clutter, and standardized measures of hoarding severity, psychiatric symptoms, and psychosocial functioning. Hoarding severity was assessed using the Saving Inventory-Revised (SI-R), a 23-item Likert-type scale that assesses the three main symptoms of hoarding: difficulty discarding, urges to save, and impact of clutter. The Patient-Reported Outcomes Measurement Information System (PROMIS) short form measures were used to assess symptoms of Anxiety (8a) and Depression (8b). </p></div><div><h3>Results</h3><p>Eight percent of participants (n = 28) answered yes to the question “Would you consider your parent(s)/guardian(s) as people who hoard?” These participants reported higher hoarding severity on the SI-R Total (M = 23.86 (SD = 2.04) vs. M = 17.21 (SD = 13.11); t (359) = 2.61, p < .01) but not on the PROMIS Anxiety 8a and Depression 8b short forms (both ps > .05). </p></div><div><h3>Conclusions</h3><p>After completing the study, epigenetic ","PeriodicalId":55534,"journal":{"name":"American Journal of Geriatric Psychiatry","volume":null,"pages":null},"PeriodicalIF":7.2,"publicationDate":"2024-02-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139907768","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-19DOI: 10.1016/j.jagp.2024.01.093
Arushi Kapoor MS , Kayla Murphy MD , Amber Khan MD , Rajesh Tampi MS
Behavioral and psychological symptoms of dementia (BPSD) affect up to 90% of people living with dementia and include agitation, hallucinations, delusions, sleep or mood changes. BPSD are challenging to treat and there are limited safe and effective pharmacologic treatments. Electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), Deep Brain Stimulation (DBS), Vagal nerve stimulation (VNS), ketamine, and cannabinoids are interventions that have proven effectiveness for other psychiatric conditions including depression and psychosis. More recently, many of these have also been investigated for the treatment of BPSD.
This presentation will review the current evidence for using ECT, TMS, ketamine, DBS, VNS, and cannabinoids for the treatment of BPSD. Out of these techniques, ECT has been the most studied and shows some benefit for the treatment of BPSD. TMS has also been studied in over 10 trials and most of these studies show an improvement in BPSD. The effect of TMS on apathy in dementia has been examined in multiple studies, the majority of which have shown benefit. DBS has shown some benefit for improving hallucinations in Parkinson disease dementia in one small RCT of six patients, and the procedure was well tolerated. VNS for BPSD has not been studied. Ketamine, in evidence from heterogeneous case reports, has shown to target three distinct behavioral disturbances, agitation, catatonia and depression, in dementia.
Cannabinoids, particularly dronabinol and nabilone, have also been investigated in a number of RCTs and show mixed results for treating agitation in dementia. Sedation was the most common side effect reported but often did not result in discontinuation of therapy.
In conclusion, neuromodulation has increasing evidence for the treatment of BPSD and most studies show good safety profiles. Larger and more rigorous trials are needed to further investigate the effectiveness, safety, and practicality of these interventions in this population. This presentation will summarize the effects of these various interventions, their side effects, doses used, and durations of treatment.
{"title":"Neuromodulation in Behavioral and Psychological Symptoms of Dementia (BPSD)","authors":"Arushi Kapoor MS , Kayla Murphy MD , Amber Khan MD , Rajesh Tampi MS","doi":"10.1016/j.jagp.2024.01.093","DOIUrl":"https://doi.org/10.1016/j.jagp.2024.01.093","url":null,"abstract":"<div><p>Behavioral and psychological symptoms of dementia (BPSD) affect up to 90% of people living with dementia and include agitation, hallucinations, delusions, sleep or mood changes. BPSD are challenging to treat and there are limited safe and effective pharmacologic treatments. Electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), Deep Brain Stimulation (DBS), Vagal nerve stimulation (VNS), ketamine, and cannabinoids are interventions that have proven effectiveness for other psychiatric conditions including depression and psychosis. More recently, many of these have also been investigated for the treatment of BPSD.</p><p>This presentation will review the current evidence for using ECT, TMS, ketamine, DBS, VNS, and cannabinoids for the treatment of BPSD. Out of these techniques, ECT has been the most studied and shows some benefit for the treatment of BPSD. TMS has also been studied in over 10 trials and most of these studies show an improvement in BPSD. The effect of TMS on apathy in dementia has been examined in multiple studies, the majority of which have shown benefit. DBS has shown some benefit for improving hallucinations in Parkinson disease dementia in one small RCT of six patients, and the procedure was well tolerated. VNS for BPSD has not been studied. Ketamine, in evidence from heterogeneous case reports, has shown to target three distinct behavioral disturbances, agitation, catatonia and depression, in dementia.</p><p>Cannabinoids, particularly dronabinol and nabilone, have also been investigated in a number of RCTs and show mixed results for treating agitation in dementia. Sedation was the most common side effect reported but often did not result in discontinuation of therapy.</p><p>In conclusion, neuromodulation has increasing evidence for the treatment of BPSD and most studies show good safety profiles. Larger and more rigorous trials are needed to further investigate the effectiveness, safety, and practicality of these interventions in this population. This presentation will summarize the effects of these various interventions, their side effects, doses used, and durations of treatment.</p></div>","PeriodicalId":55534,"journal":{"name":"American Journal of Geriatric Psychiatry","volume":null,"pages":null},"PeriodicalIF":7.2,"publicationDate":"2024-02-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139908271","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The Age-Friendly Health Systems (AFHS) is an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI). In March 2020, the Veterans Health Administration (VHA) Office of Geriatrics and Extended Care set a goal to become the most extensive integrated healthcare system in the U.S. to be recognized by IHI as Age-Friendly. As of July 10, 2023, 113 VHA Medical Centers have earned IHI recognition across all 18 VISNs in 246 care settings. AFHS uses an essential set of evidence-based practices known as the '4Ms' (Mobility, Mentation, Medication, and What Matters) to improve care for older adults.
The number of older Veterans is increasing rapidly. In Fiscal Year (FY) 2019, 48% of VHA enrollees were ages ≥ 65. Between FY2019-2039, Veterans age ≥ 85 are projected to increase by 38%. At the VA Boston Healthcare System, we identified the acute care setting as an opportunity for improving Age-Friendly care. Due to the rapidly growing number of patients with major neurocognitive disorders and ongoing challenges in finding appropriate placement for them in the community, many of these patients remain in the hospital for extended periods.
Physicians, nurses, and support staff, encounter many opportunities to improve the care of patients with behavioral and psychological disturbances associated with neurocognitive disorders and delirium. Unfortunately, behavioral codes are frequently called for wandering patients and for those who struggle with agitation due to acute or chronic confusion. For Veterans with cognitive deficits, and some with post-traumatic stress disorder, a sudden gathering of many people during these codes can result in increased distress, confusion, and agitation. Moreover, medications administered to treat these disturbances entail significant risks, such as confusion, sedation, infection, falls, and death.
To best support patients and staff, a multidisciplinary team at VA Boston came together to develop Age-Friendly 4Ms initiatives in the acute care setting to improve the safety and well-being of patients and staff. These interventions provide non-pharmacologic interventions, minimizing behavioral codes and medication administration, and shortening length of stay.
In this session, we will present multiple initiatives and innovations implemented in a VA Boston acute setting and their impact on care.
Our geropsychologists will describe the adaptation and implementation of a tailored behavioral intervention. Our clinical resource nurses will share data on dementia education developed to provide nursing and support staff with the knowledge and tools they need to provide Age-Friendly care and improve the well-being of older adults with neurocognitive disorders. This presentation will emphasize adaptations made to support acute care staff. They will also discuss an innovative resource, the “Age-Friendly toolkit”, a versatile collection of items, focusing on the 4Ms, and int
{"title":"The Age-Friendly Health Systems Initiative: Innovations in the Acute Care Setting","authors":"Talya Shahal MD , Kelly O'Malley PhD , Hannah Bashian MEd, PhD , Amanda Smith MSN, RN , Seneca Correa MSN, RN , Kylie Breadmore PTA, BS","doi":"10.1016/j.jagp.2024.01.094","DOIUrl":"https://doi.org/10.1016/j.jagp.2024.01.094","url":null,"abstract":"<div><p>The Age-Friendly Health Systems (AFHS) is an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI). In March 2020, the Veterans Health Administration (VHA) Office of Geriatrics and Extended Care set a goal to become the most extensive integrated healthcare system in the U.S. to be recognized by IHI as Age-Friendly. As of July 10, 2023, 113 VHA Medical Centers have earned IHI recognition across all 18 VISNs in 246 care settings. AFHS uses an essential set of evidence-based practices known as the '4Ms' (Mobility, Mentation, Medication, and What Matters) to improve care for older adults.</p><p>The number of older Veterans is increasing rapidly. In Fiscal Year (FY) 2019, 48% of VHA enrollees were ages ≥ 65. Between FY2019-2039, Veterans age ≥ 85 are projected to increase by 38%. At the VA Boston Healthcare System, we identified the acute care setting as an opportunity for improving Age-Friendly care. Due to the rapidly growing number of patients with major neurocognitive disorders and ongoing challenges in finding appropriate placement for them in the community, many of these patients remain in the hospital for extended periods.</p><p>Physicians, nurses, and support staff, encounter many opportunities to improve the care of patients with behavioral and psychological disturbances associated with neurocognitive disorders and delirium. Unfortunately, behavioral codes are frequently called for wandering patients and for those who struggle with agitation due to acute or chronic confusion. For Veterans with cognitive deficits, and some with post-traumatic stress disorder, a sudden gathering of many people during these codes can result in increased distress, confusion, and agitation. Moreover, medications administered to treat these disturbances entail significant risks, such as confusion, sedation, infection, falls, and death.</p><p>To best support patients and staff, a multidisciplinary team at VA Boston came together to develop Age-Friendly 4Ms initiatives in the acute care setting to improve the safety and well-being of patients and staff. These interventions provide non-pharmacologic interventions, minimizing behavioral codes and medication administration, and shortening length of stay.</p><p>In this session, we will present multiple initiatives and innovations implemented in a VA Boston acute setting and their impact on care.</p><p>Our geropsychologists will describe the adaptation and implementation of a tailored behavioral intervention. Our clinical resource nurses will share data on dementia education developed to provide nursing and support staff with the knowledge and tools they need to provide Age-Friendly care and improve the well-being of older adults with neurocognitive disorders. This presentation will emphasize adaptations made to support acute care staff. They will also discuss an innovative resource, the “Age-Friendly toolkit”, a versatile collection of items, focusing on the 4Ms, and int","PeriodicalId":55534,"journal":{"name":"American Journal of Geriatric Psychiatry","volume":null,"pages":null},"PeriodicalIF":7.2,"publicationDate":"2024-02-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139908272","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-19DOI: 10.1016/j.jagp.2024.01.069
Aaron Van Wright MD , Lessley Chiriboga MPH , Elizabeth Santos MPH, DFAPA, DFAAGP , Tatyana Shteinlukht MPH
Diversity, Equity, and Inclusion (DEI) is the organizational approach to ensure fair treatment and welcomed participation of all groups. We can trace the roots of DEI back to the 1906’s civil rights movement and the African American struggle. As the movement evolved, it encompassed other groups vulnerable to discrimination. These groups include people of different ages, races, religions, ethnicities, different physical abilities, neurodiversity, socioeconomic means, genders, and sexual orientations.
DEI is an important aspect of our healthcare institutions in the way of recruitment, admission, hiring, promotions, and practices. DEI is now under fire in several states. This has implications for the quality of training, effectiveness, and delivery of healthcare to all diverse populations. Our geriatric populations have grown more diverse by way of an aging immigrant population entering the healthcare system, as well as our own native-born needing more access to healthcare as they've aged. With these populations in mind, the need to continue creating and nurturing a diverse provider culture that is attuned to the complex needs of this growingly more diverse aging population is imperative.
At the time of this writing, there have been 30 bills that seek to eliminate DEI from public institutions. Texas has passed Senate Bill 17 which bans diversity programs in public universities. The state of Florida teetered on effectively banning AP Psychology courses as part of the governor's “Stop W.O.K.E Act.” This is an effort to stop teachings about sexual and gender identity topics. Florida has also been in the news for school history curriculum proposals that would teach how some blacks benefitted from slavery. Just as states are eliminating once-protected aspects of reproductive rights and generating talk of reproductive bans on a Federal level, DEI is following this course. This country may methodically eliminate DEI at its peril. We must examine the effects this might have on our academic and clinical practices and our endeavor to deliver thoughtful inclusive health care to our aging population.
{"title":"The Future of Diversity, Equity, and Inclusion in Embattled Environments: The Challenge to Educators and Providers Serving a Growingly More Diverse Geriatric Population and How to Overcome that Challenge","authors":"Aaron Van Wright MD , Lessley Chiriboga MPH , Elizabeth Santos MPH, DFAPA, DFAAGP , Tatyana Shteinlukht MPH","doi":"10.1016/j.jagp.2024.01.069","DOIUrl":"https://doi.org/10.1016/j.jagp.2024.01.069","url":null,"abstract":"<div><p>Diversity, Equity, and Inclusion (DEI) is the organizational approach to ensure fair treatment and welcomed participation of all groups. We can trace the roots of DEI back to the 1906’s civil rights movement and the African American struggle. As the movement evolved, it encompassed other groups vulnerable to discrimination. These groups include people of different ages, races, religions, ethnicities, different physical abilities, neurodiversity, socioeconomic means, genders, and sexual orientations.</p><p>DEI is an important aspect of our healthcare institutions in the way of recruitment, admission, hiring, promotions, and practices. DEI is now under fire in several states. This has implications for the quality of training, effectiveness, and delivery of healthcare to all diverse populations. Our geriatric populations have grown more diverse by way of an aging immigrant population entering the healthcare system, as well as our own native-born needing more access to healthcare as they've aged. With these populations in mind, the need to continue creating and nurturing a diverse provider culture that is attuned to the complex needs of this growingly more diverse aging population is imperative.</p><p>At the time of this writing, there have been 30 bills that seek to eliminate DEI from public institutions. Texas has passed Senate Bill 17 which bans diversity programs in public universities. The state of Florida teetered on effectively banning AP Psychology courses as part of the governor's “Stop W.O.K.E Act.” This is an effort to stop teachings about sexual and gender identity topics. Florida has also been in the news for school history curriculum proposals that would teach how some blacks benefitted from slavery. Just as states are eliminating once-protected aspects of reproductive rights and generating talk of reproductive bans on a Federal level, DEI is following this course. This country may methodically eliminate DEI at its peril. We must examine the effects this might have on our academic and clinical practices and our endeavor to deliver thoughtful inclusive health care to our aging population.</p></div>","PeriodicalId":55534,"journal":{"name":"American Journal of Geriatric Psychiatry","volume":null,"pages":null},"PeriodicalIF":7.2,"publicationDate":"2024-02-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139908308","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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