Fatness but Not Fitness Linked to BrainAge: Longitudinal Changes in Brain Aging during an Exercise Intervention

PURPOSE

Fitness, physical activity, body composition, and sleep have all been proposed to explain differences in brain health. We hypothesized that an exercise intervention would result in improved fitness and body composition and would be associated with improved structural brain health.

METHODS

In a randomized controlled trial, we studied 485 older adults who engaged in an exercise intervention ( n = 225) or a nonexercise comparison condition ( n = 260). Using magnetic resonance imaging, we estimated the physiological age of the brain (BrainAge) and derived a predicted age difference compared with chronological age (brain-predicted age difference (BrainPAD)). Aerobic capacity, physical activity, sleep, and body composition were assessed and their impact on BrainPAD explored.

RESULTS

There were no significant differences between experimental groups for any variable at any time point. The intervention group gained fitness, improved body composition, and increased total sleep time but did not have significant changes in BrainPAD. Analyses of changes in BrainPAD independent of group assignment indicated significant associations with changes in body fat percentage ( r (479) = 0.154, P = 0.001), and visceral adipose tissue (VAT) ( r (478) = 0.141, P = 0.002), but not fitness ( r (406) = -0.075, P = 0.129), sleep ( r (467) range, -0.017 to 0.063; P range, 0.171 to 0.710), or physical activity ( r (471) = -0.035, P = 0.444). With linear regression, changes in body fat percentage and VAT significantly predicted changes in BrainPAD ( β = 0.948, P = 0.003) with 1-kg change in VAT predicting 0.948 yr of change in BrainPAD.

CONCLUSIONS

In cognitively normal older adults, exercise did not appear to impact BrainPAD, although it was effective in improving fitness and body composition. Changes in body composition, but not fitness, physical activity, or sleep impacted BrainPAD. These findings suggest that focus on weight control, particularly reduction of central obesity, could be an interventional target to promote healthier brains.

Sex differences in plasma proteomic markers in late-life depression

Previous studies have shown significant sex-specific differences in major depressive disorder (MDD) in multiple biological parameters. Most studies focused on young and middle-aged adults, and there is a paucity of information about sex-specific biological differences in older adults with depression (aka, late-life depression (LLD)). To address this gap, this study aimed to evaluate sex-specific biological abnormalities in a large group of individuals with LLD using an untargeted proteomic analysis. We quantified 344 plasma proteins using a multiplex assay in 430 individuals with LLD and 140 healthy comparisons (HC) (age range between 60 and 85 years old for both groups). Sixty-six signaling proteins were differentially expressed in LLD (both sexes). Thirty-three proteins were uniquely associated with LLD in females, while six proteins were uniquely associated with LLD in males. The main biological processes affected by these proteins in females were related to immunoinflammatory control. In contrast, despite the smaller number of associated proteins, males showed dysregulations in a broader range of biological pathways, including immune regulation pathways, cell cycle control, and metabolic control. Sex has a significant impact on biomarker changes in LLD. Despite some overlap in differentially expressed biomarkers, males and females show different patterns of biomarkers changes, and males with LLD exhibit abnormalities in a larger set of biological processes compared to females. Our findings can provide novel targets for sex-specific interventions in LLD.

Home-based primary care-mental health integration in the Veterans Health Administration: An updated evaluation of practice patterns

Starting in 2008, the U.S. Veterans Health Administration required the integration of mental health providers (MH providers) in Home-Based Primary Care (HBPC) programs to promote access to and quality of mental health services for veterans enrolled in HBPC. Surveys were administered in both 2010 and 2019 to HBPC program directors and MH providers to evaluate the status of mental health practice in HBPC programs and inform the continued development of program resources. Findings reported here summarize responses to the 2019 survey and highlight changes compared to 2010 in key areas (e.g., mental health staffing and workload, services provided, training needs, and integration with and impact on the HBPC team). In 2019, approximately half of invited HBPC program directors (n = 66) and MH providers (n = 136) completed the voluntary, anonymous, and confidential surveys. Descriptive and bivariate analyses of quantitative data, and thematic analyses of open-text responses, were conducted. Comparisons of survey responses were made between the 2019 surveys and those collected in 2010 from MH providers (n = 132) and program directors (n = 112), and indicated similar patterns of variability in program staffing and practices across sites, with ongoing behavioral/mental health education and training needs reported for both MH providers and teams. The perceived degree and value of mental health integration in HBPC also remained high. Survey responses suggest integration of mental health services into HBPC continues to be feasible and improves access to key services. Findings may inform the expansion of home-based mental health services for meeting the needs of an aging population. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Relationship between baseline plasma p-tau181 and longitudinal changes in cognition and structural brain measures in a cohort of cognitively unimpaired older adults

INTRODUCTION

Preclinical Alzheimer's disease (AD) affects a significant proportion of cognitively unimpaired (CU) older adults. Currently, blood-based biomarkers detect very early changes in the AD continuum with great accuracy.

METHODS

We measured baseline plasma phosphorylated tau (p-tau)181 using electrochemiluminescence (ECL)-based assay (MesoScale Discovery) in 533 CU older adults. Follow-up lasted up to 18 months. Cognitive performance assessment included memory and cognitive control. Structural brain measures included cortical thickness, which includes the AD magnetic resonance imaging (AD MRI) signature, and hippocampal volume.

RESULTS

In this cohort of CU older adults, baseline plasma p-tau181 levels were not associated with short-term changes in cognition and structural brain measures. Also, baseline plasma p-tau levels did not influence the effects of behavioral interventions (exercise or mindfulness) on cognitive and structural brain changes.

DISCUSSION

The short follow-up and healthy status of this CU cohort might have limited the sensitivity of plasma p-tau181 in detecting changes associated with AD pathology.

Associations of Lean Mass, Muscular Strength, and Physical Function with Trabecular Bone Score in Older Adults

INTRODUCTION/BACKGROUND

Trabecular bone score (TBS) is an indirect measurement of bone quality and microarchitecture determined from dual-energy X-ray absorptiometry (DXA) imaging of the lumbar spine. TBS predicts fracture risk independent of bone mass/density, suggesting this assessment of bone quality adds value to the understanding of patients' bone health. While lean mass and muscular strength have been associated with higher bone density and lower fracture risk among older adults, the literature is limited regarding the relationship of lean mass and strength with TBS. The purpose of this study was to determine associations of DXA-determined total body and trunk lean mass, maximal muscular strength, and gait speed as a measure of physical function, with TBS in 141 older adults (65-84 yr, 72.5 +/- 5.1 yr, 74% women).

METHODOLOGY

Assessments included lumbar spine (L1-L4) bone density and total body and trunk lean mass by DXA, lower body (leg press) and upper body (seated row) strength by one repetition maximum tests, hand grip strength, and usual gait speed. TBS was derived from the lumbar spine DXA scan. Multivariable linear regression determined the contribution of proposed predictors to TBS.

RESULTS

After adjusting for age, sex, and lumbar spine bone density, upper body strength significantly predicted TBS (unadjusted/adjusted R2= 0.16/ 0.11, β coefficient =0.378, p=0.005), while total body lean mass index showed a trend in the expected direction (β coefficient =0.243, p=0.053). Gait speed and grip strength were not associated with TBS (p>0.05).

CONCLUSION

Maximum strength of primarily back muscles measured as the seated row appears important to bone quality as measured by TBS, independent of bone density. Additional research on exercise training targeting back strength is needed to determine its clinical utility in preventing vertebral fractures among older adults.

Beyond maintaining safety: Examining the benefit of emotion-centered problem solving therapy added to safety planning for reducing late life suicide risk

Few clinical trials have examined brief non-pharmacological treatments for reducing suicide risk in older Veterans, a high-risk group. Problem Solving Therapy (PST) is a promising psychosocial intervention for reducing late life suicide risk by increasing adaptive coping to problems through effective problem solving and related coping skills. The current randomized clinical trial will compare the efficacy of six telephone-delivered sessions of Safety Planning (enhanced usual care; EUC) only or an updated version of PST (emotion-centered PST [EC-PST]) + EUC to determine the added clinical benefit of EC-PST for reducing severity of suicidal ideation and for increasing reasons for living, a critical protective factor. Participants randomized to EC-PST + EUC or EUC only will be 150 Veterans (75 each) with active suicidal ideation who are aged 60 or older; have a current DSM-5 anxiety, depressive, and/or trauma-related disorder; and without significant cognitive impairment. Primary outcomes (Geriatric Suicide Ideation Scale and Reasons for Living-Older Adults scale) will be assessed at 11 timepoints: baseline, after each of 6 treatment sessions, posttreatment, and at follow-up at 1, 3, and 6 months posttreatment, and analyzed using mixed effects modeling. Additionally, moderators and mediators of primary outcomes will be examined-functional disability, executive dysfunction, and problem-solving ability. Qualitative feedback from participants will identify potential Veteran-centric changes to the EC-PST protocol and to EUC. Ultimately, the goal of this study is to inform the evidence-based clinical practice guidelines for treatments to reduce suicide risk in older Veterans and specifically to inform clinical decision-making regarding the merit of adding EC-PST to EUC.

Effects of Mindfulness Training and Exercise on Cognitive Function in Older Adults: A Randomized Clinical Trial

IMPORTANCE

Episodic memory and executive function are essential aspects of cognitive functioning that decline with aging. This decline may be ameliorable with lifestyle interventions.

OBJECTIVE

To determine whether mindfulness-based stress reduction (MBSR), exercise, or a combination of both improve cognitive function in older adults.

DESIGN, SETTING, AND PARTICIPANTS

This 2 × 2 factorial randomized clinical trial was conducted at 2 US sites (Washington University in St Louis and University of California, San Diego). A total of 585 older adults (aged 65-84 y) with subjective cognitive concerns, but not dementia, were randomized (enrollment from November 19, 2015, to January 23, 2019; final follow-up on March 16, 2020).

INTERVENTIONS

Participants were randomized to undergo the following interventions: MBSR with a target of 60 minutes daily of meditation (n = 150); exercise with aerobic, strength, and functional components with a target of at least 300 minutes weekly (n = 138); combined MBSR and exercise (n = 144); or a health education control group (n = 153). Interventions lasted 18 months and consisted of group-based classes and home practice.

MAIN OUTCOMES AND MEASURES

The 2 primary outcomes were composites of episodic memory and executive function (standardized to a mean [SD] of 0 [1]; higher composite scores indicate better cognitive performance) from neuropsychological testing; the primary end point was 6 months and the secondary end point was 18 months. There were 5 reported secondary outcomes: hippocampal volume and dorsolateral prefrontal cortex thickness and surface area from structural magnetic resonance imaging and functional cognitive capacity and self-reported cognitive concerns.

RESULTS

Among 585 randomized participants (mean age, 71.5 years; 424 [72.5%] women), 568 (97.1%) completed 6 months in the trial and 475 (81.2%) completed 18 months. At 6 months, there was no significant effect of mindfulness training or exercise on episodic memory (MBSR vs no MBSR: 0.44 vs 0.48; mean difference, -0.04 points [95% CI, -0.15 to 0.07]; P = .50; exercise vs no exercise: 0.49 vs 0.42; difference, 0.07 [95% CI, -0.04 to 0.17]; P = .23) or executive function (MBSR vs no MBSR: 0.39 vs 0.31; mean difference, 0.08 points [95% CI, -0.02 to 0.19]; P = .12; exercise vs no exercise: 0.39 vs 0.32; difference, 0.07 [95% CI, -0.03 to 0.18]; P = .17) and there were no intervention effects at the secondary end point of 18 months. There was no significant interaction between mindfulness training and exercise (P = .93 for memory and P = .29 for executive function) at 6 months. Of the 5 prespecified secondary outcomes, none showed a significant improvement with either intervention compared with those not receiving the intervention.

CONCLUSIONS AND RELEVANCE

Among older adults with subjective cognitive concerns, mindfulness training, exercise, or both did not result in significant differences in improvement in episodic memory or executive function at 6 months. The findings do not support the use of these interventions for improving cognition in older adults with subjective cognitive concerns.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02665481.

Fatness, fitness and the aging brain: A cross sectional study of the associations between a physiological estimate of brain age and physical fitness, activity, sleep, and body composition

Introduction

Changes in brain structure and function occur with aging. However, there is substantial heterogeneity both in terms of when these changes begin, and the rate at which they progress. Understanding the mechanisms and/or behaviors underlying this heterogeneity may allow us to act to target and slow negative changes associated with aging.

Methods

Using T1 weighted MRI images, we applied a novel algorithm to determine the physiological age of the brain (brain-predicted age) and the predicted age difference between this physiologically based estimate and chronological age (BrainPAD) to 551 sedentary adults aged 65 to 84 with self-reported cognitive complaint measured at baseline as part of a larger study. We also assessed maximal aerobic capacity with a graded exercise test, physical activity and sleep with accelerometers, and body composition with dual energy x-ray absorptiometry. Associations were explored both linearly and logistically using categorical groupings.

Results

Visceral Adipose Tissue (VAT), Total Sleep Time (TST) and maximal aerobic capacity all showed significant associations with BrainPAD. Greater VAT was associated with higher (i.e,. older than chronological) BrainPAD (r = 0.149 p = 0.001)Greater TST was associated with higher BrainPAD (r = 0.087 p = 0.042) and greater aerobic capacity was associated with lower BrainPAD (r = - 0.088 p = 0.040). With linear regression, both VAT and TST remained significant (p = 0.036 and 0.008 respectively). Each kg of VAT predicted a 0.741 year increase in BrainPAD, and each hour of increased TST predicted a 0.735 year increase in BrainPAD. Maximal aerobic capacity did not retain statistical significance in fully adjusted linear models.

Discussion

Accumulation of visceral adipose tissue and greater total sleep time, but not aerobic capacity, total daily physical activity, or sleep quantity and/or quality are associated with brains that are physiologically older than would be expected based upon chronological age alone (BrainPAD).

Mindfulness-Based Stress Reduction in Older Individuals: Who Benefits the Most?

BACKGROUND

Preexisting patient characteristics may influence the outcome of mindfulness training, and a composite predictive index may be most informative in predicting outcome.

PRIMARY STUDY OBJECTIVE

To develop a predictive index from baseline patient characteristics to determine which characteristics are associated with improvement following mindfulness-based stress reduction (MBSR) vs health education and to examine whether intreatment variables-reflecting adherence to the mindfulness intervention-predicted clinical outcome.

METHODS

In a secondary data analysis, a composite moderator statistical approach created a predictive index from baseline participant characteristics that were associated with clinical global impressions improvement following intervention.

SETTING

Data come from a 2-site, randomized controlled trial which took place in medical centers in St Louis, Missouri, and San Diego, California.

PARTICIPANTS

Included 103 older adults with anxiety and/or depressive disorders randomized to either 8 sessions of MBSR or health education classes.

INTERVENTION

MBSR was delivered in 8 sessions of 2 hours each by credentialed health care providers. The control condition consisted of health education classes designed to match the length and timing of the MBSR sessions.

PRIMARY OUTCOME MEASURES

The Clinical Global Impressions-Improvement scale was used to measure symptom improvement and was assigned by a blind rater.

RESULTS

The combined moderator approach generated a predictive index with a moderate effect size (0.46; 95% CI: 0.35, 0.57). Individuals who demonstrated improvement on the scale following MBSR were more likely to be younger, female, with lower psychological symptom severity, and less likely to have a diagnosis of depression or to be taking selective serotonin reuptake inhibitors.

DISCUSSION

Baseline characteristics predicted clinical response with MBSR in older adults. These predictive factors, if replicated and validated, could determine which patients are most likely to benefit from mindfulness training and lead to personalized strategies to maximize outcomes. The study was registered on ClinicalTrials.gov (identifier: NCT01693874).

Covariance and Correlation Analysis of Resting State Functional Magnetic Resonance Imaging Data Acquired in a Clinical Trial of Mindfulness-Based Stress Reduction and Exercise in Older Individuals

We describe and apply novel methodology for whole-brain analysis of resting state fMRI functional connectivity data, combining conventional multi-channel Pearson correlation with covariance analysis. Unlike correlation, covariance analysis preserves signal amplitude information, which feature of fMRI time series may carry physiological significance. Additionally, we demonstrate that dimensionality reduction of the fMRI data offers several computational advantages including projection onto a space of manageable dimension, enabling linear operations on functional connectivity measures and exclusion of variance unrelated to resting state network structure. We show that group-averaged, dimensionality reduced, covariance and correlation matrices are related, to reasonable approximation, by a single scalar factor. We apply this methodology to the analysis of a large, resting state fMRI data set acquired in a prospective, controlled study of mindfulness training and exercise in older, sedentary participants at risk for developing cognitive decline. Results show marginally significant effects of both mindfulness training and exercise in both covariance and correlation measures of functional connectivity.

Problem Solving Training for Veterans with Complex Comorbidities: Treatment Delivery Adaptations during COVID-19

OBJECTIVES

To summarize adaptations due to COVID-19 for VA Problem Solving Training (PST) for clinicians serving medically complex patients and to compare patient mental health outcomes in the year before (2019) and during COVID-19 (2020).

METHODS

Clinicians attended a multi-day workshop and up to 6 months of small-group consultation for two training cases. In 2019 and 2020, 122 Veteran patients completed baseline and posttreatment measures of depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7 item), and negative problem-solving beliefs (Negative Problem Orientation Questionnaire). Qualitative data were collected on clinician's pandemic-related treatment implementation challenges.

RESULTS

Program adaptations during COVID-19 addressed challenges due to delivering treatment by telephone, video, or in person; Veteran patient recruitment barriers; and privacy issues for telephone and video. Veterans in both pre-pandemic and COVID-19 cohorts had significant improvements in depression, anxiety, and negative problem-solving beliefs, with no significant differences in the amount of improvement between the two cohorts.

CONCLUSIONS

Flexibilities afforded to clinicians delivering the PST training program during the pandemic addressed key obstacles and barriers to recruitment, and implementation did not diminish the effectiveness of the intervention.

CLINICAL IMPLICATIONS

Findings support continued implementation of the PST training program with added flexibility to treatment delivery beyond the pandemic.

Guided self-management targeting anxiety and activity participation in older Veterans

OBJECTIVES

This study examined the acceptance, feasibility, and preliminary effects of a guided self-management intervention using video delivery and a telephone coach on anxiety and activity engagement.

METHOD

Ten Veterans aged 60 years or older with anxiety disorders determined by Structured Clinical Interview for Diagnostic and Statistical Manual 5^th edition (SCID-5) at baseline visit participated in this non-randomized study examining a 4-week guided self-management intervention for anxiety. Feasibility was examined using participation engagement with the intervention. Measures of anxiety (Geriatric Anxiety Scale, PROMIS Anxiety Scale, Anxiety Control Questionnaire), depression (Patient Health Questionnaire 9-item), and activity participation (modified Activity Card Sort) administered at baseline and final (week 8) visit provided estimates of preliminary intervention effects. The Geriatric Anxiety Scale also was administered by phone at week 4. Participants completed a semi-structured qualitative interview at the final visit, which provided information about the acceptability, benefits of intervention, and barriers to engagement.

RESULTS

All participants (N = 10) reported that the intervention somewhat or completely met their expectations, demonstrating intervention acceptability. Intervention completers (n = 9) experienced reduced anxiety over the first 4 weeks, alongside significant improvements in anxiety control and personalized activity goals across 8 weeks. However, anxiety symptoms tended to return to baseline at follow-up. Participants identified the relaxation videos and promotion of a daily relaxation routine as the most helpful intervention components.

CONCLUSIONS

Findings indicate that the intervention may improve activity participation and reduce anxiety. Thus, guided self-management interventions show promise for reducing distress and maintaining engagement later in life.

The Association between Age and Experienced Emotions in Hoarding Disorder

Objectives: Hoarding disorder (HD) is conceptualized as a fear-based disorder and exposure to sorting/discarding possessions is a core part of treatment. However, there has been no investigation of age-related differences in emotional reaction to sorting. The objective of this study was to explore the association between age and affective response during a sorting task.Methods: Forty-nine adults with HD completed a standardized sorting task. Participants reported their current emotion before and after the sorting task and reported their subjective distress throughout the task.Results: Older participants reported significantly lower distress ratings. Only 43% of participants reported fear prior to the task and 22% reported fear after the task. The probability of reporting fear before and after the task decreased significantly with age.Conclusions: Fear may not be the emotion experienced when discarding items, particularly for older adults with HD. Future work should focus on mechanisms of action in HD treatment.Clinical Implications: Clinicians should not assume fear or anxiety to be the primary emotional response in older adults with HD when engaged in an exposure to sorting/discarding. Older hoarding patients with a more fear-oriented aversion to sorting possessions may require a treatment emphasis on increasing the percentage of items discarded.

Acceptance and commitment therapy for older people with treatment-resistant generalised anxiety disorder: the FACTOID feasibility study

BACKGROUND

Generalised anxiety disorder, characterised by excessive anxiety and worry, is the most common anxiety disorder among older people. It is a condition that may persist for decades and is associated with numerous negative outcomes. Front-line treatments include pharmacological and psychological therapy, but many older people do not find these treatments effective. Guidance on managing treatment-resistant generalised anxiety disorder in older people is lacking.

OBJECTIVES

To assess whether or not a study to examine the clinical effectiveness and cost-effectiveness of acceptance and commitment therapy for older people with treatment-resistant generalised anxiety disorder is feasible, we developed an intervention based on acceptance and commitment therapy for this population, assessed its acceptability and feasibility in an uncontrolled feasibility study and clarified key study design parameters.

DESIGN

Phase 1 involved qualitative interviews to develop and optimise an intervention as well as a survey of service users and clinicians to clarify usual care. Phase 2 involved an uncontrolled feasibility study and qualitative interviews to refine the intervention.

SETTING

Participants were recruited from general practices, Improving Access to Psychological Therapies services, Community Mental Health Teams and the community.

PARTICIPANTS

Participants were people aged ≥ 65 years with treatment-resistant generalised anxiety disorder.

INTERVENTION

Participants received up to 16 one-to-one sessions of acceptance and commitment therapy, adapted for older people with treatment-resistant generalised anxiety disorder, in addition to usual care. Sessions were delivered by therapists based in primary and secondary care services, either in the clinic or at participants' homes. Sessions were weekly for the first 14 sessions and fortnightly thereafter.

MAIN OUTCOME MEASURES

The co-primary outcome measures for phase 2 were acceptability (session attendance and satisfaction with therapy) and feasibility (recruitment and retention). Secondary outcome measures included additional measures of acceptability and feasibility and self-reported measures of anxiety, worry, depression and psychological flexibility. Self-reported outcomes were assessed at 0 weeks (baseline) and 20 weeks (follow-up). Health economic outcomes included intervention and resource use costs and health-related quality of life.

RESULTS

Fifteen older people with treatment-resistant generalised anxiety disorder participated in phase 1 and 37 participated in phase 2. A high level of feasibility was demonstrated by a recruitment rate of 93% and a retention rate of 81%. A high level of acceptability was found with respect to session attendance (70% of participants attended ≥ 10 sessions) and satisfaction with therapy was adequate (60% of participants scored ≥ 21 out of 30 points on the Satisfaction with Therapy subscale of the Satisfaction with Therapy and Therapist Scale-Revised, although 80% of participants had not finished receiving therapy at the time of rating). Secondary outcome measures and qualitative data further supported the feasibility and acceptability of the intervention. Health economic data supported the feasibility of examining cost-effectiveness in a future randomised controlled trial. Although the study was not powered to examine clinical effectiveness, there was indicative evidence of improvements in scores for anxiety, depression and psychological flexibility.

LIMITATIONS

Non-specific therapeutic factors were not controlled for, and recruitment in phase 2 was limited to London.

CONCLUSIONS

There was evidence of high levels of feasibility and acceptability and indicative evidence of improvements in symptoms of anxiety, depression and psychological flexibility. The results of this study suggest that a larger-scale randomised controlled trial would be feasible to conduct and is warranted.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12268776.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 54. See the NIHR Journals Library website for further project information.

Acceptance and commitment therapy for late-life treatment-resistant generalised anxiety disorder: a feasibility study

Background

Generalised anxiety disorder (GAD) is the most common anxiety disorder in older people. First-line management includes pharmacological and psychological therapies, but many do not find these effective or acceptable. Little is known about how to manage treatment-resistant generalised anxiety disorder (TR-GAD) in older people.

Objectives

To examine the acceptability, feasibility and preliminary estimates of the effectiveness of acceptance and commitment therapy (ACT) for older people with TR-GAD.

Participants

People aged ≥65 years with TR-GAD (defined as not responding to GAD treatment, tolerate it or refused treatment) recruited from primary and secondary care services and the community.

Intervention

Participants received up to 16 one-to-one sessions of ACT, developed specifically for older people with TR-GAD, in addition to usual care.

Measurements

Co-primary outcomes were feasibility (defined as recruitment of ≥32 participants and retention of ≥60% at follow-up) and acceptability (defined as participants attending ≥10 sessions and scoring ≥21/30 on the satisfaction with therapy subscale). Secondary outcomes included measures of anxiety, worry, depression and psychological flexibility (assessed at 0 and 20 weeks).

Results

Thirty-seven participants were recruited, 30 (81%) were retained and 26 (70%) attended ≥10 sessions. A total of 18/30 (60%) participants scored ≥21/30 on the satisfaction with therapy subscale. There was preliminary evidence suggesting that ACT may improve anxiety, depression and psychological flexibility.

Conclusions

There was evidence of good feasibility and acceptability, although satisfaction with therapy scores suggested that further refinement of the intervention may be necessary. Results indicate that a larger-scale randomised controlled trial of ACT for TR-GAD is feasible and warranted.

Mindfulness, Education, and Exercise for age-related cognitive decline: Study protocol, pilot study results, and description of the baseline sample

BACKGROUND/AIMS

Age-related cognitive decline is a pervasive problem in our aging population. To date, no pharmacological treatments to halt or reverse cognitive decline are available. Behavioral interventions, such as physical exercise and Mindfulness-Based Stress Reduction, may reduce or reverse cognitive decline, but rigorously designed randomized controlled trials are needed to test the efficacy of such interventions.

METHODS

Here, we describe the design of the Mindfulness, Education, and Exercise study, an 18-month randomized controlled trial that will assess the effect of two interventions-mindfulness training plus moderate-to-vigorous intensity exercise or moderate-to-vigorous intensity exercise alone-compared with a health education control group on cognitive function in older adults. An extensive battery of biobehavioral assessments will be used to understand the mechanisms of cognitive remediation, by using structural and resting state functional magnetic resonance imaging, insulin sensitivity, inflammation, and metabolic and behavioral assessments.

RESULTS

We provide the results from a preliminary study (n = 29) of non-randomized pilot participants who received both the exercise and Mindfulness-Based Stress Reduction interventions. We also provide details on the recruitment and baseline characteristics of the randomized controlled trial sample (n = 585).

CONCLUSION

When complete, the Mindfulness, Education, and Exercise study will inform the research community on the efficacy of these widely available interventions improve cognitive functioning in older adults.

Does patient expectancy account for the cognitive and clinical benefits of mindfulness training in older adults?

OBJECTIVES

Patient expectations of treatment effects could influence neuropsychological and clinical outcomes in clinical trials of behavioral and lifestyle interventions, which could potentially confound the interpretation of findings. Our aim was to examine whether patient expectancy mediated effectiveness of Mindfulness-Based Stress Reduction (MBSR) for improving cognitive function and clinical outcome.

METHODS

The present study uses data from a single-blind, multi-site, randomized controlled trial comparing MBSR to a health education attention control in older adults with anxiety and/or depressive disorders and subjective cognitive concerns. Using the Credibility and Expectations Questionnaire, we measured expectancy and perceived credibility of the interventions assigned to patients. Using mediational analysis, we examined the influence of expectancy and credibility on two key outcomes: memory performance and clinical global improvement.

RESULTS

Neither expectancy nor perceived credibility of intervention accounted significantly for MBSR's effectiveness for memory test performance or clinical global improvement.

CONCLUSION

In this clinical trial, expectancy for improvement did not account for the effectiveness of MBSR on memory performance or clinical outcomes in depressed and anxious older adults. We advise that clinical trials of behavioral and lifestyle interventions for brain health in older adults should measure and test the role of expectancy.

Technology use and preferences for mental health self-management interventions among older veterans

OBJECTIVES

The United States Department of Veterans Affairs offers numerous technology-delivered interventions to self-manage mental health problems. It is unknown, however, what barriers older military veterans face to using these technologies and how willing they would be to use technologies for mental health concerns.

METHODS

Seventy-seven veterans (M_age = 69.16 years; SD = 7.10) completed interviews in a concurrent mixed methods study. Interviewers asked about technology ownership and described four modalities of delivering self-management interventions: printed materials, DVDs, Internet, and mobile apps. Interviewers obtained feedback about each modality's benefits, barriers, and facilitators. Participants ranked their self-management modalities preferences alone and compared with counseling. Multivariable adjusted logistic regression and qualitative analyses were conducted to investigate the reasons contributing to preferences.

RESULTS

Most reported owning a computer (84.4%), having home Internet (80.5%), and a smartphone (70.1%). Participants preferred printed materials (35.1%) over mobile apps (28.6%), Internet (24.7%), and DVDs (13.0%). Lower computer proficiency was associated with preferring DVDs; higher proficiency was associated with Internet and mobile interventions. Residing in an urban area was associated with mobile apps. When counseling was an option, 66% identified this as their first preference. Qualitative findings showed veterans' desire for information, training, and provider support with technology.

CONCLUSIONS

Older veterans reported high technology ownership rates but varied preferences for self-management interventions. Notably, two-thirds preferred some form of technology, which points to the importance of ensuring that providers offer existing technology-delivered interventions to older veterans. Veterans' strong preference for counseling emphasizes the need for human support alongside self-management.

A Case Report of Problem Solving Therapy for Reducing Suicide Risk in Older Adults with Anxiety Disorders

Objectives: Suicide is a global public health problem among older adults. Problem-solving therapy (PST) has demonstrated promise in reducing late-life suicide risk, chiefly in secondary analyses of studies on late-life depression. PST mitigates negative beliefs about one's problem-solving abilities and maladaptive problem-solving styles, which suicidal older adults report. The effects of PST on suicide risk in older adults with primary anxiety disorder diagnoses have not been examined. Anxiety is a risk factor for suicide, but it is less studied in research on suicide compared to depression. This paper describes two cases of older individuals with anxiety disorders and suicidal ideation who completed six sessions of PST. Methods: Assessments of suicide risk, anxiety, depressive symptoms, and problem-solving ability were administered. Results: Both cases exhibited a clinically significant reduction in suicide risk, along with reductions in anxiety, worry, and depressive symptoms by posttreatment. Conclusions & Clinical Implications: Findings highlight the potential for PST as a psychotherapeutic intervention for reducing suicide risk in older adults with anxiety disorders.

A qualitative study of older adults' perspectives on initiating exercise and mindfulness practice

Background

Mindfulness practice and exercise are ways by which older adults can improve and maintain their physical, emotional and cognitive health.

Methods

This single-site qualitative study gathered insights of older adults’ perceptions about initiating and maintaining mindfulness and exercise practices. We carried out focus groups with 41 adults aged 65–85 who had recently initiated Mindfulness Based Stress Reduction (MBSR), structured exercise, or their combination as part of participation in a clinical trial. We used a semi-structured interview to ask them open-ended questions regarding the benefits, barriers and facilitators of participating in mindfulness and/or exercise interventions. The interview also included questions regarding translation of these practices into community settings as well as the long-term maintenance potential of these practices.

Results

Older adults indicated that the mindfulness training increased their awareness and self-reflection and fostered a more self-accepting attitude. Furthermore, they improved their self-care habits and reported having better familial and social relationships. The main barrier for both the exercise and Mindfulness group was time management. The social benefits and sense of community were some of the primary motivators for older adults in the exercise and/or MBSR interventions. However, the research on how to motivate older adults to initiate healthy behavioral changes also needs to be answered. The benefits of exercise and MBSR are a motivation in and of themselves, as indicated by some of the participants.

Conclusions

This study indicates that mindfulness training and exercise can serve as tools to cultivate important health lifestyle qualities among older adults, who are in the midst of mental, social, emotional and physical change. If it were not for the purpose of the research or the incentives provided by the research team, these older adults may have never started the healthy behavioral changes. From the responses, this may indicate that older adults may need more incentives to begin and maintain behavioral changes other than for their own health benefit.

Comorbid anxiety in late-life depression: Relationship with remission and suicidal ideation on venlafaxine treatment

OBJECTIVE

The purpose of this study was to examine the influence of comorbid anxiety symptoms on antidepressant treatment remission in older adults with major depressive disorder (MDD).

METHOD

In this multisite clinical trial, 468 older adults aged 60 years or older with MDD received open-label protocolized treatment with venlafaxine extended release (ER) titrated to a maximum of 300 mg daily. At baseline, anxiety was assessed with the Anxiety Sensitivity Index, the Brief Symptom Inventory (BSI) anxiety subscale, and the Penn State Worry Questionnaire. To measure treatment response, depressive symptoms and suicidality were assessed every 1-2 weeks with the Montgomery-Asberg Depression Rating Scale and the 19-item Scale for Suicide Ideation; anxiety was assessed with the BSI. Logistic regression and survival analysis were used to evaluate whether anxiety symptoms predicted depression remission. We also examined the relationships between anxiety scores and suicidality at baseline.

RESULTS

Baseline anxiety symptoms did not predict remission or time to remission of depressive symptoms. Depressive, worry, and panic symptoms decreased in parallel in patients with high anxiety. Anxiety symptoms were associated with the severity of depression and with suicidality.

CONCLUSION

In older adults with MDD, comorbid anxiety symptoms are associated with symptom severity but do not affect antidepressant remission or time to remission.

Optimising the acceptability and feasibility of acceptance and commitment therapy for treatment-resistant generalised anxiety disorder in older adults

BACKGROUND

generalised anxiety disorder (GAD) is common in later life with a prevalence of 3-12%. Many only partially respond to cognitive behavioural therapy or pharmacotherapy and can be classified as treatment resistant. These patients experience poor quality of life, and are at increased risk of comorbid depression, falls and loneliness. Acceptance and commitment therapy (ACT) is an emerging therapy, which may be particularly suited to this population, but has not been tailored to their needs.

OBJECTIVES

to optimise the acceptability and feasibility of ACT for older adults with treatment-resistant GAD.

DESIGN

a person-based approach to ground the adapted ACT intervention in the perspectives and lives of those who will use it.

METHODS

first, we conducted qualitative interviews with 15 older adults with GAD and 36 healthcare professionals to develop guiding principles to inform the intervention. Second, we consulted service users and clinical experts and interviewed the same 15 older adults using 'think aloud' techniques to enhance its acceptability and feasibility.

RESULTS

in Stage 1, older adults' concerns and needs were categorised in four themes: 'Expert in one's own condition', 'Deep seated coping strategies', 'Expert in therapy' and 'Support with implementation'. In Stage 2, implications for therapy were identified that included an early focus on values and ACT as a collaborative partnership, examining beliefs around 'self as worrier' and the role of avoidance, validating and accommodating individuals' knowledge and experience and compensating for age-related cognitive changes.

DISCUSSION

Our systematic approach combined rigour and transparency to develop a therapeutic intervention tailored to the specific needs of older adults with treatment-resistant GAD.

Treatment of Complicated Grief in Survivors of Suicide Loss: A HEAL Report

OBJECTIVE

Suffering associated with complicated grief (CG) is profound. Because suicide loss survivors are susceptible to developing CG, identifying effective treatments for suicide loss survivors with CG is a high priority. This report provides data on the acceptability and effectiveness of antidepressant medication and complicated grief therapy (CGT), a CG-targeted psychotherapy, for suicide loss survivors with CG identified by an Inventory of Complicated Grief score ≥ 30.

METHODS

This is a secondary analysis of data collected from March 2010 to September 2014 for a 4-site, double-blind, placebo-controlled randomized trial comparing the effectiveness of antidepressant medication alone or in combination with CGT for participants with CG (score ≥ 30 on the Inventory of Complicated Grief) who were bereaved by suicide (SB; n = 58), accident/homicide (A/H; n = 74), or natural causes (NC; n = 263). Using mode of death as a grouping factor, we evaluated acceptability of treatments by comparing 12-week medication and 16-session CGT completion; we evaluated effectiveness by comparing response at week 20, defined by a score of 1 or 2 on the Complicated Grief Clinical Global Impressions-Improvement scale (CG-CGI-I), and additional secondary response measures.

RESULTS

Among participants receiving medication alone, SB medication completion rates (36%) were lower than rates for A/H (54%) and NC (68%; χ² = 11.76, P < .01). SB medication completion rates were much higher for SB individuals receiving CGT (82%; χ² = 12.45, P < .001) than for SB individuals receiving medication alone. CGT completion rates were similar in the 3 groups (SB = 74%, A/H = 64%, NC = 77%; χ² = 2.48, P = .29). For SB participants receiving CGT, CG-CGI-I response rates were substantial (64%), but lower compared to the other groups (A/H = 93%, NC = 84%; χ² = 8.00, P < .05). However, on all other outcomes, changes from baseline for SB participants were comparable to those for A/H and NC participants, including number and severity of grief symptoms, suicidal ideation, and grief-related impairment, avoidance, and maladaptive beliefs.

CONCLUSIONS

These results raise concern about the acceptability of medication alone as a treatment for complicated grief in treatment-seeking suicide-bereaved adults. In contrast, CGT is an acceptable and promising treatment for suicide-bereaved individuals with complicated grief.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01179568.

Video-Delivered Relaxation Intervention Reduces Late-Life Anxiety: A Pilot Randomized Controlled Trial

OBJECTIVE

The study's aim was to demonstrate the feasibility and preliminary efficacy of a 4-week video-delivered relaxation program called Breathing, Relaxation, and Education for Anxiety Treatment in the Home Environment (BREATHE) for reducing anxiety and increasing activity engagement in older adults with anxiety disorders.

METHODS

This was an 8-week pilot randomized controlled trial performed as outpatient and self-directed learning at home among 40 community-dwelling adults aged 60years or older who met criteria for an anxiety disorder (generalized anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, or anxiety disorder unspecified). The study looked at the BREATHE intervention compared with a wait list control condition. The primary outcome measure was anxiety symptoms (Geriatric Anxiety Scale). Secondary outcomes included activity engagement (modified Activity Card Sort), depressive symptoms (Patient Health Questionnaire), and somatic symptoms (Somatic Symptom Scale).

RESULTS

In linear mixed-effects models, findings indicated a significant reduction in anxiety symptoms. There was no significant effect of group on activity engagement. Results also showed significant reductions in depressive and somatic symptoms associated with the BREATHE intervention compared with wait list.

CONCLUSION

Our findings demonstrate feasibility and preliminary efficacy for this brief video-delivered relaxation intervention and suggest that older adults can benefit from technology-delivered interventions with minimal provider contact. Although activity engagement did not improve, lessons learned suggest that targeted coaching around activity goals may help target this outcome.

Acceptance and Commitment Therapy for Chronic Pain: Does Post-traumatic Stress Disorder Influence Treatment Outcomes?

Objective

The aim of this study was to determine whether post-traumatic stress disorder (PTSD) moderates treatment outcomes in Acceptance and Commitment Therapy for chronic pain.

Design

Longitudinal.

Setting

Veterans Affairs San Diego Healthcare System.

Subjects

A total of 126 veterans with chronic pain participating in an Acceptance and Commitment Therapy intervention for chronic pain. A structured clinical interview was used at baseline to designate PTSD-positive (N = 43) and -negative groups (N = 83).

Methods

Linear mixed-effects models to determine whether PTSD moderated change in pain interference, pain severity, pain acceptance, depressive symptoms, or pain-related anxiety at post-treatment and six-month follow-up.

Results

Participants with co-occurring PTSD reported greater pain interference, pain severity, depressive symptoms, and pain-related anxiety at baseline. PTSD status did not moderate treatment effects post-treatment. Rather, there were significant improvements on all study measures across groups (P &lt; 0.001). PTSD status moderated change in depressive symptoms at six-month follow-up (P &lt; 0.05). Specifically, participants with chronic pain alone demonstrated improvement in depressive symptoms compared with pretreatment levels, whereas participants with PTSD regressed to pretreatment levels.

Conclusions

PTSD status did not significantly affect treatment outcomes, with the exception of depressive symptoms at six-month follow-up. Overall, Acceptance and Commitment Therapy for chronic pain appears helpful for improving outcomes among veterans with co-occurring PTSD; however, veterans with co-occurring PTSD may experience fewer long-term gains compared with those with chronic pain alone.

Integrated Exposure Therapy and Exercise Reduces Fear of Falling and Avoidance in Older Adults: A Randomized Pilot Study

OBJECTIVES

To evaluate the safety and acceptability of a novel 8-week intervention integrating exercise, exposure therapy, cognitive restructuring, and a home safety evaluation, conducted by a physical therapist, in reducing fear of falling and activity avoidance. To collect preliminary evidence of efficacy.

DESIGN

Randomized pilot study comparing the intervention to time- and attention-equivalent fall prevention education.

SETTING

Participants' homes.

PARTICIPANTS

42 older adults with disproportionate fear of falling (high fear, low to moderate objective fall risk).

MEASUREMENTS

Falls Efficacy Scale-International, modified Activity Card Sort, satisfaction, falls.

RESULTS

Relative to education, the intervention reduced fear of falling (d = 1.23) and activity avoidance (d = 1.02) at 8 weeks, but effects eroded over a 6-month follow-up period. The intervention did not increase falls, and participants rated the exercise, exposure therapy, and non-specific elements as most helpful.

CONCLUSIONS

An integration of exercise and exposure therapy may help older adults with disproportionate fear of falling, but modifications to the intervention or its duration may be needed to maintain participants' gains.

An Interdisciplinary Intervention for Fear of Falling: Lessons Learned from Two Case Studies

This article describes two case studies using an interdisciplinary intervention for homebound older adults who experience fear of falling, resulting in debility and isolation. The patients discussed received separate home visits from a physical therapist (two and four visits) and psychologist (six and eight visits) and intervention components included an initial assessment of physical ability, prescription of home exercise program, exposure therapy, and cognitive restructuring. Both patients reported satisfaction with the fear of falling intervention and showed improved ability to walk, both in distance and in requiring less assistance. These findings suggest significant positive treatment effects can be achieved through interdisciplinary exposure-based interventions aimed at reducing unrealistic fear of falling and associated avoidance behaviors. Similar interventions should be considered for more systematic evaluation of effects and mechanisms of change as well as inclusion in interdisciplinary treatment planning.

Age Differences in Death and Suicidal Ideation in Anxious Primary Care Patients

OBJECTIVES

The objective of this study was to examine age differences in the likelihood of endorsing of death and suicidal ideation in primary care patients with anxiety disorders.

METHOD

Participants were drawn from the Coordinated Anxiety Learning and Management (CALM) Study, an effectiveness trial for primary care patients with panic disorder (PD), generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), and/or social anxiety disorder (SAD).

RESULTS

Approximately one third of older adults with anxiety disorders reported feeling like they were better off dead. Older adults with PD and SAD were more likely to endorse suicidal ideation lasting at least more than half the prior week compared with younger adults with these disorders. Older adults with SAD endorsed higher rates of suicidal ideation compared with older adults with other anxiety disorders. Multivariate analyses revealed the importance of physical health, social support, and comorbid MDD in this association.

CONCLUSIONS

Suicidal ideation is common in anxious, older, primary care patients and is particularly prevalent in socially anxious older adults. Findings speak to the importance of physical health, social functioning, and MDD in this association.

CLINICAL IMPLICATIONS

When working with anxious older adults it is important to conduct a thorough suicide risk assessment and teach skills to cope with death and suicidal ideation-related thoughts.

Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST) for Hoarding Disorder in Older Adults: A Randomized Clinical Trial

OBJECTIVE

To compare the efficacy of Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST) with geriatric case management (CM) in a sample of older adults meeting DSM-5 diagnostic criteria for hoarding disorder (HD).

METHODS

Fifty-eight older adults with HD were enrolled in a randomized controlled trial between December 2011 and March 2014. Thirty-one participants received CREST, and 27 participants received CM. Both interventions consisted of 26 individual sessions over a period of 6 months and included several home visits by the study therapists (CREST) or nurses (CM). The Saving Inventory-Revised (SI-R) and the UCLA Hoarding Severity Scale (UHSS) were the main outcome measures.

RESULTS

Participants in the CREST condition had significantly greater improvement on the SI-R than participants in the CM group (group × time interaction: β = 3.95, SE = 1.81, P = .029), with participants who completed the CREST condition averaging a 38% decrease in symptoms and participants who completed the CM condition averaging a 25% decrease in symptoms. In contrast, there was not a significant group × time interaction effect on the UHSS (β = 1.23, SE = 0.84, P = .144), although participants did report greater improvement in symptoms in the CREST condition (35%) than in the CM condition (24%). Treatment gains were maintained at 6-month follow-up.

CONCLUSIONS

CREST appears to be an efficacious treatment compared to CM for older adults, but CM also showed meaningful benefits.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01227057​.

Childhood Trauma Is Associated With Poorer Cognitive Performance in Older Adults

OBJECTIVE

Childhood trauma is common and associated with both worse cognitive performance and disruption to the hypothalamic-pituitary-adrenal axis in younger adults. The extent to which these associations persist into older adulthood remains unknown. The aim of this study was to investigate self-reported childhood trauma in relation to cognitive performance, and the extent to which cortisol explained this association, in 2 independent samples of older adults.

METHODS

In this cross-sectional study, participants in the discovery sample (N = 76) consisted of older adults with a DSM-IV diagnosis of generalized anxiety disorder (N = 57) and age-equated psychiatrically healthy comparison subjects (N = 19) who were referred largely through primary care clinics between 2004-2006. The replication sample (N = 48) consisted of older adults with DSM-IV anxiety or depressive disorders recruited between 2012-2013. Participants were administered the Early Trauma Inventory Self-Report-Short Form and a neuropsychological assessment (primary outcome).

RESULTS

Across both samples, childhood trauma was significantly associated with worse performance on measures of processing speed, attention, and executive functioning. The effect of trauma exposure was stronger when general, physical, and sexual traumatic events were examined specifically (all P < .05). Childhood trauma was not associated with cortisol levels, and cortisol did not explain the association between trauma and cognitive functioning.

CONCLUSIONS

Self-reported traumatic events experienced in childhood are associated with poorer cognitive performance in anxious and depressed older adults. Findings demonstrate a deleterious impact of childhood trauma on brain health in old age.

Mindfulness-Based Stress Reduction for Older Adults With Stress Disorders and Neurocognitive Difficulties: A Randomized Controlled Trial

OBJECTIVE

To determine whether neurocognitive performance and clinical outcomes can be enhanced by a mindfulness intervention in older adults with stress disorders and cognitive complaints. To explore decreased hypothalamic-pituitary-adrenal (HPA) axis activity as a possible mechanism.

METHODS

103 adults aged 65 years or older with an anxiety or depressive disorder (diagnosed according to DSM-IV criteria) and subjective neurocognitive difficulties were recruited in St. Louis, Missouri, or San Diego, California, from September 2012 through August 2013 and randomly assigned in groups of 5-8 to mindfulness-based stress reduction (MBSR) or a health education control condition matched for time, attention, and credibility. The primary outcomes were memory (assessed by immediate and delayed paragraph and list recall) and cognitive control (Delis-Kaplan Executive Function System Verbal Fluency Test and Color Word Interference Test). Other outcomes included clinical symptoms (worry, depression, anxiety, and global improvement). HPA axis activity was assessed using peak salivary cortisol. Outcomes were measured immediately post-intervention and (for clinical outcomes only) at 3- and 6-month follow up.

RESULTS

On the basis of intent-to-treat principles using data from all 103 participants, the mindfulness group experienced greater improvement on a memory composite score (P = .046). Groups did not differ on change in cognitive control. Participants receiving MBSR also improved more on measures of worry (P = .042) and depression (P = .049) at posttreatment and on worry (P = .02), depression (P = .002), and anxiety (P = .002) at follow-up and were more likely to be rated as much or very much improved as rated by the Clinical Global Impressions-Improvement scale (47% vs 27%, χ² = 4.5, P = .03). Cortisol level decreased to a greater extent in the mindfulness group, but only among those participants with high baseline cortisol.

CONCLUSIONS

In this population of older adults with stress disorders and neurocognitive difficulties, a mindfulness intervention improves clinical outcomes such as excessive worry and depression and may include some forms of immediate memory performance.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01693874.

Complicated grief after suicide bereavement and other causes of death

The authors compared baseline demographic characteristics, clinical features, and grief-related thoughts, feelings, and behaviors of individuals bereaved by suicide, accident/homicide and natural causes participating in a complicated grief (CG) treatment clinical trial. Severity of CG and depression and current depression diagnosis did not vary by loss type. After adjusting for baseline demographic features, time since death and relationship to the deceased, those with CG after suicide had the highest rates of lifetime depression, preloss passive suicidal ideation, self-blaming thoughts, and impaired work and social adjustment. Even among this treatment-seeking sample of research participants with CG, suicide survivors may face unique challenges.

Temporal dynamics of cognitive performance and anxiety across older adulthood

Cognitive decline and anxiety symptoms commonly co-occur in later life, but the temporal order of changes on these two attributes is unclear. Specifically, it is unknown if greater anxiety leads to subsequent declines in cognitive performance or if worse cognitive performance leads to increased anxiety. In this study, we sought to elucidate the temporal dynamics between anxiety symptoms and cognitive performance across old age-that is, the extent to which level and change in one variable influence subsequent changes in a second variable. We examined data from 721 nondemented participants from the Swedish Adoption/Twin Study of Aging. Participants completed as many as eight assessments of cognitive performance and anxiety over a 26-year period. Bivariate dual-change score models were fit to examine the dynamic association between anxiety and cognitive performance. Bidirectional associations between anxiety and cognitive performance were found among measures of processing speed, attention, and memory but not visuospatial abilities. Higher anxiety was associated with greater declines in processing speed over the duration of 6 years and worsening attention over a span of 3 years. The reverse direction was also significant in that slower processing speed, worse attention, and poorer nonverbal and working memory performance were associated with larger increases in anxiety 3 years later. These findings highlight that in cognitively intact older adults, the association between anxiety and worse cognitive performance is bidirectional and complex. (PsycINFO Database Record

Acceptance and Commitment Therapy and Selective Optimization with Compensation for Institutionalized Older People with Chronic Pain

OBJECTIVE

Recent studies support the efficacy of Acceptance and Commitment Therapy (ACT) with people with chronic pain. In addition, Selective Optimization with Compensation strategies (SOC) can help the elderly with chronic pain to accept their chronic condition and increase functional autonomy. Our aim was to analyze the efficacy of an ACT treatment program combined with training in SOC strategies for elderly people with chronic pain living in nursing homes.

METHODS

101 participants (mean age = 82.26; SD = 10.00; 78.6% female) were randomized to the intervention condition (ACT-SOC) or to a minimal support group (MS). Complete data are available for 53 participants (ACT-SOC: n = 27; MS: n = 26). Assessments of functional performance, pain intensity, pain acceptance, SOC strategies, emotional well being and catastrophizing beliefs were done preintervention and postintervention.

RESULTS

Significant time by intervention changes (P = 0.05) were found in acceptance, pain related anxiety, compensation strategies, and pain interference in walking ability. Simple effects changes were found in acceptance (P = 0.01), selection strategies (P = 0.05), catastrophizing beliefs (P = 0.03), depressive symptoms (P = 0.05), pain anxiety (P = 0.01) and pain interference in mood and walking ability (P = 0.03) in the ACT-SOC group. No significant changes were found in the MS group.

CONCLUSIONS

These results suggest that an ACT intervention combined with training in SOC strategies could help older people with pain to improve their emotional well being and their functional capability.

Telehealth Versus In-Person Acceptance and Commitment Therapy for Chronic Pain: A Randomized Noninferiority Trial

The purpose of this randomized noninferiority trial was to compare video teleconferencing (VTC) versus in-person (IP) delivery of an 8-week acceptance and commitment therapy (ACT) intervention among veterans with chronic pain (N = 128) at post-treatment and at 6-month follow-up. The primary outcome was the pain interference subscale of the Brief Pain Inventory. Secondary outcomes included measures of pain severity, mental and physical health-related quality of life, pain acceptance, activity level, depression, pain-related anxiety, and sleep quality. In intent to treat analyses using mixed linear effects modeling, both groups exhibited significant improvements on primary and secondary outcomes, with the exception of sleep quality. Further, improvements in activity level at 6-month follow-up were significantly greater in the IP group. The noninferiority hypothesis was supported for the primary outcome and several secondary outcomes. Treatment satisfaction was similar between groups; however, significantly more participants withdrew during treatment in the VTC group compared with the IP group, which was moderated by activity level at baseline. These findings generally suggest that ACT delivered via VTC can be as effective and acceptable as IP delivery for chronic pain. Future studies should examine the optimal delivery of ACT for patients with chronic pain who report low levels of activity. This trial was registered at ClinicalTrials.gov (NCT01055639).

PERSPECTIVE

This study suggests that ACT for chronic pain can be implemented via VTC with reductions in pain interference comparable with IP delivery. This article contains potentially important information for clinicians using telehealth technology to deliver psychosocial interventions to individuals with chronic pain.

Stability of Genetic and Environmental Contributions to Anxiety Symptoms in Older Adulthood

Anxiety symptoms are common in later life and are associated with diverse adverse health outcomes. Little is known about how genetic and environmental influences on anxiety symptoms might vary across older adulthood. The purpose of this study was to explore change and stability of contributions to anxiety symptoms across older adulthood. We examined data from the Swedish Adoption/Twin Study of Aging (SATSA). Between the years 1984 and 2010, 2021 participants (including 753 complete twin pairs) completed up to seven assessments containing two measures of anxiety symptoms. Longitudinal genetic simplex models were fit to examine the stability and change in genetic and environmental influences. Amplification of genetic factors at ages 75-80 suggests tentative new genetic contributions to anxiety symptoms. These findings suggest that the heritability of anxiety symptoms may increase later in life. Physiological factors associated with aging are discussed as potential factors explaining this increase.

Activity, balance, learning, and exposure (ABLE): a new intervention for fear of falling

OBJECTIVE

Fear of falling is an important problem among older adults, even those with relatively low rates of objective fall risk, who are often overlooked as targets for intervention.

METHOD

We developed and pilot tested a new intervention, Activity, Balance, Learning, and Exposure (ABLE), in a sample of 10 older adults with excessive fear of falling. The ABLE intervention integrates exposure therapy and cognitive restructuring with a home safety evaluation and an exercise program and is conducted in the home. In this pilot project, ABLE was jointly conducted by a physical therapist and a psychologist with expertise in geriatric anxiety disorders.

RESULTS

The intervention was feasible and acceptable and resulted in decreases in fear and activity avoidance for most participants. One participant experienced an injurious fall.

DISCUSSION

We learned a number of important lessons resulting in modifications to the inclusion criteria, assessments, and intervention over the course of this pilot study. Results suggest that ABLE has promise for treating excessive fear of falling in the elderly and support testing the intervention in a larger randomized trial. Copyright © 2016 John Wiley & Sons, Ltd.

Feasibility and Acceptability of Smartphone Assessment in Older Adults with Cognitive and Emotional Difficulties

OBJECTIVES

Ecological momentary assessment (EMA) has several advantages in clinical research yet little is known about the feasibility of collecting EMA data with mobile technologies in older adults, particularly those with emotional or cognitive difficulties. The aim of this feasibility study was to assess perceived acceptability, adherence rates, and reasons for non-adherence to smartphone-based EMA.

METHOD

At two sites, participants (n=103) aged 65 years or older with a DSM-IV-defined anxiety or depressive disorder and cognitive concerns responded three times daily to smartphone-based EMA questions assessing clinical outcomes for two 10-day periods. Quantitative and qualitative measures assessed acceptability, adherence, and reasons for non-adherence following both 10-day EMA periods.

RESULTS

Participants were moderately satisfied with and comfortable using smartphone-based EMA. Overall, 76% of participants completed surveys on ≥10 of the 20 assessment days, and 70% of participants completed at least 30% of the total surveys. Reasons for non-adherence included technical (malfunction), logistical (competing demands), physiological (hearing difficulties), and cognitive (forgetting) issues.

DISCUSSION

Smartphone-based EMA is feasible in older adults with cognitive and emotional difficulties. EMA tools should be responsive to the needs and preferences of participants to ensure adequate acceptability and adherence in this population. Our findings can inform the design, development, and implementation of mobile technologies in older adults in research and clinical contexts.

Executive Functioning in Participants Over Age of 50 with Hoarding Disorder

OBJECTIVES

The current investigation utilized mid-life and late-life participants diagnosed with hoarding disorder (HD) to explore the relationship between executive functioning and hoarding severity.

DESIGN

Correlational analyses were used to investigate the associations between executive functioning and hoarding severity in nondemented participants. Multiple regression was used to determine if executive functioning had a unique association with HD severity when accounting for depressive symptoms.

SETTING

Participants were recruited from the San Diego area for HD intervention studies.

PARTICIPANTS

Participants were 113 nondemented adults aged 50-86 years who met DSM-5 criteria for HD. The mean age of the sample utilized in the analyses was 63.76 years (SD, 7.2; range, 51-85 years). The sample was mostly female (72%), Caucasian (81.4%), and unmarried (78%).

MEASUREMENTS

Hoarding severity was assessed using the Saving Inventory-Revised and the Clutter Image Rating and depression was assessed using the Hospital Anxiety and Depression Scale. Executive functioning was assessed using the Wisconsin Card Sorting Test (WCST-128) and the Trail Making and Verbal Fluency subtests of the Delis-Kaplan Executive Function System.

RESULTS

Executive function (operationalized as perseveration on the WCST-128) was significantly associated with Clutter Image Ratings. In a multivariate context, executive function and depressive symptom severity were both significant predictors of variance in Clutter Image Rating.

CONCLUSIONS

Our results suggest that executive function is related to severity of HD symptoms and should be considered as part of the conceptualization of HD.

Ecological momentary assessment versus standard assessment instruments for measuring mindfulness, depressed mood, and anxiety among older adults

As mobile data capture tools for patient-reported outcomes proliferate in clinical research, a key dimension of measure performance is sensitivity to change. This study compared performance of patient-reported measures of mindfulness, depression, and anxiety symptoms using traditional paper-and-pencil forms versus real-time, ambulatory measurement of symptoms via ecological momentary assessment (EMA). Sixty-seven emotionally distressed older adults completed paper-and-pencil measures of mindfulness, depression, and anxiety along with two weeks of identical items reported during ambulatory monitoring via EMA before and after participation in a randomized trial of Mindfulness-Based Stress Reduction (MBSR) or a health education intervention. We calculated effect sizes for these measures across both measurement approaches and estimated the Number-Needed-to-Treat (NNT) in both measurement conditions. Study outcomes greatly differed depending on which measurement method was used. When EMA was used to measure clinical symptoms, older adults who participated in the MBSR intervention had significantly higher mindfulness and significantly lower depression and anxiety than participants in the health education intervention at post-treatment. However, these significant changes in symptoms were not found when outcomes were measured with paper-and-pencil measures. The NNT for mindfulness and depression measures administered through EMA were approximately 25-50% lower than NNTs derived from paper-and-pencil administration. Sensitivity to change in anxiety was similar across administration modes. In conclusion, EMA measures of depression and mindfulness substantially outperformed paper-and-pencil measures with the same items. The additional resources associated with EMA in clinical trials would seem to be offset by its greater sensitivity to detect change in key outcome variables.

Age moderates response to acceptance and commitment therapy vs. cognitive behavioral therapy for chronic pain

OBJECTIVE

The purpose of this study was to examine age differences in response to different forms of psychotherapy for chronic pain.

METHODS

We performed a secondary analysis of 114 adults (ages 18-89 years) with a variety of chronic, nonmalignant pain conditions randomly assigned to 8 weeks of group-administered acceptance and commitment therapy (ACT) or cognitive behavioral therapy (CBT). Treatment response was defined as a drop of at least three points on the Brief Pain Inventory-interference subscale.

RESULTS

Older adults were more likely to respond to ACT, and younger adults to CBT, both immediately following treatment and at 6-month follow-up. There were no significant differences in credibility, expectations of positive outcome, attrition, or satisfaction, although there was a trend for the youngest adults (ages 18-45 years) to complete fewer sessions.

CONCLUSIONS

These data suggest that ACT may be an effective and acceptable treatment for chronic pain in older adults.

Anxiety is associated with increased risk of dementia in older Swedish twins

INTRODUCTION

We asked whether anxiety is associated with prospective risk of dementia, and the extent to which genetic influences mediate this association.

METHODS

Nondemented twins (n = 1082) from the Swedish Adoption Twin Study of Aging completed an assessment of anxiety symptoms in 1984 and were followed for 28 years.

RESULTS

Baseline anxiety score, independent of depressive symptoms, was significantly associated with incident dementia over follow-up (hazard ratio [HR] = 1.04; 95% confidence interval [CI] = 1.01-1.06). There was 48% increased risk of becoming demented for those who had experienced high anxiety at any time compared with those who had not. In co-twin analyses, the association between anxiety symptoms and dementia was greater for dizygotic (HR = 1.11; 95% CI = 1.02-1.20) compared with monozygotic twins (HR = 1.06; 95% CI = 0.95-1.20), indicating genetic mediation.

DISCUSSION

Anxiety symptoms were associated with increased risk of dementia. Genetic factors common to dementia and anxiety partially mediated this association.

Mindfulness-based stress reduction for older adults with worry symptoms and co-occurring cognitive dysfunction

BACKGROUND

Mindfulness-based stress reduction (MBSR) has the potential to reduce worry and improve cognitive functioning.

OBJECTIVES

In this treatment development project, we examined MBSR in older adults with worry symptoms and co-occurring cognitive dysfunction. We examined (i) acceptability of MBSR, (ii) whether MBSR needs to be lengthened providing more repetition, (iii) MBSR's benefits for worry reduction and cognitive improvements, and (iv) continued use of MBSR techniques during follow-up.

METHODS

Two sites (St. Louis and San Diego) enrolled individuals aged 65 years or older with significant anxiety-related distress plus subjective cognitive dysfunction, into traditional 8-session MBSR groups and 12-session groups that had the same content but more repetition of topics and techniques. We examined measures of mindfulness, worry, and a neuropsychological battery focused on memory and executive function before and after the MBSR program, and we followed up participants for 6 months after the completion of MBSR regarding their continued use of its techniques.

RESULTS

Participants (N = 34) showed improvements in worry severity, increases in mindfulness, and improvements in memory as measured by paragraph learning and recall after a delay, all with a large effect size. Most participants continued to use MBSR techniques for 6 months post-instruction and found them helpful in stressful situations. There was no evidence that the extended 12-week MBSR produced superior cognitive or clinical outcomes, greater satisfaction, or greater continuation of MBSR techniques than 8-week MBSR.

CONCLUSIONS

These preliminary findings are promising for the further testing and use of MBSR in older adults suffering from clinical worry symptoms and co-occurring cognitive dysfunction. These are common problems in a broad range of older adults, many of whom have anxiety and mood disorders; therefore, stress reduction intervention for them may have great public health value.

Illness conceptualizations among older rural Mexican-Americans with anxiety and depression

Research on barriers and utilization of mental health services in older ethnic minorities has been productive. However, little is known about the characterization and beliefs about anxiety and depression symptoms among older Mexican-Americans. Exploration of these conceptualizations will lead to better detection and provision of care to this large, yet underserved group. The present study used a mixed methods approach to explore conceptualizations of anxiety and depression in a group of rural older Mexican-Americans. Twenty-five Spanish-speaking participants (mean age 71.2) responded to flyers that solicited individuals who felt “tense or depressed.” Participants completed a structured diagnostic interview as well as self-report questionnaires about medical health, anxiety and depressive symptoms, and cognitive functioning. Qualitative interviews included questions about how participants describe, conceptualize, and cope with anxiety and depression symptoms. Sixty-eight percent of the sample met criteria for at least one anxiety or mood disorder with high comorbidity rates. Self-reported symptoms of depression, anxiety, and somatization were below clinical ranges for all participants. Medical illness, cognitive impairment, age, education, and acculturation were not associated with distress. Qualitative analyses revealed that nearly half of the terms used by the sample to describe distress phenomena deviated from Western labels traditionally used to indicate anxious and depressive symptomatology. Multiple methods of symptom endorsement demonstrated that older Mexican-Americans may report distress differently than detected by traditional self-report measures or common Western terminology. Understanding these additional illness conceptualizations may have implications for improving the detection of mental illness and increasing service use among this growing population.

Motivational interviewing with primary care populations: a systematic review and meta-analysis

This meta-analysis synthesized the findings from randomized controlled trials (RCTs) of motivational interviewing (MI) for health behavior outcomes within primary care populations. Published and unpublished RCTs were identified using databases and online listservs. Studies were synthesized by outcome subgroup and meta-regression analyses were conducted to determine potential moderators accounting for heterogeneity within samples. Mean effect sizes ranged from .07 to .47; significant effect sizes were found for the adherence subgroup of studies (p = .04) and all outcomes combined (p = .02). Professional credentials of intervention deliverer were found to significantly moderate the association between MI and effect size in substance use subgroup (p = .0005) and all outcomes combined (p = .004). Mean effect sizes were largest in outcomes related to weight loss, blood pressure, and substance use. MI appears to be useful in clinical settings and as few as 1 MI session may be effective in enhancing readiness to change and action directed towards reaching health behavior-change goals.

Novel treatment for geriatric hoarding disorder: an open trial of cognitive rehabilitation paired with behavior therapy

OBJECTIVES

To investigate the feasibility of an age-adapted, manualized behavioral treatment for geriatric hoarding.

METHODS

Participants were 11 older adults (mean age: 66 years) with hoarding disorder. Treatment encompassed 24 individual sessions of psychotherapy that included both cognitive rehabilitation targeting executive functioning and exposure to discarding/not acquiring. Hoarding severity was assessed at baseline, mid-treatment, and posttreatment.

RESULTS

Results demonstrated clinically and statistically significant changes in hoarding severity at posttreatment. No participants dropped out of treatment. Eight participants were classified as treatment responders, and three as partial responders. Partial responders reported severe/extreme hoarding and psychiatric comorbidities at baseline.

CONCLUSIONS

The combination of cognitive rehabilitation and exposure therapy is a promising approach in the treatment of geriatric hoarding. Targeting neurocognitive deficits in behavioral therapy for these geriatric patients with hoarding disorder doubled response rates relative to our previous trial of cognitive behavior therapy alone.

Executive functioning in older adults with hoarding disorder

BACKGROUND

Hoarding disorder (HD) is a chronic and debilitating psychiatric condition. Midlife HD patients have been found to have neurocognitive impairment, particularly in areas of executive functioning, but the extent to which this is due to comorbid psychiatric disorders has not been clear.

AIMS/METHOD

The purpose of the present investigation was to examine executive functioning in geriatric HD patients without any comorbid Axis I disorders (n = 42) compared with a healthy older adult comparison group (n = 25). We hypothesized that older adults with HD would perform significantly worse on measures of executive functioning (Wisconsin Card Sort Task [Psychological Assessment Resources, Lutz, Florida, USA] ( Psychological Assessment Resources, 2003) and the Wechsler Adult Intelligence Scale-IV digit span and letter-number sequencing tests [Pearson, San Antonio, TX, USA]).

RESULTS

Older adults with HD showed significant differences from healthy older controls in multiple aspects of executive functioning. Compared with healthy controls, older adults with HD committed significantly more total, non-perseverative errors and conceptual level responses on the Wisconsin Card Sort Task and had significantly worse performance on the Wechsler Adult Intelligence Scale-IV digit span and letter-number sequencing tests. Hoarding symptom severity was strongly correlated with executive dysfunction in the HD group.

CONCLUSIONS

Compared with demographically-matched controls, older adults with HD have dysfunction in several domains of executive functioning including mental control, working memory, inhibition, and set shifting. Executive dysfunction is strongly correlated with hoarding severity and is not because of comorbid psychiatric disorders in HD patients. These results have broad clinical implications suggesting that executive functioning should be assessed and taken into consideration when developing intervention strategies for older adults with HD.