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Posttraumatic Stress Disorder (PTSD) is not typically viewed as a prototypic mental health concern in the context of geriatric mental health; however, it is profoundly important for clinicians and researchers in geriatric psychiatry to attend to this condition. In part, there is the demographic imperative, the “graying of America,” that applies across many if not most psychiatric conditions as the first of the BabyBoom generation (notably, the generation most directly subject to the draft during the Vietnam War) began turning 65 in 2010. Given the high rates of PTSD among military combat veterans it is notable that in 2014 there were already an estimated 9.4 million veterans age 65 or older, including 4.5 million over age 75. In addition, future generations will see a second wave of combat-related PTSD from veterans involved in the wars in Afghanistan and Iraq. Indeed, a recent meta-analysis suggested a prevalence of PTSD among Afghanistan/Iraq veterans of up to 23%. In addition, as noted by Smith et al. (this volume), for a complex array of reasons these recent conflicts have resulted in an increase in newly diagnosed PTSD among Vietnamera veterans. In addition, there is the much less studied issue of PTSD from non-military related traumas among older adults. Estimates of lifetime prevalence of PTSD in the general community have varied widely across studies, but appear to be between 3.6%–6.3% among men and 7.9% and 13.8% among women. The above statistics suggest we are beginning a period of increased prevalence of PTSD among older adults. This trend is likely to continue even beyond the demographic influence of the Baby-Boom generation on the population parameters particularly as the OEF/ OIF/OND veterans and their civilian peers with PTSD continue to age. Moreover, the issue of aging and PTSD is not limited to a future concern when people reach 65 or some other cut-off defining “older age.” As documented in the comprehensive review by Lohr et al. recently published in this journal, there is strong evidence that PTSD is associated with an accelerated or premature aging process. For example, Lohr et al.’s review indicated PTSD is associated with significantly increased risk of mortality (pooled hazard ratio weighted by sample size was 1.29 indicating a 29% increased risk of mortality for those with PTSD). Lohr et al.’s review also indicated an association of PTSD with increased prevalence of several age-related medical conditions, including heart/cardiovascular disease, new onset metabolic syndrome or type 2 diabetes mellitus, and gastrointestinal ulcers. There was also a consistent finding of increased risk of dementia among those with PTSD, which parallels findings from an earlier meta-analysis showing increased risk of neurocognitive deficits among those with PTSD. In short, the issue of PTSD and aging has considerable public health and humanitarian significance. Yet there is a clear need for further research to better document the prevalence, long-term outcomes, and mechanisms of interaction of PTSD and aging, as well as to guide age-appropriate interventions. This information is critical for both researchers and clinicians (both mental health professionals and general physicians) to better guide treatment of older adults with PTSD, as well as to help prevent premature aging among those with PTSD across the life-span. The present volume of American Journal of Geriatric

Objective Cognitive dysfunction is common in patients with advanced, life-threatening illness and can be attributed to a variety of factors (e.g., advanced age, opiate medication). Such dysfunction likely affects decisional capacity, which is a crucial consideration as the end-of-life approaches and patients face multiple choices regarding treatment, family, and estate planning. This study examined the prevalence of cognitive impairment and its impact on decision-making abilities among hospice patients with neither a chart diagnosis of a cognitive disorder nor clinically apparent cognitive impairment (e.g., delirium, unresponsiveness). Design A total of 110 participants receiving hospice services completed a 1-hour neuropsychological battery, a measure of decisional capacity, and accompanying interviews. Results In general, participants were mildly impaired on measures of verbal learning, verbal memory, and verbal fluency; 54% of the sample was classified as having significant, previously undetected cognitive impairment. These individuals performed significantly worse than the other participants on all neuropsychological and decisional capacity measures, with effect sizes ranging from medium to very large (0.43–2.70). A number of verbal abilities as well as global cognitive functioning significantly predicted decision-making capacity. Conclusion Despite an absence of documented or clinically obvious impairment, more than half of the sample had significant cognitive impairments. Assessment of cognition in hospice patients is warranted, including assessment of verbal abilities that may interfere with understanding or reasoning related to treatment decisions. Identification of patients at risk for impaired cognition and decision making may lead to effective interventions to improve decision making and honor the wishes of patients and families.

Objective The objectives are to delineate the nature of subsyndromal depressive symptoms (SSD) in midlife and older patients with schizophrenia and schizoaffective disorder by: 1) describing the relationship of SSD with a number of other clinical features; and 2) examining which specific depressive symptoms are increased in patients broadly defined as having SSD. Methods A total of 204 participants with schizophrenia or schizoaffective disorder and SSD who entered a federally funded intervention study at the University of California San Diego (UCSD) and University of Cincinnati were matched with schizophrenic and schizoaffective participants from the Geriatric Research Center at UCSD who had minimal or no depressive symptoms. The SSD and no depression groups were compared on a variety of clinical features including general psychopathology, positive and negative symptoms, medical and mental functioning, cognition, movement abnormalities, and specific depressive symptomatology. Results SSD was associated with increases in overall psychopathology; positive and negative symptoms; severity of general medical conditions; impaired physical and mental functioning; possibly more severe akathisia; and more depressive symptoms throughout the spectrum of symptom clusters measured by the Hamilton Depression Rating Scale, including anxiety and suicidality. Conclusions SSD in middle aged and older patients with schizophrenia is an important clinical dimension that appears to be associated with substantial morbidity and distress. The findings suggest that is important for clinicians to look for and assess subsyndromal depressive symptoms in patients with chronic schizophrenia.

Objective The objective of this study was to evaluate the feasibility, acceptability, and preliminary efficacy of two enhanced consent procedures provided to patients with Alzheimer disease or mild cognitive impairment that used either a PowerPoint presentation or an enhanced printed consent form. Methods Patients randomly assigned to an enhanced written consent procedure or slideshow presentation were assessed with the MacArthur Competence Assessment Tool for Clinical Research. Results Verbal reexplanation was associated with improved understanding in both conditions. Level of understanding did not significantly differ between the two consent groups, but administration time for slideshow presentation was less than that for an enhanced written consent procedure. Conclusion Enhanced consent procedures are feasible and useful for consent to research among patients with mild cognitive impairment or mild Alzheimer disease.

This analysis examined whether patients with Alzheimer disease (AD) tolerate continuous positive airway pressure (CPAP).Thirty patients with AD were randomized to CPAP or sham CPAP and completed sleep, depression, and quality-of-life questionnaires. Participants could choose to continue treatment after the trial.Patients wore CPAP for 4.8 hours per night. More depressive symptoms were associated with worse adherence (rS=-0.37; N=30, p0.04). Patients who continued using CPAP had fewer depressive symptoms (t [19]=2.45, p=0.02) and better adherence (t [19]=2.32, p=0.03) during the trial.Patients with AD with obstructive sleep apnea can tolerate CPAP. Adherence and long-term use may be more difficult among those patients with more depressive symptoms.

hen Emil Kraepelin (1856e1926) made his Wnow famous quote, in which he states that the science of psychoses of old age are the “darkest area of psychiatry,” 259) he can hardly have anticipated that, over the next 100 years, it would become the opener to numerous talks, book chapters, and editorials about late-life schizophrenia. In his days, life expectancy was rather short, and the number of older patients with dementia praecox therefore rather small. He would not have thought that this patient group would one day be a major motor behind the crisis in geriatric mental health. The double graying of society (more older people who are living longer) together with better antipsychotic treatment and clinical care have resulted in the fact that today much larger numbers of people with schizophrenia are surviving into older age. Unfortunately, this increase has not been fully matched by increased scientific and public interest in this patient group. The field remains far detached from the booming science industry that propels research into schizophrenia at younger ages. The median incidence rate of schizophrenia is 15.2 per 100,000 person-years, with a median lifetime morbid risk of 0.4%. Onset typically peaks in late adolescence and early adulthood, and gradually declines thereafter, although a second peak in middleaged women has sometimes been noted, and some report increasing rates after the age of 65 years. Schizophrenia has been associated with an increased risk of suicide and all-cause mortality. As a consequence, older patients with schizophrenia constitute a subpopulation of survivors, skewed toward the

The authors conducted a preliminary examination of treatment-related decision-making capacity (DMC) in middle-aged and older psychosis patients. The MacArthur Competency Assessment Tool for Treatment (MacCAT-T) was administered to measure DMC among 16 patients with psychotic disorders and without dementia (mean age: 54.6 [SD 7.2] years). The impact of repeated learning trials on patients' understanding was assessed with the Hopkins Competency Assessment Test (HCAT). Subjects were also assessed with the Positive And Negative Syndrome Scale and Mattis' Dementia Rating Scale. There was a wide range of performance on the MacCAT-T; the levels and range of MacCAT-T scores were similar to those previously reported among younger acutely hospitalized patients in the MacCAT-T validation study. Patients' understanding of disclosed material on the HCAT improved significantly over repeated presentations. Although there were no statistically significant correlations observed between DMC and demographic characteristics, severity of symptoms, or global cognitive deficits, the sample size provided limited power to detect such associations. Results point to the importance of assessing DMC and to the potential modifiability of initial difficulties in understanding.