Emerging Concepts in Geriatric Psychiatry: an Update on the Canadian Academy of Geriatric Psychiatry Annual Scientific Meeting

CANADIAN GERIATRICS JOURNAL, VOLUME 17, ISSUE 1, MARCH 2014 The Annual Scientific Meeting of the Canadian Academy of Geriatric Psychiatry was held in Ottawa, Ontario on September 25th 2013. Given greater weight this year due to the inaugural Royal College Geriatric Psychiatry subspecialty certification exam being written across the country the following day, the meeting proved to be not only a venue for dissemination of current knowledge in Geriatric Psychiatry, but also for networking and meeting with colleagues. Preceded by the 2nd Annual CAGP Review Course, the theme of the ASM, “Emerging Concepts in Geriatric Psychiatry”, was all the more relevant in the context of the exam and the changes in Geriatric Psychiatry certification in Canada. The keynote presentation this year was given by Dr. Benoit Mulsant on the topic of the changes relevant to Geriatric Psychiatry that were introduced with the publication of the 5th edition of the Diagnostic and Statistical Manual of Psychiatric Disorders by the American Psychiatric Association. Dr. Mark Rapoport has written an editorial discussing Dr. Mulsant’s presentation with his own reflections, as well. The plenary session was a panel entitled “Advances in Therapeutic Brain Stimulation”, presented by Dr. Daniel Blumberger and Dr. Paul Lespérance. Dr. Blumberger started by categorizing brain stimulation into non-convulsive, convulsive, and surgical intervention categories. As an example of non-convulsive treatment, he discussed the advent of Transcranial Direct Current Stimulation, in which low-voltage current is delivered to the prefrontal cortex (PFC) over 20–40 minutes.(1) He described the mechanism of anode stimulation leading to increased neuronal activity (depolarization), leading to enhanced cortical excitability, leading to the choice of the prefrontal cortex for stimulation. He then discussed electroconvulsive therapy (ECT), and described the importance of ultrabrief pulse width stimuli of 0.3–0.37 ms and the evidence indicating that it is more effective than bilateral standard pulse width ECT with fewer cognitive side effects.(2) He also described the use of nortryptiline and lithium for postECT maintenance treatment, and highlighted the need for more research in this area. Dr. Blumberger also described Magnetic Seizure Therapy(3) as a new advance in brain stimulation. He described it as a high-power Transcranial Magnetic Stimulation (rTMS) device for seizure induction, ideally with less cognitive impairment and faster recovery, compared to ECT, due to more focal electrical fields, narrower pulse widths, and lower anaesthesia requirements. Dr. Lespérance further elaborated on rTMS, looking at the evidence for this treatment modality, and leading a discussion on whether the data is clinically meaningful. (4) He indicated that the parameters of stimulation are still in development and that predictors of response are not yet available. Dr. Lespérance concluded with an update on Vagus Nerve Stimulation, indicating that it is approved for treatment-resistant depression, with sustained remission with no switch to mania and improved cognition compared to ECT.(5) While he described the mechanisms working via deactivation of the orbitofrontal cortex, he acknowledged that there is little data in the geriatric population thus far. In addition to the keynote and plenary session, this year’s annual meeting included a number of additional highlights. These included a workshop on how to disclose a diagnosis of dementia using a person-centred, comprehensive, and progressive approach. Participants were asked to work through disclosure of a diagnosis of dementia using a three-tiered process involving pre-disclosure, disclosure, and post-disclosure. There was also time allocated for reflection. Keeping with the theme of dementia, there was also a workshop devoted to reviewing the 4th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia guidelines(6) with respect to imaging and dementia. Participants had an opportunity to interact directly with members of the expert panel who came up with the guidelines, and increase their knowledge of neuroimaging as it pertains to dementia. In addition, there was a workshop entitled “Too Old for Therapy”, in which the principles of Cognitive Behavioural Therapy were adapted for use in older adults. Further, Dr. Mulsant, in conjunction with Drs. Daniel Blumberger, Zahinoor Ismail, Kiran Rabheru, and Mark Rapoport, led a workshop on developing an algorithmic Emerging Concepts in Geriatric Psychiatry: an Update on the Canadian Academy of Geriatric Psychiatry Annual Scientific Meeting