A Novel Mind-Body Program for Grieving Older Adults: Development and Initial Piloting

Awardee Recipients

  • Eric Bui, MD, PhD

    Eric Bui, MD, PhD

    Associate Director for Research and Assistant Professor of Psychiatry

    Massachusetts General Hospital and Harvard Medical School

     Eric Bui, MD, PhD is an Assistant Professor of Psychiatry at Harvard Medical School and currently serves as the Interim Director for Research at the Center for Anxiety and Traumatic Stress Disorders and Complicated Grief Program at the...

  • John Denninger, MD, PhD

    John Denninger, MD, PhD

    Director of Research, Associate Psychiatrist and Instructor

    Massachusetts General Hospital and Harvard Medical School

    John Denninger, MD, PhD, is Director of Research at the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital. He also serves as Associate Director of the MGH-McLean Adult Psychiatry Residency Training Program and...

Award

  • 2015 - Pilot Grant

Specific Aims

The overall aim of this project is to adapt, pilot, and refine a mind-body group program targeting psychiatric, medical, biological and physiological manifestations of the stress of spousal bereavement in older age.

Specific Aim 1: To create an innovative mind-body intervention for widowed older men and women with bereavement-related psychiatric and/or medical symptoms, by adapting an existing relaxation-response program (based on focus group feedback), and piloting it;
Specific Aim 2: To collect pilot feasibility, and acceptability data, as well as assess psychiatric and medical symptoms, and stress reactivity data pre- and post-program in a pilot group of 10 adults aged 55 or more who lost their spouse in the prior year;
Specific Aim 3: To develop and use an innovative paradigm to measure bereavement-related biological and physiological stress reactivity.

1. SIGNIFICANCE

1.1 Bereavement Is a Common, Distressing, and Impairing Major Life Stressor in Older Age

Over the past decades, the number of older people has been on the rise in Westernized countries. The growing number of older people has also brought an increase in the rates of widowhoods. Among the 40 million Americans older than 65, 40% of women and 13% of men are widowed (NCHS 2012).

The loss of a loved one is often one of the most painful and disruptive events survivors will experience, and many develop distressing and impairing symptoms grief (Shear et al. 2011), but also traumatic stress (Mutabaruka et al. 2012), anxiety (Bui et al. 2015), and depression (Prigerson et al. 1995). For example, in a representative cohort of older adults, 19% reported currently experiencing grief, with 25% of those meeting criteria for complicated grief, a severe and persistent form of grief (Newson et al. 2011). Further, in this sample, complicated grief was associated with increased depression and anxiety.

In parallel, widowhood has also been found to be associated in both sexes with a range of physical complaints and problems including limitations in daily activities, general health, pain, fainting and falling out, stiffness, and leg weakness (Wilcox et al. 2003, Williams et al. 2005). Unsurprisingly, older bereaved individuals utilize a high level of health care services, with results from a longitudinal study of medicare claims among n=1,138 older women (mean age = 75.1) indicating that recent widows exhibited a 40% higher risk for hospitalization compared to women who were not recently widowed (Laditka and Laditka 2003).

1.2 Bereavement Triggers a Range of Maladaptive Beliefs

The stress of widowhood has been associated with a number of bereavement-related maladaptive beliefs. A recent longitudinal study thus reported that almost one in four widowed older adults exhibited high levels of bereavement-related regrets that were stable (or increasing) over 48 months post-loss, and were associated with poorer outcomes (Holland et al. 2014). In a recent spousal bereavement study, guilt was also a powerful determinant of grief-specific difficulties following the loss of a loved one (Stroebe et al. 2014). Similarly, self-blame was found significantly associated to the severity of symptoms of grief, but also depression, and anxiety, even when controlling for background and loss-related variables (Boelen et al. 2003). Taken together, these data suggest that bereavement-related maladaptive beliefs including guilt, regrets, and self-blame are frequent after the loss of a loved one and may contribute to poorer psychiatric and functional outcomes.

1.3 Bereavement Triggers a General Physiological Stress Response

Separation from an attachment figure is a threat to homeostasis, and triggers a range of protest and search behaviors to facilitate reunion (Bowlby 1980). These initial manifestations can be understood in the context of an alarm reaction, or general adaptation syndrome (Selye 1956), and are thought to be associated with activation of both sympathetic adrenal medullary and hypothalamo-pituitary adrenal systems. In order to mobilize resources to face the stress of separation, the sympathetic system activates an epinephrine and norepinephrine-mediated “fight or flight” physiological response (including increase in heart rate and blood pressure), and the hypothalamo-pituitary adrenal axis triggers a glucocorticoid and inflammatory response (Sbarra and Hazan 2008). The loss of a loved one in the context of bereavement has thus been found to trigger a general physiological stress response involving the cardiovascular system, hypothalamic-pituitary-adrenal axis, and immune system (for review see: O’Connor 2012). In addition, a recent study reported that bereavement was associated with specific alterations of the immune and stress systems (e.g., reduced neutrophil phagocytosis and reactive oxygen species production, and increased stress hormone levels) only in the elderly (Vitlic et al. 2014), suggesting that this population may be more vulnerable to the biological effects of bereavement than younger adults.

1.4 Bereavement Increases Morbidity and Mortality

In line with bereavement-triggered stress, endocrine, and immune responses, widowed individuals are at high risk for accelerated aging through increased physical morbidity and mortality. A recent study reported that within 30 days of spousal loss, adults aged 60 to 89 (n=114,000) were exposed to a two-fold increased risk for myocardial infarction or stroke (incidence Ratio Risk = 2.2 [95% CI, 1.52-3.15]) (Carey et al. 2014).Two recent meta-analyses also highlighted the effects of widowhood on mortality in the six month following spousal death. Pooling data from 15 studies (n=2,263,888), Moon et al. (2011) reported a 1.41 [95%CI, 1.26-1.57] overall relative risk for mortality, while using mortality risk estimates from 124 publications reporting over 500 million individuals, Shor et al. (2012) found an adjusted hazard ratio of 1.58 [95%CI, 1.32-1.88].

1.5 There Is a Need for an Integrative Treatment Approach Targeting Bereavement-Related Psychiatric and Medical Symptoms in Older Age

Spousal bereavement, therefore, is common in older age, may trigger a general bereavement-related distress syndrome that includes psychiatric and somatic symptoms (see 1.1), maladaptive bereavement-related self-blaming and guilty beliefs (see 1.2), increased sympathetic and inflammatory responses to the loss (see 1.3), and that may accelerate aging through increased morbidity and mortality (see 1.4). This suggests that an integrative (i.e., mind-body) program targeting grief and other psychiatric symptoms, maladaptive self-blaming beliefs, somatic symptoms and complaints, increased sympathetic and inflammatory responses, may promote healthy aging in this underserved population of widowed older adults.

However, the treatment strategies available to date have mainly targeted the psychiatric manifestations of the stress of bereavement, including depression (Reynolds et al. 1999) or complicated grief (Shear et al. 2005). To our knowledge, only one study has examined the potential efficacy of a mind-body intervention for bereaved individuals with promising results. The authors reported that 17 Korean widowed women receiving self-help associated with Dan-jeon, a practice involving concentrating the mind and taking slow deep lower abdominal breaths exhibited significant pre-post changes in grief and depressive symptoms, and life-satisfaction (Yoo and Kang 2006, Kang and Yoo 2007). However, this small study was limited by possible cultural factors that may be specific to this population, the lack of assessment of somatic symptoms, or maladaptive cognitions, and was not specifically adapted to bereaved individuals. There is therefore a critical need for an integrative treatment approach targeting both bereavement-related psychiatric and medical symptoms that may also reduce grief-related self-blame beliefs and the adrenergic and inflammatory responses triggered by bereavement.

1.6 A Mind-Body Intervention Based on the Relaxation-Response and Self-Compassion May Be Efficacious to Support Older Adults Cope with the Stress of Bereavement

The relaxation response (RR) is a state, elicited by mind-body techniques such as meditation and yoga, which is conceptually opposite to the stress (or fight-or-flight) response (Benson et al. 1975). We have previously reported some preliminary efficacy data for an RR-based group intervention on a wide range of psychiatric symptoms, including anxiety, stress, and depression among n=124 treatment seeking individuals attending community health centers (Jacquart et al. 2014). Another similar RR-based symptom reduction group program showed promising significant pre-post program drops in somatic symptoms frequency (d=0.79) including gastrointestinal symptoms, palpitations and chest pain, fatigue, and muscle pain, as well as in psychological distress including depressive (d=0.953), anxiety (d=0.83), and somatization (d=0.96) (Samuelson et al. 2010). In addition, we recently reported in a transcriptome analysis that RR practice reduced expression of genes linked to inflammatory response and stress-related pathways including those connected with the pro-inflammatory transcription factors NF-kB and RELA, and TNFR2, IL7 and TCR signaling (Bhasin et al. 2013).

Self-compassion is defined by the extension of compassion to one’s self in instances of perceived inadequacy, failure, or general suffering. Self-compassion is composed of self-kindness, common humanity, and mindfulness, has been found associated negatively with shame and self-criticism (Gilbert and Procter 2006). Self-compassion training has shown promising results in decreasing trauma-related guilt (pre-post change d=0.82) (Held and Owens 2015), and has thus been proposed as a potential intervention for grievers (Wada and Park 2009).

Taken together, a program based on RR and self-compassion may be efficacious on psychiatric, medical, and biological manifestations of the stress of bereavement in older age. In addition, recent data (Ghesquiere et al. 2013) suggest that the group format may be best adapted to grievers. The Benson-Henry Institute for Mind Body Medicine has developed a range of programs aimed at increasing resiliency including the Relaxation Response Resiliency Program (3RP), a multimodal mind-body intervention that combines RR elicitation strategies (e.g., meditation, imagery) with stress reappraisal skills, and components from positive psychology including self compassion (Park et al. 2013). In the present proposal, we aim to adapt, pilot, and refine the 3RP to meet the specific needs of older adults who lost their spouse and present with psychiatric and medical manifestations of the stress of bereavement. In line with the Osher Center for Integrative Medicine’s strategic themes, our proposal aims to develop a mind-body program to promote healthy aging.

References

  1. Attkisson, C. C. and R. Zwick (1982). “The client satisfaction questionnaire. Psychometric
    properties andcorrelations with service utilization and psychotherapy outcome.” Eval Program Plann 5(3): 233-237.
  2. Benson, H., M. M. Greenwood and H. Klemchuk (1975). “The relaxation response: psychophysiologic aspects and clinical applications.” Int J Psychiatry Med 6(1-2): 87-98.
  3. Bhasin, M. K., J. A. Dusek, B. H. Chang, M. G. Joseph, J. W. Denninger, G. L. Fricchione, H. Benson and T. A. Libermann (2013). “Relaxation response induces temporal transcriptome changes in energy metabolism, insulin secretion and inflammatory pathways.” PLoS One 8(5): e62817.
  4. Blanchard, E. B., J. Jones-Alexander, T. C. Buckley and C. A. Forneris (1996). “Psychometric
    properties of the PTSD Checklist (PCL).” Behav Res Ther 34(8): 669-673.
  5. Boelen, P. A., J. van den Bout and M. A. van den Hout (2003). “The role of cognitive variables in
    psychological functioning after the death of a first degree relative.” Behav Res Ther 41(10):
    1123-1136.
  6. Borysenko, J. (1988). Minding the Body Mending the Mind. New York, Bantam. Bowlby, J. (1980).
    Attachment and loss, volume 3: loss; sadness and depression.
    Braun, V. and V. Clarke (2006). “Using thematic analysis in psychology.” Qualitative Research in
    Psychology 3(2): 77-101.
  7. Bui, E., A. Horenstein, R. Shah, N. A. Skritskaya, C. Mauro, Y. Wang, N. Duan, C. F. Reynolds, 3rd,
    S. Zisook, M. K. Shear and N. M. Simon (2015). “Grief-related panic symptoms in Complicated Grief.” J Affect Disord 170: 213-216.
  8. Bui, E., C. Mauro, D. J. Robinaugh, N. A. Skritskaya, Y. Wang, C. Gribbin, A. Ghesquiere, A.
    Horenstein, N. Duan, C. Reynolds, S. Zisook, N. M. Simon and M. K. Shear (Under Revision). “The
    Structured Clinical Interview for Complicated Grief: Reliability, Validity, and Exploratory Factor
    Analysis.” Depression and Anxiety.
  9. Bui, E., S. P. Orr, R. J. Jacoby, A. Keshaviah, N. J. LeBlanc, M. R. Milad, M. H. Pollack and N. M.
    Simon (2013). “Two weeks of pretreatment with escitalopram facilitates extinction learning in
    healthy individuals.” Hum Psychopharmacol 28(5): 447-456.
  10. Carey, I. M., S. M. Shah, S. DeWilde, T. Harris, C. R. Victor and D. G. Cook (2014). “Increased
    risk of acute cardiovascular events after partner bereavement: a matched cohort study.” JAMA
    internal medicine 174(4): 598-605.
  11. Cohen, S., T. Kamarck and R. Mermelstein (1983). “A global measure of perceived stress.” J Health
    Soc Behav 24(4): 385-396.
  12. Endicott, J., J. Nee, W. Harrison and R. Blumenthal (1993). “Quality of Life Enjoyment and
    Satisfaction Questionnaire: a new measure.” Psychopharmacol Bull 29(2): 321-326.
  13. First, M. S., RL, Gibbon, M; Williams, JBW (1994). Structured Clinical Interview for Axis I DSM-IV
    Disorders – Patient version (SCID-1/P version 2.0). New York, New York State Psychiatric Institute
    Biometrics Research Department.
  14. Ghesquiere, A., M. K. Shear and N. Duan (2013). “Outcomes of bereavement care among widowed older adults with complicated grief and depression.” J Prim Care Community Health 4(4): 256-264.
  15. Gilbert, P. and S. Procter (2006). “Compassionate mind training for people with high shame and
    self‐criticism: Overview and pilot study of a group therapy approach.” Clinical Psychology &
    Psychotherapy 13(6): 353-379.
  16. Granger, D. A., K. T. Kivlighan, C. Blair, M. El-Sheikh, J. Mize, J. A. Lisonbee, J. A. Buckhalt,
    L. R. Stroud, K. Handwerger and E. B. Schwartz (2006). “Integrating the measurement of salivary
    α-amylase into studies of child health, development, and social relationships.” Journal of Social
    and Personal Relationships 23(2): 267-290.
  17. Guy, W. (1976). Clinical Global Impression. Rochville, NIMH.
    Held, P. and G. P. Owens (2015). “Effects of Self-Compassion Workbook Training on Trauma-Related Guilt in a Sample of Homeless Veterans: A Pilot Study.” J Clin Psychol.
  18. Holland, J. M., K. L. Thompson, V. Rozalski and W. G. Lichtenthal (2014). “Bereavement-related
    regret trajectories among widowed older adults.” J Gerontol B Psychol Sci Soc Sci 69(1): 40-47.
  19. Holt, C. S. and R. G. Heimberg (1990). “The Reaction to Treatment Questionnaire: Measuring
    treatment credibility and outcome expectancies.” The Behavior Therapist 13: 213-214, 222.
  20. Jacquart, J., K. M. Miller, A. Radossi, V. Haime, E. Macklin, D. Gilburd, M. Nelson Oliver, D. H.
    Mehta, A. Yeung, G. L. Fricchione, H. Benson and J. W. Denninger (2014). “The effectiveness of a
    community-based, mind-body group for symptoms of depression and anxiety.” Adv Mind Body Med 28(3): 6-13.
  21. Kang, H. Y. and Y. S. Yoo (2007). “Effects of a bereavement intervention program in middle-aged widows in Korea.” Arch Psychiatr Nurs 21(3): 132-140.
  22. Kirschbaum, C., K. M. Pirke and D. H. Hellhammer (1993). “The ‘Trier Social Stress Test’–a tool for investigating psychobiological stress responses in a laboratory setting.” Neuropsychobiology 28(1-2): 76-81.
  23. Laditka, J. N. and S. B. Laditka (2003). “Increased hospitalization risk for recently widowed older women and protective effects of social contacts.” J Women Aging 15(2-3): 7-28; discussion 185-187.
  24. Moon, J. R., N. Kondo, M. M. Glymour and S. V. Subramanian (2011). “Widowhood and mortality: a meta- analysis.” PLoS One 6(8): e23465.
  25. Mutabaruka, J., N. Sejourne, E. Bui, P. Birmes and H. Chabrol (2012). “Traumatic grief and traumatic stress in survivors 12 years after the genocide in rwanda.” Stress Health 28(4): 289-296. NCHS (2012). Older Americans 2012: Key Indicators of Well-being, Federal Interagency Forum on Aging Related Statistics.
  26. Neff, K. D. (2003). “Development and validation of a scale to measure self-compassion.” Self and Identity 2: 223-250.
  27. Newson, R. S., P. A. Boelen, K. Hek, A. Hofman and H. Tiemeier (2011). “The prevalence and characteristics of complicated grief in older adults.” J Affect Disord.
  28. O’Connor, M. F. (2012). “Immunological and neuroimaging biomarkers of complicated grief.” Dialogues Clin Neurosci 14(2): 141-148.
  29. Park, E. R., L. Traeger, A. M. Vranceanu, M. Scult, J. A. Lerner, H. Benson, J. Denninger and G. L.
    Fricchione (2013). “The Development of a Patient-Centered Program Based on the Relaxation Response: The Relaxation Response Resiliency Program (3RP).” Psychosomatics.
  30. Plag, J., K. Gaudlitz, S. Schumacher, F. Dimeo, T. Bobbert, C. Kirschbaum and A. Strohle (2014).
    “Effect of combined cognitive-behavioural therapy and endurance training on cortisol and salivary
    alpha-amylase in panic disorder.” J Psychiatr Res 58: 12-19.
  31. Prigerson, H. G., E. Frank, S. V. Kasl, C. F. Reynolds, 3rd, B. Anderson, G. S. Zubenko, P. R.
    Houck, C. J. George and D. J. Kupfer (1995). “Complicated grief and bereavement-related depression as distinct disorders: preliminary empirical validation in elderly bereaved spouses.” Am J
    Psychiatry 152(1): 22-30.
  32. Prigerson, H. G., P. K. Maciejewski, C. F. Reynolds, 3rd, A. J. Bierhals, J. T. Newsom, A.
    Fasiczka, E. Frank, J. Doman and M. Miller (1995). “Inventory of Complicated Grief: a scale to measure maladaptive symptoms of loss.” Psychiatry Res 59(1-2): 65-79.
  33. QRS (2002). QSR-NVivo. Melbourne, Australia, QSR International Pty Ltd.
  34. Reynolds, C. F., 3rd, M. D. Miller, R. E. Pasternak, E. Frank, J. M. Perel, C. Cornes, P. R. Houck,
    S. Mazumdar, M. A. Dew and D. J. Kupfer (1999). “Treatment of bereavement-related major depressive episodes in later life: a controlled study of acute and continuation treatment with nortriptyline and interpersonal psychotherapy.” Am J Psychiatry 156(2): 202-208.
  35. Rounsaville, B. J., K. M. Carroll and L. S. Onken (2001). “A Stage Model of Behavioral Therapies
    Research: Getting Started and Moving on From Stage I.” Clinical Psychology: Science and Practice
    8(2): 133-142.
  36. Rush, A. J., M. H. Trivedi, H. M. Ibrahim, T. J. Carmody, B. Arnow, D. N. Klein, J. C. Markowitz,
    P. T. Ninan, S. Kornstein, R. Manber, M. E. Thase, J. H. Kocsis and M. B. Keller (2003). “The
    16-Item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and
    self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression.” Biol
    Psychiatry 54(5): 573-583.
  37. Samuelson, M., M. Foret, M. Baim, J. Lerner, G. Fricchione, H. Benson, J. Dusek and A. Yeung
    (2010). “Exploring the effectiveness of a comprehensive mind-body intervention for medical symptom relief.” J Altern Complement Med 16(2): 187-192.
  38. Sbarra, D. A. and C. Hazan (2008). “Coregulation, dysregulation, self-regulation: an integrative
    analysis and empirical agenda for understanding adult attachment, separation, loss, and recovery.”
    Pers Soc Psychol Rev 12(2): 141-167.
  39. Scult, M., V. Haime, J. Jacquart, J. Takahashi, B. Moscowitz, A. Webster, J. W. Denninger and D. H.
    Mehta (2015). “A healthy aging program for older adults: effects on self-efficacy and morale.” Adv
    Mind Body Med 29(1): 26-33.
  40. Selye, H. (1956). “The stress of life.”
  41. Shalev, A. Y., S. P. Orr and R. K. Pitman (1992). “Psychophysiologic response during script-driven
    imagery as an outcome measure in posttraumatic stress disorder.” J Clin Psychiatry 53(9): 324-326.
  42. Shear, K., E. Frank, P. R. Houck and C. F. Reynolds, 3rd (2005). “Treatment of complicated grief: a
    randomized controlled trial.” Jama 293(21): 2601-2608.
  43. Shear, M. K., N. Simon, M. Wall, S. Zisook, R. Neimeyer, N. Duan, C. Reynolds, B. Lebowitz, S. Sung, A. Ghesquiere, B. Gorscak, P. Clayton, M. Ito, S. Nakajima, T. Konishi, N. Melhem, K. Meert, M. Schiff, M. F. O’Connor, M. First, J. Sareen, J. Bolton, N. Skritskaya, A. D. Mancini and A. Keshaviah (2011). “Complicated grief and related bereavement issues for DSM-5.” Depress Anxiety 28(2): 103-117.
  44. Shear, M. K., J. Vander Bilt, P. Rucci, J. Endicott, B. Lydiard, M. W. Otto, M. H. Pollack, L.
    Chandler, J. Williams, A. Ali and D. M. Frank (2001). “Reliability and validity of a structured
    interview guide for the Hamilton Anxiety Rating Scale (SIGH-A).” Depress Anxiety 13(4): 166-178.
  45. Sheehan, D. V., K. Harnett-Sheehan and B. A. Raj (1996). “The measurement of disability.” Int Clin
    Psychopharmacol 11 Suppl 3: 89-95.
  46. Shor, E., D. J. Roelfs, M. Curreli, L. Clemow, M. M. Burg and J. E. Schwartz (2012). “Widowhood and mortality: a meta-analysis and meta-regression.” Demography 49(2): 575-606.
  47. Stroebe, M., W. Stroebe, R. van de Schoot, H. Schut, G. Abakoumkin and J. Li (2014). “Guilt in
    bereavement: the role of self-blame and regret in coping with loss.” PLoS One 9(5): e96606.
  48. Vitlic, A., R. Khanfer, J. M. Lord, D. Carroll and A. C. Phillips (2014). “Bereavement reduces
    neutrophil oxidative burst only in older adults: role of the HPA axis and immunesenescence.” Immun
    Ageing 11: 13.
  49. Wada, K. and J. Park (2009). “Integrating Buddhist psychology into grief counseling.” Death studies
    33(7): 657- 683.
  50. Wilcox, S., K. R. Evenson, A. Aragaki, S. Wassertheil-Smoller, C. P. Mouton and B. L. Loevinger
    (2003). “The effects of widowhood on physical and mental health, health behaviors, and health
    outcomes: The Women’s Health Initiative.” Health Psychol 22(5): 513-522.
  51. Williams, B. R., P. S. Baker and R. M. Allman (2005). “Nonspousal family loss among
    community-dwelling older adults.” OMEGA–Journal of Death and Dying 51(2): 125-142.
  52. Wolpe, J. (1969). “Basic principles and practices of behavior therapy of neuroses.” American
    Journal of Psychiatry 125(9): 1242-1247.
  53. Yoo, Y. S. and H. Y. Kang (2006). “Effects of a bereavement intervention program on depression and
    life satisfaction in middle aged widows in Korea.” Taehan Kanho Hakhoe Chi 36(8): 1367-1373.
  54. Zetumer, S., I. Young, M. K. Shear, N. Skritskaya, B. Lebowitz, N. Simon, C. Reynolds, C. Mauro and S. Zisook (2015). “The impact of losing a child on the clinical presentation of complicated grief.”
    Journal of affective disorders 170: 15-21.

Outcomes

Eric Bui, MD, PhD, Emma Chad-Friedman, BA, Sarah Wieman, BA, Rachel H. Grasfield, BA, Allison Rolfe, BA, Melissa Dong, Elyse R. Park, PhD, MPH, and John W. Denninger, MD, PhD. Patient and Provider Perspectives on a Mind–Body Program for Grieving Older Adult. American Journal of Hospice and Palliative Medicine. (2017) 35:858-865.

Bui E and Okereke O. From Bereavement to Grief to Cognitive Decline: A Call for Novel Treatment and Prevention Approaches. The American Journal of Geriatric Psychiatry. (2018) 26:461-462.