Challenges

The therapeutic management of mental health problems in older adults brings many challenges. Some of the critical factors contributing to these challenges are:

• increased tendency for cognitive impairment,
• drug interactions,
• electrolyte disturbances (hyponatraemia),
• risk of falling,
• bradycardia,
• treatment resistance
• increased risk of mortality (1).

The efficacy of antidepressants for depression in dementia still remains low (2,3,4).

The implementation of non-pharmacological interventions for behavioural and psychological symptoms of dementia is limited by:

• therapist availability,
• the willingness of the patient and family to participate,
• the presence of cognitive problems, sensory impairments and financial problems(5).

The COVID-19 pandemic has further complicated healthcare for older adults. Older adults with chronic health conditions are likely to be most affectedas they appear to be at risk of disease relapse plus the risk of contracting COVID-19 while accessing healthcare(7).

The treatment of mental health conditions in older adults is also a challenge, given their multiple co-morbidities. Therefore, safe and effective treatment options are needed (5,6).

Opportunities:

Role of Stimulation Electrical Stimulation (tDCS) in geriatric mental health

Depression and neurocognitive disorders are the most common mental health problems in older adults (8). They require rapid and effective intervention to prevent negative impact on quality of life as well as negative effects on coexisting medical conditions.

Over the past two decades, non-invasive brain stimulation (NIBS) has proven effective in managing symptoms of mental disorders. The same has been shown in older adults, with Transcranial Electrical Stimulation being used either to accelerate symptom remission as a stand-alone intervention (monotherapy) or as a strategy to augment the efficacy of existing antidepressant medications (9,10 11).

In recent years, tDCS has been presented as a potential treatment modality for neurocognitive disorders and depression. It works by creating a subpathic modulation of neuronal membrane potentials, thereby altering excitability and cortical activity. In this respect, tDCS is different from TMS in that it does not induce a massive synchronized neuronal discharge; instead, it changes the threshold and thus the probability of discharge. In addition, it has other biological effects, such as changes in neurotransmitters, effects on glial cells and microvessels, and modulation of inflammatory processes (12,13).

In Mildcognitive impairment (MCI) and Alzheimer’s dementia, preliminary evidence suggests the efficacy tDCSin cognitive symptoms, with efficacy on behavioural and psychological symptoms (14). Concurrent cognitive interventions such as cognitive stimulation computerized (e.g., memory training and language training), have shown additional benefit (15, 16).

Use of Transcranial Electrical Stimulation treatment in conjunction with Computerized Cognitive Stimulation training in older adults increases the patient’s ability to function and improves performance of daily activities based on stimulation of neuroplasticity and neural growth factor secretion. In order to maintain the long-term benefits, it is important that these treatments are applied over a period of 6 months.

Because tDCS works mainly by altering the resting potential of the neuronal membrane, several sessions over a set period of time are required. A recent study has shown the efficacy of tDCS in vascular depression resistant to usual drug treatment (17). There is also a wealth of evidence for tDCS as an effective treatment for apathy, insomnia, alcohol dependence, etc.(18,19,20). Therefore, tDCS may be an extremely useful intervention for older adults with neuropsychiatric disorders.

The benefit of applying Transcranial Electrical Stimulation for geriatric mental health conditions is becoming increasingly relevant, particularly in the context of the COVID-19 pandemic, as precautions are needed to avoid high-risk exposure in hospital settings. There is growing evidence of benefits in terms of neurobehavioral changes after daily application of Transcranial Electrical Stimulation (tDCS)

Opportunities:

Advantages of tDCS (Transcranial Electrical Stimulation) at home

Several studies have shown the efficacy and safety of home tDCS in older adults. Indications for which home tDCS has been recommended include depression, stroke and motor or sensory weakness, tinnitus, amyotrophic lateral sclerosis, osteoarthritis and vertigo syndrome.

Conclusions:

It is important to note that home tDCS can be used safely in the geriatric population, provided that studies in those conditions report efficacy for the clinical indication.

In order to access Transcranial Electrical Stimulation services at home for people who are difficult to move or who have disabilities, the following are required:

1. One or more training sessions for the person who is to carry out the treatment for the patient to explain the correct administrative procedure (with an evaluation procedure to assess the effectiveness of the training).
2. Identify a suitable custom fitting with prefixed or marked positions for electrodes, which are colour coded.
3. Perform device settings by trained clinic staff;
4. A manual (and video demonstration) to be handed to the patient and relatives with details of the device
5. Remote monitoring by the clinical team to ensure correct administration and assessment of possible adverse effects.

Bibliography

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