Geriatric Psychiatry

Keys to diagnosis, assessment, and management.

As with all medical emergencies, psychiatric emergencies are among the most clinically challenging situations.

At the end of life, psychiatrists are often asked to assess a patient’s capacity to refuse treatment, but the role of the psychiatrist in this situation is much broader.

Nothing can replace talking with patients. This can take substantial amounts of time, but it is the only way to obtain as clear a view as possible about whether a patient is benefiting from treatment.

Almost the first memory I have of a physician is our family doctor at my bedside, leaning over to press his warm fingers against my neck and beneath my jaw. I’m 5, maybe 6 years old. I have a fever and a sore throat, and Dr Gerace is carefully palpating my cervical and submandibular lymph nodes. In my family, Dr Gerace’s opinion carried a lot of weight. It was the 1950s, and my mother did not quite trust those new-fangled antibiotics. She usually tried to haggle with the doctor over the dose-“Can’t the boy take just half that much?”-but even my mother would ultimately bow to Dr Gerace’s considered opinion.

Help in Clinical Decision Making

The impact of FDA alerts and label warnings was examined in 2 recently published studies of antipsychotic drug use. In one study, researchers gauged physician response to the 2005 warning of increased mortality with antipsychotic use in elderly patients with dementia, and in the other study, researchers determined whether recommended safeguards were implemented following the 2003 advisories on adverse metabolic effects of second-generation antipsychotics.

Dateline: Portland, Oregon, April, 2011[From the office notes of Prescribing Psychologist, R.X. Sciolus, PhD]“Ms Malfortuna is a 60-year-old white female with a recent history of significant depressive symptoms, including insomnia, poor appetite, decreased energy, anhedonia, and lack of motivation. . .

Posted on February 3, I asked the question, CAUTION! Who Should Be the DSM5 Diagnostician? I suggested that we needed to pay as much attention to who would be designated as the diagnostician as on the revised diagnostic criteria.

Mr V had appeared at our appointment in a panic, after an episode of premature ventricular contractions and a terrifying nightmare. In the dream, he was threatened by a blue, masklike face with white circles for eyes and 2 slits for a nose.

Resources, books, and practice guidelines

This article reviews the differences between dementia types and future directions.

A Serious Man-a film that explores their Jewish roots in Minnesota. Not roots in the genealogical or autobiographical sense but from a removed and more philosophical perspective-what does it mean to be a Jew, both as a matter of social identity and as someone who is supposed to believe in God or Hashem, the word religious Jews invoke so as not to take the name of the Lord in vain. Hashem will roll so glibly off the tongues of the Coens’ Jews, it will seem more like affectation than piety.

The United States Census Bureau projects that by 2010 nearly 13% of the US population will be over the age of 65. The elderly are one of the most rapidly growing segments of the US population and are expected to account for more than 20% of the total population by 2050.1 In 2001, the prevalence of dementia in North America was 6.4%. A 49% increase in the number of people with dementia is expected by 2020, and a 172% increase by 2040.2 Patients with dementia may lack the capacity to consent to treatment. The need to evaluate capacity to consent to treatment will therefore increase as the aging population grows.

November/December 2009 Special Report: Forensic Psychiatry

The NIMH-sponsored New Clinical Drugs Evaluation Unit (NCDEU) meeting is a favored venue for reports and reviews of NIH-funded psychopharmacological studies, and this was true of the recent annual meeting in Hollywood, Fla. The meeting included a workshop on new investigations of antidepressant use in Alzheimer disease and a panel session on the safety of pharmacotherapy in older adults.

Of the screening tools available to help identify early symptoms of Alzheimer’s disease, which is best?

Surveys show that approximately 60% of the general population has gambled within the past 12 months.1 The majority of people who gamble do so socially and do not incur lasting adverse consequences or harm. Beyond this, approximately 1% to 2% of the population currently meets criteria for pathological gambling.2 This prevalence is similar to that of schizophrenia and bipolar disorder, yet pathological gambling often goes unrecognized by most health care providers.

As a standing member of the Editorial Board of Psychiatric Times, I read with particular interest the front-page story in the March issue, “Pharmonitor: Reality-Checking and Journalistic Integrity” by Editor in Chief Ronald Pies, MD. In it, Dr Pies pointed out that “disclosures do not guarantee scientific or journalistic objectivity and accuracy.” He set out the critical scientific questions that ought to be asked, and he promised that “Pharmonitor” would be “a reader-driven commentary . . . focusing on articles and reports in Psychiatric Times that the reader considers biased.”

For pharmaceutical companies, off-label use of a drug represents a substantial “gray market,” to which the company is unable to sell their product directly, yet may be a significant revenue stream. Some drugs have been used more for off-label purposes than for originally approved indications.1

Delirium has been recognized and described since antiquity. It is a brain disturbance manifested by a syndrome of diverse neuro­­psychiatric symptoms. Various terms have been used for delirium, such as acute brain disorder, metabolic enceph­alopathy, organic brain syndrome, and ICU psychosis.

Persistent pain is not an inevitable part of aging, but it is, unfortunately, fairly common among those aged 65 years and older. Between 25% and 50% of the general geriatric population and 45% to 80% of those in nursing homes have this problem.

Alarmed by the rising suicide rate among soldiers returning from Iraq and Afghanistan and “wanting to help,” Matthew “Matt” Houseal, MD, a psychiatrist with the Texas Panhandle Mental Health Mental Retardation Center (TPMHMR), reenlisted as an Army Reservist and volunteered to serve in Iraq.

If I closed my eyes, it would have been easy to imagine that I was visiting a peaceful city park. The sounds of birdsong and children’s laughter rang in the air, and the odor of freshly cut grass filled my nostrils. But the sweet smells and soothing sounds belied the horror of the place where I actually stood-inside the wrought iron gates of Auschwitz-Birkenau, the Holocaust’s most infamous concentration camp. Today the camp is a museum, and there is an eerie dissonance between the tranquility of its sprawling grounds and the mass murders that were carried out here almost 70 years ago. Like many visitors to Auschwitz, I experienced powerful emotions-a mixture of revulsion, anger, and a deep empathy for the millions of souls who suffered and perished there. I also felt a discomfiting sense of doubt about the goodness of humanity, including my own.

Mortality in elderly patients with dementia markedly and progressively increases with extended use of antipsychotics, according to the first long-term controlled study of risk in this population. Earlier evidence of this risk was from short-term trials not exceeding 14 weeks.