Geriatric Psychiatry

It is my great honor and pleasure as a psychiatric educator to teach many excellent medical students and residents. These young and not-so-young men and women are by and large diligent, highly professional, and caring.

Almost 3 years after the FDA warned of increased mortality in elderly patients who received atypical antipsychotics off-label for neuropsychiatric syndromes of dementia, no medication has been approved as safe and effective for this increasingly challenging problem. Recent publications, however, including a white paper from the American College of Neuropsychopharmacology (ACNP), indicate that clinical investigators are wrestling with the dilemma and considering potential alternatives to antipsychotics.

Precision of psychiatric drug safety assessments, availability of adequately trained psychiatric researchers, and participation of a diverse research population were prominent among the topics of several panels and workshops on research methodology at the NIMH-sponsored 47th annual New Clinical Drug Evaluation Unit (NCDEU) meeting that took place earlier this year in Boca Raton, Fla.

I was taken ill with the flu. They gave me up. The paper had my obit set in type. . . . My hair turned white and then it fell out. The first time I tried to rise to a sitting position I fell and broke an arm. I had phlebitis in one leg and they said I'd never walk again.

Although methadone (Dolophine, Methadose) is primarily thought of as treatment for opioid addiction, it is also an excellent and underused analgesic. This column discusses the issues to consider when deciding whether to prescribe methadone for pain relief.

Among clinicians and researchers in geriatric psychiatry, interest in late-life bipolar disorder is growing, fueled not only by the increasing size of this clinical population but also by the recent discovery that mood stabilizers such as lithium may influence the pathogenesis of Alzheimer disease.

Bipolar disorder (BD) in later life is a complex and confounding neuropsychiatric syndrome with diagnostic and therapeutic challenges.

Many of the things that we busy ourselves with have no apparent utility. Blogging, playing games, and collecting come to mind. To declare that we are compelled to do these things may be too strong, but we do pursue these activities with little deliberation and without concern as to their usefulness. The ubiquity of these pursuits suggests that these activities or their variants helped humans survive at some point and that they now rest on innate brain programs.

There are hundreds of studies that show that pharmacotherapy is used to treat depression in adult and geriatric populations. There are far fewer studies that test the efficacy of psychotherapies and even fewer studies that focus on combined treatment for older patients.

One consequence of the "graying" of the world's population is that psychiatrists, along with all health care professionals, will increasingly be providing services to older adults. In the United States, the first set of people belonging to the baby boom generation turned 60 in 2005, and the number of people older than 60 will soonoutnumber children for the first time in recorded history.

Parkinson disease (PD) is a progressive neurodegenerative disorder affecting 1% of people 65 years and older. The core symptoms include the motor manifestations of tremor, bradykinesia, and rigidity.

Depression is primarily a mood disorder, but it can also be viewed as a cognitive disorder for many older adults.

Bone mineral density (BMD) was reduced at a greater rate in older women when they had symptoms of depression, according to one recent report from the Study of Osteoporotic Fractures Research Group, while another report implicated treatment with SSRI antidepressants.

In lecturing to medical students, residents, and psychiatrists during the past several years, we have encountered widespread hesitancy in the use of MAOIs and even TCAs, mainly because of concerns about their safety but also because of doubts about their effectiveness compared with newer alternatives. Thus, it is timely to review the literature on the efficacy and safety of TCAs and MAOIs, with a view to maintaining an appropriate place for these 2 drug classes in the pharmacotherapy of depression.

What factors affect a decision by Medicare beneficiaries to stop taking a medication because they cannot afford it? Dr Kara Zivin Bambauer and colleagues found that depressive symptoms were a significant predictor of cost-related medication nonadherence (CRN) in Medicare beneficiaries. The results of their study were published in the May 2007 issue of Archives of General Psychiatry. The researchers integrated measures of CRN into the 2004 Medicare Current Beneficiary Survey; 2321 nonelderly Medicare beneficiaries with disabilities and 11,514 elderly Medicare beneficiaries were included.

Epidemiological studies report a lifetime prevalence rate of 24.9% for (any) anxiety disorder. Feelings of anxiety can also be related to normal fear of pain, loneliness, ridicule, illness, injury, grief, or death. In both these types of situations, anxiety can be difficult to deal with. Consequently, benzodiazepines, which offer almost immediate symptomatic relief for anxiety, can be quite appealing to many persons.

To assist in meeting the daunting challenge of medication management, the Clinical Manual of Geriatric Psychopharmacology is a valuable, up-to-date resource for any clinician who prescribes for elderly patients.

More than any other branch of medicine, the profession of psychiatry is unable to coexist with business because the suffering of mentally ill persons is deeper and darker and more pervasive and powerful than any other form of human anguish, whether biological or social.

This article examines the risks involved in prescribing psychotropic medication and offers suggestions for managing those risks to ensure the best possibility for a favorable outcome.

Psychiatrists who work in inpatient units are faced with daily decisions about predicting which patients will be violent, both in the hospital and after discharge. These decisions are often made using unstructured clinical judgment based on the clinician's experience and knowledge of the literature. How long such judgment stays the standard of care remains to be seen, because psychiatric researchers have produced a number of assessment and management tools to improve the accuracy and use of violence risk assessment. This article briefly outlines 3 tools: the Brøset Violence Checklist (BVC), the Classification of Violence Risk (COVR), and the Historical Clinical Risk-20 (HCR-20).

The role of no-suicide contracts is but a small tactical piece of the larger strategic approach to the assessment and prevention of suicide. Its many obvious limitations-to some degree in assessment, but primarily in suicide prevention-should have driven serious discussion of no-suicide contracts out of consideration as a practical measure in clinical practice and a legal talking point in the courtroom.

Four physicians work on the same patient for days at a time, continually returning to a white board, where they list the patient's changing symptoms and their own differential diagnoses. They think inside and outside the box. As data come in from tests and as interventions succeed or fail, they remain flexible in their way of thinking. The attending physician's main lesson to his 3 fellows is to remain unencumbered by preconceived notions and to constantly revise their thinking to fit the data. Only then, he tells his trainees, is there any chance of a correct diagnosis and medical treatment.

Delirium is characterized by an altered level of consciousness, decreased attention span, acute onset, and fluctuating course. Approximately 15% of elderly patients admitted to the hospital have delirium as a presenting or associated symptom. Delirium will develop in another 15% of elderly patients during hospitalization.

Medical school graduation usually involves taking the Hippocratic oath, in which physicians vow not to intentionally harm their patients. Keeping patients safe is another basic principle of patient care. Physicians are charged with ensuring that their patients are in a safe environment and minimizing risks to their patients by carefully selecting treatment options.

In the article by Drs Kunen and Mandry, "Should Emergency Medicine Physicians Screen for Psychiatric Disorders?" (Psychiatric Times, October 2006), no mention was made of formally assessing a patient's mental status to diagnose delirium.