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Guide to the Psychiatry of Old Age

Richard Balon, MD

Wayne State University, Detroit, MI, USA

By David Ames, Edmond Chiu, James Lindesay, and Kenneth I. Shulman. New York, NY; Cambridge University Press; 2010; ISBN 978-0-521-68191-9; pp 158; $49.99 (paperback).

The psychiatry of old age, as defined by the authors of this small book, “is concerned with the identification, assessment, treatment and care of older adults with mental disorders, and of those who look after them” (p 1). As the population, especially in developed countries, is getting older, the number of older adults—whatever the term “older adult” means—with mental illness, especially dementia, is growing. Currently, there are approximately 30 million people with dementia in the world, “with 4.6 million new cases annually. The number of those affected by dementia is projected to double every 20 years…” (p 2). Dementia is not the only disorder that will increase in prevalence with demographic ageing (p 3). The increase of prevalence of numerous diseases combined with the global explosion of obesity is going to create a spectrum of necessary changes and needs. The authors of this book point out that with these changes, individuals in developed countries will need to continue working beyond traditional retirement age (eg, recent changes of retirement age in many European countries), and there will be a continuous growth in the number of single-person households. The authors also predict an increased competition for health care between younger and older age groups. All these changes will have profound social and economic implications (p 3). First, the resources will be more and more stretched and limited. Second, there will be a greater focus on primary prevention of various chronic diseases (eg, cerebrovascular, but also dementia). New models of secondary prevention will have to be developed. Last but not least, there will be an increased demand for physicians and psychiatrists to take care of older adults.

Books devoted to psychiatry of old age—also known as geriatric psychiatry—are plentiful. Some of them are hefty textbooks, serving better as a reference text. Some are slim, serving as an overview or introduction to the area. Guide to Psychiatry of Old Age is the latter, basically an introduction to the problems of geriatric psychiatry. It is written by 4 specialists in this area who are from Australia, the United Kingdom, and Canada. The book consists of a Foreword by Marshal Folstein, Preface, and 12 brief chapters.

The first chapter, “What is psychiatry of old age and why do we need it,” is an introduction to the volume and I summarized its message in my introduction to this review. The second chapter, “Assessing the elderly psychiatric patient,” reviews the assessment of affective, behavioral, and cognitive symptoms in older adults and outlines some special features in the evaluation of these persons. The authors emphasize that, as Brice Pitt noted, psychiatry of old age is “general psychiatry only more so” (p 5). The special features in the evaluation of the elderly patient are: 1) flexibility in adapting to the most appropriate place and mode of assessment; 2) inclusion of the informant/caregiver as a fundamental and essential component of the assessment; 3) skill in taking a history that spans a lifetime; 4) special understanding of medical comorbidities, especially neurologic disorders and the impact of drugs on the central nervous system; and 5) particular skill in cognitive screening, including frontal/executive brain functions (p 5). The text also emphasizes the doctor’s office may not be the best place for assessment of any patient, except for the highly functioning ones, and that particular patient’s own setting is preferred, especially in frail, resistant, or incapable patients (p 5). The chapter further discusses the setting for evaluation before turning to the role of the caregiver/informant, history taking (“perhaps the most important element in establishing a provisional diagnosis” [p 8]), mental status examination, physical examination, special investigations, and referral for assessment by allied health professionals. The discussion of mental status examination stresses that, “One needs to resist the inclination to avoid a formal cognitive screen when the older adult appears to be superficially intact” (p 9). The mental status examination part also reviews which cognitive assessment instruments to use and capacity assessment. The third chapter, “Differential diagnosis—the 3D” “addresses an approach to the differential diagnosis of the major syndromes encountered in the psychiatry of old age, namely the 3Ds—depression, delirium, and dementia” (p 23). The authors focus especially on the differential diagnosis of depression and dementia. The authors review several theories about the relationship between depression and dementia, which may appear to have intuitive merit, but are false: 1) major depression in later life is primarily due to the loses associated with old age (losses in early life are more relevant for development of depression); 2) depression, delirium, and dementia are distinct syndromes (they are not as distinct as originally postulated); 3) subjective cognitive impairment or complaints of memory impairment are associated with depression (not so, in a significant proportion of cases, these complaints could be prodromes of developing dementia); 4) the use of antidepressants with marked anticholinergic properties may be the cause of dementia (studies do not support this notion); and 5) depression is a psychological reaction to impaired cognition (no good evidence is available). The chapter ends with a discussion of the clinical implications of the growing relationship between depression and dementia.

Chapter 4, “The dementias,” provides a brief overview of various types and causes of dementia, their epidemiology, symptoms, natural history, assessment, diagnosis, and finally management of persons with dementia and their caregivers. The part on management emphasizes the huge responsibility of telling someone they have dementia and how this should be done with compassion, honesty, and sufficient time available to answer questions and discuss implications (p 42). The text on drug treatments is a standard review of the few available medications for dementia. The following chapter, “Behavioural and psychological symptoms of dementia,” focuses on the noncognitive, neuropsychiatric, behavioral, psychological, and psychiatric symptoms of dementia (eg, agitation, delusions, mood symptoms) and their management. These symptoms frequently are the trigger for referral of a patient with dementia to psychiatric services (p 51). The authors remind us that “first no harm” should be the guiding principle in managing these symptoms. Chapter 6, “Delirium,” is again a standard review of clinical features, differential diagnosis, neuropathophysiology, epidemiology, risk factors, course, prognosis, and management of delirium in older persons. Similarly, chapter 7, “Mood disorders in late life,” summarizes depression, bipolar disorders, and mania in late life. Important information to remember include the fact that depressed patients report significantly greater medical comorbidity than nondepressed patients and that there is a strong relationship between depression and vascular disease. I was happy to see the statement that “a number of recent studies suggest that effectiveness and adverse events are not significantly different between tricyclic antidepressants and selective serotonin reuptake inhibitors.”

The following 3 chapters review, in a fashion similar to the previous chapters, “Schizophrenia and related disorders in late life,” “Neurotic and personality disorders,” and “Substance abuse and iatrogenesis in late life.” Chapter 11, “Services for older patients with psychiatric disorders,” presents the international consensus model on organizations of care, and then briefly discusses issues such as the multidisciplinary team, residential care, community-based assessment, respite care, advocacy, spiritual and leisure needs, and what the necessary components of a service are (the minimum includes community mental health teams for older persons, inpatient assessment and treatment, day hospitals, outpatient services, respite care in-home or facility-based, continuing hospital care, residential care, liaison services for general and geriatric hospitals, primary care collaborations community and social support services, prevention programs, educational programs for health professionals, destigmatization programs, public education, and health promotion). The book ends with the standard fare, a chapter on “The future of the psychiatry of old age.” This chapter deals mostly with the notion of clinical neuroscience, a concept originally proposed by the late Thomas Detre, and with the debate of age-based vs needs-based services.

This book is what the title suggests—a guide or introduction to psychiatry of old age. It is brief, practically oriented, and without much unnecessary detail. It is well-written. One useful feature is that there are no references included, but the authors provide “Further reading” accompanying each chapter, which includes pertinent articles, books, and chapters. Residents, fellows in geriatric psychiatry or geriatric medicine, and some clinicians for whom geriatric psychiatry constitutes part of their practice, will find this to be a useful introduction. However, full-fledged practicing geriatric psychiatrists may find this text to be “too light,” especially with regard to management guidance of mental disorders of old age.