Clinical manual of geriatric psychiatry

429 Pages·2006·3.329 MB·English

by  James E Spar, Asenath La Rue

Clinical Manual of
Geriatric Psychiatry
This page intentionally left blank
Clinical Manual of
Geriatric Psychiatry
James E. Spar, M.D.
Professor of Clinical Psychiatry
Department of Psychiatry & Biobehavioral Sciences
Geffen School of Medicine at UCLA
Los Angeles, California
Asenath La Rue, Ph.D.
Senior Scientist
Wisconsin Alzheimer’s Institute
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Washington, DC
London, England
Note: The authors have worked to ensure that all information in this book is accurate
at the time of publication and consistent with general psychiatric and medical standards,
and that information concerning drug dosages, schedules, and routes of administration
is accurate at the time of publication and consistent with standards set by the U.S.
Food and Drug Administration and the general medical community. As medical
research and practice continue to advance, however, therapeutic standards may change.
Moreover, specific situations may require a specific therapeutic response not included
in this book. For these reasons and because human and mechanical errors sometimes
occur, we recommend that readers follow the advice of physicians directly involved in
their care or the care of a member of their family.
Books published by American Psychiatric Publishing, Inc., represent the views and
opinions of the individual authors and do not necessarily represent the policies and
opinions of APPI or the American Psychiatric Association.
Copyright © 2006 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED
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10 09 08 07 06 5 4 3 2 1
First Edition
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Library of Congress Cataloging-in-Publication Data
Spar, James E.
Clinical manual of geriatric psychiatry / James E. Spar, Asenath La Rue.—1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 1-58562-195-1 (pbk. : alk. paper)
1. Geriatric psychiatry—Handbooks, manuals, etc. 2. Older people—Mental
health—Handbooks, manuals, etc. 3. Older people—Psychology—Handbooks,
manuals, etc.
[DNLM: 1. Aged. 2. Mental Disorders—diagnosis. 3. Mental Disorders—therapy.
4. Age Factors. 5. Aging—psychology. WT 150 S736c 2006] I. La Rue, Asenath,
1948– II. Title.
RC451.4.A5S63 2006
618.97'689—dc22
2006005228
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
Contents
1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
An Aging World. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Health and Functioning of Older Adults. . . . . . . . . . . . . .3
Mental Disorders in Later Life . . . . . . . . . . . . . . . . . . . . . .6
Barriers to Geriatric Mental Health Care. . . . . . . . . . . . . .8
Diversity in Patterns of Health and Aging. . . . . . . . . . . .12
Working Effectively With Older Adults. . . . . . . . . . . . . . .15
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
2
Normal Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Conceptual Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Cognitive Abilities in Later Life: A Processing
Resource Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Personality and Emotional Changes. . . . . . . . . . . . . . . .38
Social Context of Aging . . . . . . . . . . . . . . . . . . . . . . . . . .43
Biological Aging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
Aging and the Clinical Process. . . . . . . . . . . . . . . . . . . . .50
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61
3
Mood Disorders—Diagnosis . . . . . . . . . . . . . . . .67
“Normal” Grief (Bereavement) . . . . . . . . . . . . . . . . . . . .68
Complicated Grief. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
Depression Due to a General Medical Condition . . . . .70
Substance-Induced Mood Disorder . . . . . . . . . . . . . . . .76
Major Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80
Dysthymic Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91
Minor Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92
Depressive Personality Disorder . . . . . . . . . . . . . . . . . . .95
Laboratory Evaluation of Depression . . . . . . . . . . . . . . .95
Psychological Tests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96
Symptom Rating Scales and Depression Screening . . .97
Assessing Suicidality in the Elderly . . . . . . . . . . . . . . . .105
Theories of Depression . . . . . . . . . . . . . . . . . . . . . . . . .107
Hypomania and Mania. . . . . . . . . . . . . . . . . . . . . . . . . .110
Mixed Mood Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . .117
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117
4
Mood Disorders—Treatment. . . . . . . . . . . . . . .127
Psychotherapy for Geriatric Depression . . . . . . . . . . . .127
New Directions in Psychotherapy Research. . . . . . . . .130
Combined Psychotherapy and Pharmacotherapy. . . .132
Psychopharmacotherapy for Geriatric Depression . . .132
Psychopharmacotherapy for Psychotic Depression. . .156
Psychopharmacotherapy for Bipolar Depression. . . . .157
Electroconvulsive Therapy . . . . . . . . . . . . . . . . . . . . . . .157
Experimental Therapies . . . . . . . . . . . . . . . . . . . . . . . . .159
Complementary and Alternative Approaches . . . . . . .161
Hypomania and Mania. . . . . . . . . . . . . . . . . . . . . . . . . .162
Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166
5
Dementia and
Alzheimer’s Disease. . . . . . . . . . . . . . . . . . . . . .173
Identifying the Dementia Syndrome. . . . . . . . . . . . . . .173
Common Etiologies of Dementia . . . . . . . . . . . . . . . . .186
Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . .192
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .221
Resources for Dementia Caregivers . . . . . . . . . . . . . . .228
6
Other Dementias and Delirium . . . . . . . . . . . .229
Frontotemporal Dementia. . . . . . . . . . . . . . . . . . . . . . .229
Dementia With Lewy Bodies. . . . . . . . . . . . . . . . . . . . .235
Vascular Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .241
Mixed Dementia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248
Dementia Due to General Medical Conditions . . . . . .249
Substance-Induced Persisting Dementia . . . . . . . . . . .254
Reversible Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . .255
Delirium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .256
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265
7
Anxiety Disorders and
Late-Onset Psychosis. . . . . . . . . . . . . . . . . . . . .273
Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .273
Late-Onset Psychosis . . . . . . . . . . . . . . . . . . . . . . . . . . .293
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .306
8
Other Common Mental Disorders
of the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . .313
Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .313
Alcohol Abuse and Dependency. . . . . . . . . . . . . . . . . .320
Other Psychoactive Substance Abuse
and Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . .326
Sexual Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . . .329
Psychiatric Illness Related to a General
Medical Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . .334
Chronic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .337
Influence of Aging on Disorders of Early Onset. . . . . .339
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .341
9
Competency and Related Forensic Issues. . . .347
Decisional Competency. . . . . . . . . . . . . . . . . . . . . . . . .348
Undue Influence: The Question of Voluntariness . . . .358
Competency to Care for Oneself and
Manage One’s Finances. . . . . . . . . . . . . . . . . . . . . . . .360
Expert Consultation and Testimony
on Competency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .366
Competency to Drive . . . . . . . . . . . . . . . . . . . . . . . . . . .367
Elder Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .371
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .373
Appendix: Clinical Assessment
Instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . .379
Geriatric Depression Scale. . . . . . . . . . . . . . . . . . . . . . .380
Six-Item Orientation-Memory-Concentration Test. . . .382
Cognistat profile: Example. . . . . . . . . . . . . . . . . . . . . . .383
Instrumental Activities of Daily Living (IADL) Scale. . .384
Revised Memory and Behavior Problems
Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .386
Items Rated on the Neuropsychiatric Inventory. . . . . .388
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .389
1
Introduction
An Aging World
For the first time in history, most people in societies such as our own can plan
on growing old. Life expectancy from birth has increased dramatically in the
United States, from about 47 years in 1900 to 77.3 years in 2002 (Federal In-
teragency Forum on Aging-Related Statistics 2004). Even those people who
are currently “old” can expect to live for many years. For men at age 65, aver-
age life expectancy is more than 16 years, and for women at age 65, it is almost
20 years; at age 85, men can expect to live 6 more years and women 7 years
(Federal Interagency Forum on Aging-Related Statistics 2004).
More than 20% of the current U.S. population are older than age 55, and
more than 12% are 65 or older (Federal Interagency Forum on Aging-Related
Statistics 2004). The elderly population is the only age segment of the popu-
lation that is expected to grow substantially in the next quarter century, so
that by the year 2030, one in three Americans will be age 55 or older, and one
in five will be at least age 65. Very old people (85 years and older) constitute
one of the fastest-growing subgroups of the elderly population (Figure 1–1).
In 1900, a little more than 100,000 people were age 85 years or older in the
United States, compared with an estimated 4.2 million in 2000 (National
Center for Health Statistics 2004). By 2050, there will be 19 million to 24
million people in this 85 and older age group, or nearly 5% of the total pop-
ulation. In 2003, more than 50,000 U.S. residents were 100 years or older, an
increase of 36% since 1990 (Administration on Aging 2004).
1