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1 19 Advances in Psychosomatic Medicine Editor: T.N. Wise Issues in Geriatric Psychiatry Editors : N. Billig, P.V. Rabins Issues in Geriatric Psychiatry Advances in Psychosomatic Medicine Vol. 19 Series Editor Thomas N. Wise, Falls Church, Va. Editors G.A. Fava, Bologna; H. Freyberger, Hannover; F. Guggenheim, Little Rock, Ark.; M. Hale, Farmington, Conn.; O. W. Hill, London; Z.J. Lipowski, Toronto, Ont.; G. Lloyd, Edinburgh; A. Reading, Tampa, Fla.; P. Reich, Boston, Mass.; M.B. Rosenthal, Cleveland, Ohio Consulting Editors G.L. Engel, Rochester, N.Y.; H. Weiner, Bronx, N.Y.; L. Levi, Stockholm Editor Emeritus Franz Reichsman, Brooklyn, N.Y. Basel Mnchen Paris London NewYork NewDelhi Bangkok Singapore Tokyo Sydney Issues in Geriatric Psychiatry Volume Editors Nathan Billig, Washington, D.C. Peter V. Rabins, Baltimore, Md. 1 figure and 5 tables, 1989 Basel Mnchen Paris London NewYork NewDelhi Bangkok Singapore Tokyo Sydney
2 Advances in Psychosomatic Medicine Library of Congress Cataloging-in-Publication Data Issues in geriatric psychiatry/volume editors, Nathan Billig, Peter V. Rabins. (Advances in psychosomatic medicine; vol. 19) 1. Geriatric psychiatry. I. Billig, Nathan. II. Rabins, Peter V. III. Series. [DNLM: I. Geriatric Psychiatry. 2. Mental Disorders - in old age. W1 AD81 v. 19/ WT ] ISBN Bibliographic Indices This publication is listed in bibliographic services, including Current Contents and Index Medicus. Drug Dosage The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Copyright 1989 by S. Karger AG, P.O. Box, CH-4009 Basel (Switzerland) Printed in Switzerland by Thr AG Offsetdruck, Pratteln ISBN Contents Introduction: Psychosomatic Medicine and Geriatric Psychiatry, by N. Billig and P.V. Rabins...VI Lipowski, Z.J. (Toronto, Ont.): Delirium in Older Adults...1 Peters, D.W.; Reifler, B.V.; Larson, E. (Winston-Salem, N.C.): Excess Disability in Dementia...17
3 Waldhorn, R.E. (Washington, D.C.): Sleep Disorders in the Elderly...31 Wise, T.N. (Washington, D.C./Baltimore, Md.): Sexuality in the Aging Individual: A Biopsychosocial Perspective...53 Gottlieb, G.L. (Philadelphia, Pa.): Hypochondriasis: A Psychosomatic Problem in the Elderly. Nosology, Etiologic Hypotheses, Health Care Ramifications...67 Liptzin, B. (Belmont/Boston, Mass.): The Nursing Home Resident as a Psychiatric Patient...85 Cohen-Mansfield, J. (Washington, D.C.): Agitation in the Elderly Meyers, B.S.; Kalayam, B. (White Plains, N.Y.): Update in Geriatric Psychopharmacology Goldberg, R.L. (Washington, D.C.): Geriatric Consultation/Liaison Psychiatry Mishkin, B. (Washington, D.C.): Determining the Capacity for Making Health Care Decisions Lebowitz, B.D.; Cohen, G.D. (Rockville, Md.): Education and Training in Geriatric Psychiatry Subject Index Introduction: Psychosomatic Medicine and Geriatric Psychiatry Geriatric psychiatry, with its roots and resources in both geriatric medicine and psychiatry, may be the best example of an area of study and body of clinical knowledge that typifies 'psychosomatics'. In the broadest application of the term 'psychosomatics', the older adult population presents us with complex problems that result from the overlap and coexistence of medical and psychological issues. It is impossible to responsibly treat older adult patients, either as a geriatrician or psychiatrist, without a familiarity with a medical/psychological composite. The elderly help us focus, as clinicians and researchers, on the complicated nature of normal
4 and abnormal states as we attempt to integrate social, biological and psychological factors. While the concept of mind/body integration is as old as recorded thought, a systematic medical approach to understanding the effects that mind and body have on each other in health and disease has occurred only in the last 150 years [E. Meyer, 1959]. The creative research and descriptive clinical work, within the past 60 years, of Adolph Meyer, Cannon, Alexander, Engel, Selye, Reiser and others have created the field of psychosomatics as an entity within medicine which has had far-reaching implications to medicine in general, and to psychiatry in particular. Only in the last 20 years, however, has there been a significant interest in the application of those ideas to the geriatric population. This volume represents a sampling of the many subjects with which geriatric psychiatry is concerned and highlights the truly 'psychosomatic' nature of the field. Delirium and dementia are the most frequently occurring organic mental disorders in the elderly. The patient presenting with cognitive impairment and altered state of consciousness requires the intense collaboration Introduction: Psychosomatic Medicine and Geriatric Psychiatry VII of internist, neurologist and psychiatrist to define the etiology of the delirium syndrome and then institute treatment as rapidly as possible. Patients with the diagnosis of dementia have, until the past decade, largely been seen as having irreversible and therefore untreatable illnesses. The concept of treatability has evolved to include not only those cases secondary to medication intolerance, endocrine and metabolic disorders, tumors, infections and other systemic illnesses. We look at Alzheimer's disease and other primary dementias as being 'treatable' even though they are not yet curable. The issue of excess disability and the treatability of those entities to achieve maximum function in a patient with progressive dementia is important for clinicians to appreciate. With the advent of the sleep laboratory for research and clinical applications, we have been better able to assess, define and categorize sleep patterns in elderly patients. There are clearly age-associated changes which affect the quality and quantity of sleep which are compounded by the multiple effects of illness, medications and emotional issues. Sleep apnea represents just one clinical entity, more common in older adults, which frequently draws the internist and psychiatrist together to better understand and treat a complex disorder. Older adults challenge us to look at sexual function for the purpose of recreation, long after the function of procreation has passed. From clinical
5 assessments we know that sexual interest, feelings and activity, while not often discussed in the later years, remain important aspects of biological and psychosocial functioning. Clinicians often know little about their older patients' sexual function and dysfunction and the significance of these to them. There is no more vexing problem for the clinician than that of hypochondriasis. The distinction between 'somatization' and the subtle presentation of chronic illness is often a difficult one. Similarly, the preoccupation with bodily sensations may reflect social, behavioral and intrapsychic issues which are otherwise covert. The nursing home, until very recently, was a poorly understood institution and its residents woefully ignored in meaningful clinical research which might lead to advances in treatment techniques. It has now been demonstrated that the prevalence of diagnosable and potentially treatable mental disorders in nursing homes is enormous. The role of the psychiatrist in a consulting relationship in that setting is complex, and one that is increasingly being defined. The syndromes of dementia and depression complicated by severe chronic medical problems, agitation and other behavioral symptoms present an opportunity for true multidisciplinary efforts. Billig/Rabins VIII For most of the time that psychopharmacological agents have been used in a systematic fashion, the elderly have largely been ignored in terms of their peculiar responses and reactions to those medications. It is now known that the pharmacodynamic and pharmacokinetic effects of medications change with age, and that this can dramatically affect the efficacy and toxicity of these agents. These facts are vital to understand if we are to responsibly treat older adult patients. Clinicians who work with the elderly have long accepted the axiom that older adults are more diverse and complex than any other age group. The older medical and surgical patient, particularly in the hospital setting, presents us with a wide-ranging interplay of factors which must be sorted in our attempts to diagnose and treat their medical and psychological maladies. The consultation/liaison psychiatrist is challenged in his work with geriatric patients to master a rather large body of medical and psychiatric knowledge, and to develop skills in working with medically ill elderly and their primary-care providers. Psychiatrists are called upon to assess the capacity and competence of people for a variety of reasons. Many of these people are elderly. The determination of competency and capacity for health care decision-making are necessary parts of medical/psychiatric practice. They represent a part of the legal system that physicians must understand in order to act appropriately
6 and responsibly on behalf of patient and family. Geriatric psychiatry is a substantive de facto subspecialty area within general psychiatry. Its growth within the past decade points to the needs within the growing geriatric population, the increased interest in a wide range of research areas in geriatrics and the recognition that while many general psychiatrists can treat elderly patients, a cadre of academic, research-oriented and highly trained clinicians are required to energize this new area of psychiatry. The National Institute of Mental Health and various private foundations have actively funded efforts to stimulate the training of psychiatrists in geriatrics. The chapters in this volume cover many of the crucial aspects of geriatric psychiatry which have implications for psychosomatic medicine in eneral. The field is growing rapidly as accumulating research data yield clinically significant insights. Opportunities for gathering and learning new information occur weekly and clinical collaborative efforts are a necessary feature of our work. Nathan Billig, MD Peter V. Rabins, MD
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