PSYCHIATRIC CONSEQUENCES OF BRAIN DISEASE IN THE ELDERLY A Focus on MANAGEMENT
PSYCHIATRIC CONSEQUENCES OF BRAIN DISEASE IN THE ELDERLY A Focus on MANAGEMENT Edited by David K. Conn Bayerest Centre for Geriatric Care and University qf Toronto Toronto, Ontario, Canada Adrian Grek Queen Street Mental Health Centre and University qf Toronto Toronto, Ontario, Canada and Joel Sadavoy Bayerest Centre for Geriatric Care and University of Toronto Toronto, Ontario, Canada PLENUM PRESS NEW YORK AND LONDON
Library of Congress Cataloging in Publication Data Psychiatric consequences of brain disease in the elderly: a focus on mangement edited by David K. Conn, Adrian Grek, andjoei Sadavoy. p. cm. Based on a symposium held May 29, 1987 in Toronto, Ont., Canada. Includes bibliographies and index. ISBN 0-306-43216-1 ISBN-13: 978-1-4684-1308-3 e-isbn-13: 978-1-4684-1306-9 DOl: 10.1007/978-1-4684-1306-9 1. Geriatric neuropsychiatry-congresses. 2. Brain-Aging-Congresses. 3. Brain -Diseases-Complications and s e q u e l a e ~ C I. o nconn, g r edavid s s ek. s II.. Grek, Adrian. III. Sadavoy, Joel, 1945- [DNLM: 1. Mental Disorders-in old age-congresses. 2. Mental Disorderstherapy-congresses. WT 150 P974 1987) RC451.4.A5P75 1989 618.97'689-dc20 DNLM/DLC for Library of Congress 89-8434 CIP Based on proceedings of a symposium entitled Psychiatric Consequences of Brain Disease in the Elderly: A Focus on Management, held May 29, 1987, in Toronto, Ontario, Canada 1989 Plenum Press, New York Softcover reprint of the hardcover 1st edition 1989 A Division of Plenum Publishing Corporation 233 Spring Street, New York, N.Y. 10013 All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher
TO OUR WIVES AND CHILDREN
CONTRIBUTORS Graham Berman, M.B., Ch.B., F.R.C.P.(C) Staff Psychiatrist, Baycrest Centre for Geriatric Care Assistant Professor, Department of Psychiatry, University of Toronto Training Analyst, Toronto Institute of Psychoanalysis, Toronto, Ontario Gene D. Cohen, M.D., Ph.D. Director of the Program on Aging at the National Institute of Mental Health Clinical Professor of Psychiatry, Georgetown University School of Medicine, Washington, D.C. David K. Conn, M.B., B.Ch., F.R.C.P.(C) Coordinator, Consultation-Liaison Psychiatry Service, Baycrest Centre for Geriatric Care Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario Jeffrey L. Cummings, M.D. Director of the Neurobehaviour Unit, West Los Angeles Veterans Administration Medical Center Associate Professor of Neurology and of Psychiatry and Biobehavioural Science, UCLA School of Medicine, Los Angeles, California Adrian Grek, M.B., B.Ch., F.R.C.P.(C) Chief, Psychogeriatric Service, Queen Street Mental Health Centre Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario Guy-Bernard Proulx, Ph.D. Director, Department of Psychology, Baycrest Centre for Geriatric Care, Toronto, Ontario Anne Robinson, R.N. Nurse Clinician, Department of Psychiatry, Baycrest Centre for Geriatric Care, Toronto, Ontario Joel Sadavoy, M.D., F.R.C.P.(C) Head, Department of Psychiatry, Baycrest Centre for Geriatric Care Associate Professor, Department of Psychiatry, University of Toronto Toronto, Ontario Stuart A. Schneck, M.D. Professor of Neurology and Pathology (Neuropathology) and Associate Dean for Clinical Affairs, University of Colorado School of Medicine, Denver, Colorado vii
viii CONTRIBUTORS Kenneth Shulman, M.D., F.R.C.P.(C) Head, Division of Geriatric Psychiatry, Sunnybrook Medical Centre Interim Director, Division of Geriatrics, Faculty of Medicine and Coordinator, Division of Geriatrics, Department of Psychiatry, University of Toronto, Toronto, Ontario Sheldon S. Tobin, Ph.D. Director of the Ringel Institute of Gerontology and Professor in the School of Social Welfare, State University of New York at Albany
PREFACE Alzheimer's disease, stroke and Parkinson's disease are the most prevalent brain diseases in the elderly. The psychiatric and behavioural consequences of these and other brain disorders contribute greatly to the decline in function of these patients, often leading to greater suffering and a decreased quality of life, placement in institutions and increased stress on the family and other caregivers. The authors in this book discuss the psychiatric consequences of brain disease in the elderly with a particular focus on the management of these disorders. We have tried to keep the content of this book clinically relevant throughout by using a series of case examples and by emphasizing the various treatment strategies and forms of management available to the health care professional. In attempting to understand these disorders, it is important to place equal emphasis on biological, psychological and social factors. Because of the complexity and chronicity of these conditions, multidisciplinary intervention is crucial. We believe that this book will be helpful to all those working with the elderly, whether in the community or in the institution. This includes physicians, nurses, social workers, occupational therapists, psychologists and all those working with this patient population. The initial planning and development of this book resulted from a Symposium entitled "Psychiatric Consequences of Brain Disease in the Elderly: A Focus on Management" which was presented in Toronto, Ontario, Canada on the 29th of May, 1987 by the Department of Psychiatry, Baycrest Centre for Geriatric Care and the Division of Geriatric Psychiatry of the University of Toronto. This symposium brought together a panel of international speakers to discuss specific approaches to the management of neuropsychiatric disorders in the elderly. The case vignettes in this book bring life and added meaning to the subject and form a bridge between theory and actual clinical problems. Our understanding of these issues often stems from the special and deep relationship which develops between professionals and their patients. As clinicians we must be aware of our indebtedness to our patients and their families, as we search together for an understanding of how to cope with these often insurmountable problems. We hope that this book will stimulate and guide the reader to consider the variety of possible interventions in the care of these patients and to understand that the most effective treatment may involve the employment of several of these approaches. This may help to keep the wolf of nihilism away from our door. David Conn Adrian Grek Joel Sadavoy ix
ACKNOWLEDGEMENTS We would like to thank Mrs. Paula Ferreira for her great patience, hard work and diligence in the preparation of the manuscript and Ms. Malerie Feldman for her ongoing help and encouragement. We would also like to thank Ms. Pat Vann and Ms. Melanie Yelity at Plenum for their support and helpful advice. We would like to acknowledge the excellent efforts of Mr. John Conner (Illustration) and Mr. Simon Tanenbaum (Design), who prepared the book cover. We would like to thank our colleagues, who have contributed to this volume, for their cooperation and enthusiasm. Finally we are indebted to the administrative and clinical staff of Baycrest Centre for Geriatric Care for their continuing support and for their encouragement with regard to this publication. x
CONTENTS Chapter 1 Neuropsychiatric Syndromes in the Elderly: An Overview.... David K. Conn, M.B., B.Ch., F.R.C.P.(C) Chapter 2 Investigation of Neuropsychiatric Disorders... 51 Stuart A. Schneck, M.D. Chapter 3 Neuropsychiatric Syndromes in the Elderly: Pharmacologic Management... 59 Jeffrey L. Cummings, M.D. Chapter 4 Psychodynamic Perspectives in the Clinical Approach to Brain Disease in the Elderly... 85 Gene D. Cohen, M.D., Ph.D. Chapter 5 Psychotherapy and the Cognitively Impaired Elderly... 101 Joel Sadavoy, M.D., F.R.C.P.(C) Anne Robinson, R.N. Chapter 6 Helping the Family... 137 Graham Berman, M.B., Ch.B., F.R.C.P.(C) Chapter 7 Management of Disruptive Behaviours in the Cognitively Impaired Elderly: Integrating Neuropsychological and Behavioural Approaches... 147 Guy-Bernard Proulx, Ph.D. Chapter 8 Issues of Care in Long-Term Settings... 163 Sheldon S. Tobin, Ph.D. Chapter 9 Telling Needs from Wishes: A Practical and Integrated Approach to Psychiatric Care of the Elderly... 189 Adrian Grek, M.B., B.Ch., F.R.C.P.(C) Kenneth Shulman, M.D., F.R.C.P.(C) Index... 195 xi