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Book Forum: Other Subspecialties   |    
Geriatric Psychiatry
ANDREI PIKALOV, M.D., Ph.D.
Am J Psychiatry 2004;161:770-771. doi:10.1176/appi.ajp.161.4.770
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Edited by Alan M. Mellow, M.D., Ph.D. Arlington, Va., American Psychiatric Publishing, 2003, 195 pp., $31.95.

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This book is one of four titles published this year in the Review of Psychiatry series. It starts with an introduction authored by series editors, who inform the reader about topics covered by other 2003 titles: Molecular Neurobiology, Standardized Evaluation, Trauma and Disaster Responses, and Management.

In addition to the preface by Alan Mellow, you will find five chapters with extensive references and an index (fairly helpful features even in this small book). The first chapter, "Depression and Anxiety in Late Life," by Alan Mellow, Helen Kales, and Susan Maixner, is a short review (34 pages with references) presenting a brief summary of geriatric depression, including epidemiology, diagnosis, and treatment of late-life depression, with emphasis on the complications of depression in dementia. The authors devote several pages to anxiety in late life, and, after a review of epidemiology, they discuss panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, generalized anxiety disorder, and phobias. This chapter is not likely to serve as a source of extensive information on the topic but will be helpful for those who choose to refresh their knowledge in this area of geriatric psychiatry or as a starting point for future studies.

The second chapter, authored by Myron F. Weiner, covers dementia and presents "an overview of clinically relevant advances in the diagnosis, treatment, and prevention of dementing illness in older adults." I found this chapter to be the most interesting and informative of the volume. Despite being concise (38 pages with references), it covers lots of recent data in this rapidly developing area of geriatric psychiatry. Discussion of mild cognitive impairment is followed by a well-done review of different types of dementias, including variants of Lewy body dementia, with specifics of clinical presentations and pathophysiology-based recommendations for optimal treatment strategies for different types of dementias. I would like to compliment Dr. Weiner for his ability to line up a substantial amount of material in a constructive order and easy-to-read format. It was interesting to learn, however, that "no strong evidence has yet shown that efforts at intellectual problem solving are prophylactic against or affect the onset or course of AD [Alzheimer’s disease]." The author suggests that new data do not support the notion that individuals with higher educations may enjoy lower risk or slower progression of this devastating disorder.

Chapter 3, by George T. Grossberg and Abhilash K. Desai, covers late-life psychosis. After short statements about prevalence and risk factors associated with psychosis in the elderly, the authors discuss classification of psychotic disorders and comorbidity in the elderly. Because of the multifactorial nature of psychosis in geriatric patients, I found the classification presented in this chapter to be a useful tool for differential diagnosis. It could be implemented easily in my everyday clinical practice as well, with two figures illustrating decision trees for determining etiology of psychotic symptoms and primary psychotic disorders in the elderly. The authors’ subsequent discussion of psychotic disorders in the elderly and treatment options is based on analysis of the literature and makes an important point that psychotic disorders in the geriatric population need better recognition and "are eminently treatable." Use of atypical antipsychotics in the elderly is a focus of many recent pharmaceutical trials, and more recent data are available on safety and efficacy of antipsychotics than were available when this chapter was written.

We definitely see growing attention to the topic of late-life addictions, not only because of surprising numbers of alcohol- and drug-related problems among the elderly but also because of the increasing recognition of polypharmacy problems and use of potentially addictive medications in the geriatric population. Frederic C. Blow and David W. Oslin start their chapter with an introduction and description of the prevalence of the problem. Drinking guidelines put out by the National Institute on Alcohol and Alcoholism recommend an equivalent of no more than one standard drink per day for older men and even less for women. This recommendation is based on age-related physiological changes. It is known that such consumption has been associated with possible cardioprotective and cerebrovascular-protective effects. The authors provide clinicians with a list of signs and symptoms of potential alcohol problems in older adults as well as a copy of the Alcoholism Screening Test and discuss the controversy of related DSM-IV-TR criteria. Table 4-4 provides the reader with the list of psychoactive medications with substantial alcohol interactions, which is a useful reference tool. The information provided is a timely reminder about the variety of existing and developing treatment options for addictions in the elderly, which include brief strategies (minimal advice, structured brief intervention protocols) and referral to specialized treatment. The authors also briefly discuss the literature on late-life addictions and comorbid psychiatric disorders such as depression, suicide, and dementia.

The final chapter, "Geriatric Psychiatry at the Crossroads of Public Policy and Clinical Practice," has four authors: Christopher C. Clenda, Stephen J. Bartels, Joel E. Streim, and Christine deVries. If not for the task of writing this review, I would most likely have skipped this chapter during my leisure reading (who wants to be bothered by numbers and percentages of Medicare expenditures in national health expenditures, anyway?). Skipping it would be a mistake. The current political climate, driven by rises and falls in the economy, inevitably affects the system of health care delivery. Moreover, the consequences of political changes are not necessarily immediate but continue for years. The medical profession recognizes the importance of interacting with lawmakers to ensure the best possible care for our patients today and in the future. Up to 10.3 million individuals over the age of 55, or up to 6 million individuals over the age of 65, may have clinically significant mental disorders, and these numbers will increase with time because the number of elderly citizens is growing. After a review of current trends in federal expenditures for health care and mental health care, this chapter has a report on trends in Medicare managed care enrollments and regulatory trends in long-term care. The authors describe federal regulations and statutory requirements but note the troubling fact that "a substantial proportion of residents [in nursing homes] still have undetected psychiatric symptoms and…others do not receive care they require." The authors review special concerns for older adults with severe mental illness as well as current legislative and executive policy initiatives to improve their lot. The unfortunate conclusion of this chapter is that "the United States is far from creating an integrated longitudinal continuum of mental health care for elderly," which leaves a lot of food for thought.

My overall impression of this volume is positive. It provides a concise review on specific topics with an extensive bibliography to be used by the reader for future study. Each chapter could be studied individually and provides sufficient analysis of research data on the topic. Arguably, more detail might be added, but its goal is to review, which it successfully fulfills. Nevertheless, I would add several paragraphs on the use of complementary (alternative) medicine remedies in the elderly with mental illness, which is seen more and more in my clinical practice. The size of the book is convenient for travel, and the font size is good for easy reading, without excessive eye strain.

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