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Chapter 37. Treatment of Seniors

Dan G. Blazer, M.D., Ph.D.
DOI: 10.1176/appi.books.9781585623402.335375

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Excerpt

Psychiatrists who work with older adults encounter diagnostic and therapeutic problems that are more complex than those encountered in young adult and middle-aged patients. Most older patients with psychiatric disorders do not fit easily into the diagnostic categories of DSM-IV-TR (American Psychiatric Association 2000) because they experience multiple symptoms that affect both physical and psychiatric functioning. This is especially true when treating the oldest members of this population (Blazer 2000). Once the problem is formulated by the clinician, usual treatment approaches must be modified both to manage the functional disability that results from the psychiatric problem and to reverse the underlying disorder.

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TABLE 37–1. Geriatric psychiatric syndromes
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TABLE 37–2. Characteristics of acute confusion
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TABLE 37–3. Common external biological stressors that precipitate acute confusion in the at-risk older adult
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TABLE 37–4. Treatment of acute confusion
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TABLE 37–5. Clinical characteristics of memory loss
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TABLE 37–6. Differential diagnosis of memory loss
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TABLE 37–7. Diagnostic workup of memory loss
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TABLE 37–8. Medications for the primary treatment of memory loss
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TABLE 37–9. Sleep disturbances leading to insomnia in the elderly
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TABLE 37–10. Diagnostic workup of insomnia in later life
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TABLE 37–11. Sleep hygiene in the elderly
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TABLE 37–12. Medications and recommended doses for treating late-life insomnia
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TABLE 37–13. Medical causes of anxiety in the elderly
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TABLE 37–14. Medications and typical starting doses for treating anxiety in the elderly
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TABLE 37–15. Causes of suspiciousness, delusions, and agitation in the elderly
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TABLE 37–16. Medications for the management of suspiciousness and agitation in the elderly
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TABLE 37–17. Suggestions for preventing aggressive and violent behavior in the older adult
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TABLE 37–18. Characteristics of seniors with depression
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TABLE 37–19. Laboratory workup of the depressed older adult
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TABLE 37–20. Antidepressant therapy for seniors with typical starting doses
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TABLE 37–21. Characteristics of hypochondriasis in the elderly
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TABLE 37–22. Goals for managing hypochondriasis in the older adult
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Acute confusion is much more common in hospitalized older adults than usually recognized. Careful screening is necessary to identify these patients.

Working with the family of the patient with memory loss is key to easing the suffering of the patient and preventing institutionalization prior to when absolutely necessary.

Good sleep hygiene is more important than pharmacological management of insomnia in older adults.

Generalized anxiety is usually comorbid with other conditions, such as depression or physical illness. Diagnosing comorbid conditions is the first step to managing anxiety in older adults.

Suspiciousness and agitation are the most disruptive symptoms of dementing disorders.

Uncomplicated depression in late life is as responsive to treatment as in midlife. Depression comorbid with physical illness or memory loss is much more difficult to treat.

Implementing a structured approach to each patient contact with a hypochondriacal patient can reduce the overuse of health care services significantly.

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Sample questions:
1.
Which of the following statements concerning acute confusion in the elderly is false?
2.
Memory loss is often insidious in onset and well established clinically by the time a patient is brought to care. Which of the following statements concerning the management of memory loss is false?
3.
Many changes in sleep architecture are seen in aging, and these changes may play a role in late-life insomnia. Which of the following is a typical sleep architecture change affecting the elderly?
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