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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
Manufactured in the United States of America on acid-free paper
10 09 08 07 06 5 4 3 2 1
First Edition
Typeset in Adobe’s Formata and AGaramond.
American Psychiatric Publishing, Inc.
1000 Wilson Boulevard
Arlington, VA 22209-3901
www.appi.org
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
2 Clinical Manual of Geriatric Psychiatry

100

80

60
Population
(millions)

65 and older
40

85 and older
20

0
1900 1930 1960 1990 2020 2050

Projected

Figure 1–1. Populations of older adults in the United States (in millions).
Source. Adapted from Federal Interagency Forum on Aging-Related Statis-
tics 2004.

Worldwide, average life expectancy has increased to about 65 years (Cohen

2003), and by 2050, the number of people age 65 years and older is projected
at 2.5 billion worldwide (20% of the total population) (Olshansky et al. 1993).
Substantial increases in elderly populations are projected in the next quarter
century for North America, Europe, Asia, Latin America, and the Caribbean,
with smaller increases expected for areas such as sub-Saharan Africa, where both
fertility and mortality rates are high. China alone is expected to have 270 mil-
lion persons age 65 and older—nearly the total current population of the
United States—by the middle of this century. As one demographer recently
pointed out, the twentieth century may well be the last in which younger people
outnumbered older ones (Cohen 2003). By 2050, there will be more than three
adults age 60 years or older for every child age 4 years or younger.
 Introduction 3

Health and Functioning of Older Adults

Most people age 65 and older have at least one chronic medical illness, and
many have multiple conditions. The most common illnesses affecting elderly
people in the United States are arthritis, hypertension, and heart conditions
(Figure 1–2). Sensory impairments are also prevalent. Of 65- to 74-year-olds,
30% report problems seeing and 18% report problems hearing; these rates are
approximately twice as high for persons age 85 and older (Federal Interagency
Forum on Aging-Related Statistics 2004). Each of these conditions can limit
independent function and detract from quality of life. Being overweight or
obese has increased dramatically among older Americans in recent years. The
percentage of 65- to 74-year-olds who were overweight rose from 57% to
73% between 1976 and 2002, and the obesity rate increased from 18% to
36% (Federal Interagency Forum on Aging-Related Statistics 2004). By con-
trast, rates of cigarette smoking declined by 2002 to 10% among older men
and have remained steady in recent years at about 9% among older women.
Heart disease, cancer, and stroke account for two of every three deaths among
the elderly and also account for many doctor visits and days of hospitalization.
Death rates due to heart disease and stroke decreased by approximately one-third
from 1981 through 2001, whereas death rates due to diabetes and chronic lower
respiratory diseases increased by 43% and 62%, respectively (Federal Interagency
Forum on Aging-Related Statistics 2004). Alzheimer’s disease ranked sixth, after
heart disease, cancer, cerebrovascular diseases, respiratory diseases, and influenza
or pneumonia, among causes of death for Americans age 65 years and older in
2002 (National Center for Health Statistics 2004).
In 2002, people age 65 and older were hospitalized more than three times
as often as those ages 45–64, and they remained in the hospital about a day
longer on average than did middle-aged adults (Administration on Aging
2004). Older adults visited their physicians six to seven times per year on av-
erage, compared with three to four times for 45- to 64-year-olds.
In 1999, about 20% of older adults were chronically disabled as a result
of health problems; about 3% had limitations in only higher-order activities
of daily living (e.g., financial management, transportation, medication sched-
ules), 6% had impairment in one or two basic activities of daily living (e.g.,
eating, bathing, toileting), another 6% were impaired in three to six basic ac-
tivities, and slightly fewer than 5% were institutionalized (Federal Inter-
4 Clinical Manual of Geriatric Psychiatry

100

80
Americans age ≥65 (%)

Men Women
60

40

20

0
Heart Hyper- Stroke Emphy- Asthma Chronic Cancer Diabetes Arthritic
disease tension sema bronchitis symptoms

Figure 1–2. Percentage of people age 65 and older with selected chronic
conditions, 2001–2002.
Source. Adapted from Federal Interagency Forum on Aging-Related Statis-
tics 2004.
agency Forum on Aging-Related Statistics 2004). Of disabled older people
living in the community, 66% received informal care only, generally from rel-
atives; 26% received a combination of formal and informal services; and 9%
had formal care only (Federal Interagency Forum on Aging-Related Statistics
2004). The proportion receiving paid care has increased since the early 1980s,
reflecting improved financial resources of older persons as well as liberaliza-
tion in coverage rules under Medicare and Medicaid. Figure 1–3 shows age
trends in independent and assisted living within the United States.
Those with chronic needs that cannot be met at home generally receive care
in nursing homes. Although fewer than 5% of elderly Americans are in nursing
homes at a given time, the proportion of older persons requiring such care in-
creases quite sharply with age (see Figure 1–3). Among persons who reached
their 60th birthday in 1990, more than one-half of the women and one-third
of the men are expected to enter a nursing home at some point in the future.
However, older black Americans and elders from other minority groups use
 Introduction 5

1
100 5
1
5 Long-term-
2 3
19 care facility
Medicare enrollees (%)

80 7
Community housing
with services

60 93
98
92

Traditional
74
40 community

20

0
≥65 65–74 75–84 ≥85

Age (years)

Figure 1–3. Percentage of Medicare enrollees age 65 and older, by type of

residence, 2003.
Source. Adapted from Federal Interagency Forum on Aging-Related Statis-
tics 2004.
paid in-home services and nursing home care less frequently than do white
Americans (National Center for Health Statistics 2004). Between 1985 and
1999, the percentage of older adults residing in nursing homes in the United
States declined slightly, from 5.4% to 4.3%, but the total number of older nurs-
ing home residents increased from 1.3 million to 1.5 million because of growth
in the older population (Federal Interagency Forum on Aging-Related Statistics
2004). Three-fourths of current nursing home residents are women.
Health care costs for older Americans increased substantially from 1992
through 2001, after adjustment for inflation. During this time span, the pro-
portion of health care dollars spent on acute hospital care decreased, while the
proportion spent on prescription drugs increased. The average cost of provid-
ing health care for persons age 65 or older is currently three to five times
greater than health care costs for younger persons (Centers for Disease Con-
trol and Prevention 2004). Long-term-care costs, including nursing home
and home health expenditures, doubled between 1990 and 2001, a trend
6 Clinical Manual of Geriatric Psychiatry

shared by other developed nations. In 2001, the average annual cost for el-
derly residents of long-term-care facilities in the United States was $46,810,
compared with $8,466 for community residents of comparable age (Federal
Interagency Forum on Aging-Related Statistics 2004). Total Medicare spend-
ing increased from $33.9 billion in 1980 to $252.2 billion in 2002 and is pro-
jected to grow to twice that amount by 2012 (Centers for Disease Control
and Prevention 2004).
These trends present a significant challenge to the health care community.
The need to learn about aging and older people extends throughout the med-
ical and mental health professions. Creative approaches are required to stem
rising costs while maintaining quality assessment and intervention. Alliances
with families and other natural supports must be formed to ensure continuity
of care, and the strengths of older patients themselves must be marshaled to
cope with illness and to interact effectively within the health care system.

Mental Disorders in Later Life

Older people with mental disorders constitute a significant subgroup of the
elderly population. The multisite Epidemiologic Catchment Area (ECA)
Study conducted in the 1980s (Robins and Regier 1991) found that nearly
20% of Americans age 55 and older had diagnosable mental disorders, in-
cluding dementia (U.S. Public Health Service 1999). The ECA findings are
believed by many experts in the field to be underestimates because of meth-
odological limitations in the ECA assessment procedures. A 1999 consensus
conference on geriatric mental health estimated the prevalence of psychiatric
disorders in community-residing older adults at 25% or more (Jeste et al.
1999). Rates of mental disorder are much higher among elderly patients seen
in primary care or hospitalized for medical conditions, 30%–50% of whom
have psychiatric conditions (Borson and Unützer 2000; Rapp et al. 1988);
and in long-term-care settings, 68%–94% of residents have been found to
have mental disorders (Hybels and Blazer 2003). Table 1–1 compares rates for
several different types of mental disorders in the ECA community-based sur-
vey (1-month prevalence data) with a survey of hospitalized geriatric patients
conducted at about the same time. Overall, it is reasonable to estimate that
15%–25% of Americans who are currently age 65 or older have significant
mental health problems.
 Introduction 7

Older patients experience the same broad spectrum of mental disorders as

do younger adults. However, certain conditions are particularly notable in later
life because of either increased prevalence or high morbidity (see Table 1–1).
The elderly are at much greater risk for cognitive impairment than are
younger adults. In the community, at least 5% of people age 65 years or older
have prominent cognitive deficits, compared with fewer than 1% of people ages
18–64 (Regier et al. 1988). A larger proportion of older people have mild cog-
nitive problems, with estimates varying widely depending on the procedures
used to assess impairment (see Chapter 2, “Normal Aging”). The numbers in
Table 1–1 may underestimate the extent of problems related to cognitive defi-
cits, especially in the oldest age ranges. Recent data from the national Health
and Retirement Study showed that among Americans age 85 and older residing
in the community, one-third had moderate to severe memory impairment (Ad-
ministration on Aging 2004), and a widely cited epidemiological survey in the
East Boston area reported a prevalence of 47% for Alzheimer’s disease alone
among community residents age 85 and older (Evans et al. 1989).
Cognitive deficits in older patients have many different possible causes,
and in many cases, treatment of underlying problems can substantially allevi-
ate cognitive symptoms or slow the course of further decline (see Chapter 5,
“Dementia and Alzheimer’s Disease,” and Chapter 6, “Other Dementias and
Delirium”). Even for individuals with dementia of the Alzheimer’s type, gains
in functional ability can be obtained by treating coexisting medical or psychi-
atric illnesses. These small gains can make a great difference to family mem-
bers caring for these patients, as can support, psychotherapy, and respite
provided for caregivers.
Depression is an equally important condition in older adults. In the com-
munity, the percentage of older people meeting strict diagnostic criteria for
major depression is generally estimated at 5% or less (U.S. Public Health Ser-
vice 1999). However, traditional diagnostic criteria may not do justice to the
prevalence of depressive symptoms among older people. Serious depressive
symptoms were found in 8%–20% of elderly community residents and in up
to 37% of the elderly in primary care settings (U.S. Public Health Service
1999). In acute-care hospitals, as many as 25% of older patients have diag-
nosable mood disorders (e.g., Rapp et al. 1988), and nearly 50% of the ad-
missions of older adults to psychiatric hospitals are for depressive conditions.
The presence of comorbid depression or anxiety greatly increases health care
8 Clinical Manual of Geriatric Psychiatry

costs for patients in primary care (Simon et al. 1995), and over time, depres-
sion is associated with decrements in function and well-being that are similar
to, or greater than, those associated with chronic medical disease (Hays et al.
1995). Geriatric depression can be treated effectively with standard therapies
in 60%–80% of cases (U.S. Public Health Service 1999), but it is unlikely to
resolve spontaneously. Depression, anxiety, and alcohol and drug abuse in the
elderly today are only about one-quarter to one-third as common as among
middle-aged persons, and as the 55 million baby boomers grow old, their
mental health needs may prompt a crisis in geriatric care (Jeste et al. 1999).
Many older people without major mental disorders experience adjust-
ment reactions to personal stresses, bereavement, pain syndromes, and sleep
disturbance. Education and interventions directed at these problems may pre-
vent more serious psychiatric or medical problems from developing. The im-
portance of increasing prevention efforts for older adults as well as other age
groups was underscored in the U.S. surgeon general’s report on mental health
(U.S. Public Health Service 1999).
For psychiatrists, therefore, it is important not only to identify and treat
specific psychiatric disorders but also to provide education, support, and pre-
ventive interventions to strengthen older people and their families in manag-
ing common stresses of aging.

Barriers to Geriatric Mental Health Care

Improvements have been made since the early 1990s in the detection and
treatment of mental disorders in older adults in the United States. In an anal-
ysis of national Medicare fee-for-service data, for example, rates of diagnosed
depression in older adults increased from 2.8% in 1992 to 5.8% in 1998, and
two-thirds of those diagnosed received treatment of some type (Crystal et al.
2003). Similarly, since passage of the Omnibus Budget Reconciliation Act in
1987, efforts have been made, with varying degrees of success, to recognize and
treat mental disorders in patients in skilled nursing facilities. The number of
effective antidepressant medications has increased (Chapter 4, “Mood Disor-
ders—Treatment”), and medications to slow the course of common progres-
sive dementias have been introduced (Chapter 5, “Dementia and Alzheimer’s
Disease,” and Chapter 6, “Other Dementias and Delirium”). The usefulness
of psychotherapeutic interventions for common mental disorders of older
 Introduction 9

Table 1–1. Mental disorders among older adults

Distribution of psychiatric diagnoses (%)
Medical-surgical
Category of illness Community residentsa inpatientsb

Cognitive impairment 4.9 30.2

Affective disorders 2.5 18.5
Anxiety disorders 5.5 5.2
Alcohol abuse or 0.9 2.6
dependence
Schizophrenic disorders 0.1 0
Somatization 0.1 0
Personality disorder 0 8.3
Other psychiatric disorder 0 7.9
aAdapted
from Regier et al. 1988.
b
Adapted from Rapp et al. 1988.

adults has been more thoroughly confirmed (Chapters 4 through 8, “Mood

Disorders—Treatment,” “Dementia and Alzheimer’s Disease,” “Other De-
mentias and Delirium,” “Anxiety Disorders and Late-Onset Psychosis,” and
“Other Common Mental Disorders of the Elderly,” respectively), as have the
complex relationships between mental disorders and medical illness.
Despite these improvements, significant inequities remain in identifica-
tion and treatment of mental health conditions in older people and in acces-
sibility and use of geriatric mental health services (Areán and Unützer 2003;
Charney et al. 2003; Moak and Borson 2000). Adults older than 75, minor-
ity group members, and persons with Medicare only were less likely than
younger, white, and better-insured patients to have received treatment for
depression in recent years (Crystal et al. 2003), and even the most recent
studies continue to show that most cases of cognitive impairment without
obvious dementia go undetected and untreated in primary care (Chodosh et
al. 2004; Ganguli et al. 2004). Less common or less widely publicized con-
ditions are even more likely to remain unrecognized and inadequately
treated. In nursing homes, psychiatric services are generally restricted to a
consultative, as-requested mode instead of being a consistent and integrated
part of care management teams, and in the burgeoning numbers of assisted-
10 Clinical Manual of Geriatric Psychiatry

living and community-based programs for senior care, mental health services
are patchy and largely unregulated (Moak and Borson 2000).
Contemporary older Americans report less past use of mental health ser-
vices than do younger adults, and older Americans are less likely to express a
need for such services (Klap et al. 2003; Wetherell et al. 2004). Older adults
most often turn to primary care providers for help with mental health problems
(Kaplan et al. 1999), and typically, only one-half or fewer follow through with
referrals to specialty mental health providers. In a recent multisite randomized
trial, elderly primary care patients who screened positive for depression, anxiety,
or increased risk of alcohol use problems were offered collaborative mental
health services within primary care or enhanced referral assistance (e.g., sched-
uling, transportation, and payment assistance to outside mental health special-
ists) (Bartels et al. 2004). A significantly higher percentage of the patients
followed through on pursuing mental health treatment when it was available
within primary care (71% vs. 49%), and they completed more mental health
visits overall, than did those referred to mental health clinics or specialists, even
with enhanced assistance aimed at increasing the odds of compliance with the
referral. As the baby boom generation edges into the geriatric age range, the
“stiff upper lip” approach to managing emotional distress (Wetherell et al.
2004) may change, but the desire for proximal, integrated medical and mental
health services is likely to continue. Without more effective collaborative care,
underrecognition of mental health problems, especially among older patients
(Young et al. 2001), is likely to continue for several reasons:

• Multiple medical illnesses in elderly patients may divert physicians’ attention

away from psychiatric signs and symptoms, especially within the time-pres-
sured context of the standard brief office visit.
• Depression, anxiety, or memory problems may be viewed as normal for
older people with serious medical illness.
• Physicians with neither psychiatric nor geriatric training may have difficulty
distinguishing normal aging changes from signs of mental disorder or may
be reluctant to “open the can of worms” that treatment of emotional or cog-
nitive problems may entail.

A probability survey of primary care providers found that only 6% of gen-

eral internal medicine physicians and 22% of family practice physicians used
 Introduction 11

questionnaires or other structured procedures to screen for depression in their

older patients, relying instead on very brief informal interviews (Kaplan et al.
1999). Primary care physicians report that the subtlety of mild dementia
makes it difficult to recognize during brief interviews, but many physicians
remain reluctant to use formal cognitive screening tests (Boise et al. 1999);
many also believe that in the absence of effective treatment, there is little pur-
pose to diagnosing mild dementia, although this attitude may delay arrange-
ments for community support services and increase family strain (see Chapter
5, “Dementia and Alzheimer’s Disease”).
Among psychiatrists, attitudes about aging and age-related conditions
and limited training in geriatric psychiatry may further restrict the availability
and quality of mental health care for older patients. Many psychiatrists and
other mental health professionals find it difficult to work with elderly pa-
tients. Understandably, they may prefer to work with patients who have less
daunting problems with physical illness and personal loss, who remind them
less of their own mortality, and who are less likely to die in the course of treat-
ment. Nonetheless, recent research has not found mental health professionals
to be strongly or pervasively negative in their attitudes about older patients.
Instead, age bias seems to take more specific forms (Gatz and Pearson 1988).
American psychiatrists and other mental health professionals tend to refer
older patients less often for psychotherapy than comparably ill younger pa-
tients, and some of these professionals, in an attempt to avoid discrimination
against the elderly, may exaggerate the competencies and excuse the deficits
of elderly patients. “Fallacy for good reasons” is a phrase coined to refer to the
common situation in which a provider, as well as the patient and family mem-
bers, attributes the depression or anxiety experienced by the older patient to
medical illness, multiple losses, or financial difficulties that many older per-
sons face, especially the very old (Cole et al. 1997).
Inadequate insurance coverage for patients and limited reimbursement
for providers are ongoing barriers to geriatric mental health care. Because pre-
scription drugs have not been covered under Medicare until very recently, el-
ders who could not afford a coinsurance policy with drug benefits were
unable to afford psychiatric medications. The 50% copayment rule for psy-
chotherapy services under most insurance policies makes the decision to en-
gage in therapy costly to the patient, and allowable fees are often inadequate
(e.g., under Medicare, the psychotherapy fees allowed for an experienced psy-
12 Clinical Manual of Geriatric Psychiatry

chiatrist are half or less of the typical fee expected for this service). The elderly,
who generally have many health care needs, often have trouble coordinating
their own care, but there is usually no reimbursement for mental health pro-
viders to help with coordination.
The need for psychiatrists who are capable and willing to work with el-
derly patients, both in primary care and in specialty roles, is clear. Effective
models for collaborative medical and mental health services recently have
been developed for primary care (see Chapter 4, “Mood Disorders—Treat-
ment”), but this approach needs to be extended beyond clinical research, and
additional models need to be developed for geropsychiatric services within
community mental health settings and the full spectrum of long-term-care
services (Moak and Borson 2000). Older adults with medical comorbidity,
the oldest old, and those with significant chronic mental illness present par-
ticular challenges to existing service models (Borson et al. 2001).

Diversity in Patterns of Health and Aging

In 2003, persons of minority descent, including Hispanic whites, accounted
for 17.6% of the U.S. population age 65 and older, but by 2050, this percent-
age is projected to rise to 36%. Hispanic and Asian American groups as a
whole are the most rapidly growing minority populations, and these trends
are projected to continue (Figure 1–4).
Methodological difficulties encountered in the processes of sampling, de-
signing valid interview protocols, achieving subject cooperation, and control-
ling interviewer and subject bias have hampered attempts to generalize about
the health and other characteristics of black, Hispanic, American Indian, and
Asian populations in the United States. However, in key areas such as life ex-
pectancy, prevalence of chronic health conditions, residential patterns, and
education, significant differences have been documented across groups. In the
United States in 2001, average life expectancy from birth was 5.5 years longer
for white persons than for black Americans (Federal Interagency Forum on
Aging-Related Statistics 2004). At age 65, however, the life expectancy gap
narrowed to about 2 years, and by age 85, life expectancy was slightly longer
for older black persons compared with white persons. In 2000–2001, among
people age 65 and older, hypertension and diabetes were more common
among black than among non-Hispanic white persons; older Hispanics were
 Introduction 13

100

2003
80
2050–projected
Americans age ≥65 (%)

60

40

20

0
Non-Hispanic Black alone Asian alone All other races alone Hispanic
white alone or in combination of any race

Figure 1–4. Percentage of population age 65 and older, by race and His-
panic origin.
Source. Adapted from Federal Interagency Forum on Aging-Related Statis-
tics 2004.
comparable to non-Hispanic white Americans in rates of hypertension but
were more likely to have diabetes. By contrast, older white people were more
likely to have some form of cancer than were older Hispanic or black people
(National Center for Health Statistics 2004). Black and Hispanic elders are
less well educated than non-Hispanic white and Asian elders (see Figure 2–1
in Chapter 2, “Normal Aging”), and older black and non-Hispanic white per-
sons are more likely to find themselves living alone in old age than are their
Hispanic or Asian peers (see Figure 2–2 in Chapter 2).
Reports of prevalence of mental disorders for minority groups must be
viewed with caution because language and cultural differences can affect re-
sults on tests and interviews assessing depression, dementia, and other psychi-
atric disorders. However, data are emerging on the relative prevalence of
mental health–related problems in various groups and on availability and use
of mental health services. A recent supplement (U.S. Public Health Service
14 Clinical Manual of Geriatric Psychiatry

2005) to Mental Health: A Report of the Surgeon General (U.S. Public Health
Service 1999) concluded that the prevalence of mental disorders within the
most populous racial and ethnic minority groups in the United States (blacks,
Hispanics, and Asian Americans and Pacific Islanders) is similar to that of
white Americans. Among older adults, however, some important differences
in prevalence of mental health–related conditions have been documented for
racial/ethnic and gender subgroups. For example, the suicide rate is much
higher among non-Hispanic white men than in any other elderly subgroup
(National Center for Health Statistics 2004), and rates of alcohol abuse and
dependence are higher among elderly black men and women compared with
elderly white and Hispanic persons (U.S. Public Health Service 1999).
The surgeon general’s recent supplement underscored the pivotal role of
culture in maintaining mental health and the continuing, often striking, dis-
parities in availability of and access to mental health services among Ameri-
cans from minority backgrounds. Although not specific to older adults, the
recommendations for reducing barriers are as important for diverse geriatric
populations as they are for younger groups. The recommendations include
the following:

• Continuing research to establish the efficacy of evidence-based treatments

for racial and ethnic minorities and to better characterize how factors such
as acculturation and ethnic identity affect risk for, and protection from,
mental illness
• Improving access to treatment by improving geographic distribution of
services, increasing availability of services in preferred languages, and co-
ordinating care for the most vulnerable, high-need subgroups in which
racial and ethnic minorities are overrepresented (e.g., low-income or
homeless persons)
• Delivering effective, evidence-based treatments that are individualized ac-
cording to age, gender, race, ethnicity, and culture
• Working toward equitable racial and ethnic representation among mental
health providers, administrators, and policy makers

Women constitute the majority of older persons in the United States, out-
numbering men by a ratio of nearly 3 to 1 by age 85 and older. Important
gender differences have been reported for longevity, prevalence of specific
 Introduction 15

Table 1–2. Knowledge needed to work effectively with elderly

patients
Normal aging: biological, psychological, and social changes
Mental disorders predominantly observed in later life, including Alzheimer’s disease,
related dementias, late-onset psychoses
Effects of age on other psychiatric disorders, including mood and anxiety disorders
Adjusting psychiatric treatments for aging changes: dose and schedule of
psychoactive medications, drug-drug interactions, format and pace of
psychotherapy
Managing social and physical problems of later life: bereavement, role loss, pain,
sleep disturbance
Interactions of psychiatric and medical-surgical illnesses and their treatments

medical or mental conditions (e.g., heart disease, Alzheimer’s disease), and

rates of disability. At present, the price that women pay for longer lives ap-
pears to be a greater proportion of the late life span compromised by func-
tional disability, limited options for home care, and an increased likelihood of
spending their last years in a nursing home. Recent research, prompted by the
Women’s Health Initiative, is helping to elucidate whether preventive health
care, or more prompt and appropriate diagnosis and treatment of medical
conditions, can reduce the functional limitations now experienced dispropor-
tionately by women in later years.

Working Effectively With Older Adults

Psychiatric care of older patients requires a blending of specialized knowledge
with a broadly based, flexible approach to the patient (Table 1–2).
In addition to mastering the content areas covered in this Clinical Man-
ual, a psychiatrist treating older patients needs certain personal qualities and
professional approaches that are important for effective work in geriatric psy-
chiatry (Table 1–3). Although some older people can manage today’s complex
health care system, many more lack the energy, sophistication, cognitive abil-
ity, or funds to negotiate a specialty-oriented system successfully. As a result,
psychiatrists working with older people must be willing to play a generalist
role, combining routine medical management with psychiatric interventions
or helping with specific social or situational problems.
16 Clinical Manual of Geriatric Psychiatry

Table 1–3. Personal qualities and professional approaches

needed to work effectively with elderly patients
Willingness to provide broadly based, flexible management
Comfort in working closely with other health care professionals
Patience and skill in providing medical information and assisting in medical decision
making
Willingness to explore one’s own feelings about aging
Openness to discuss patients’ concerns about being treated by younger professionals
Acceptance of and comfort with limited treatment goals
Ability to maintain therapeutic optimism in the context of an ultimately poor
prognosis

The psychiatrist also must have patience and skill in explaining diagnoses
and treatments and in assisting older people in medical decision making. El-
derly patients often defer to physicians without truly comprehending benefits
and risks. This deference may increase efficiency of care in the short run, but
it may place the older person at risk for iatrogenic illness (e.g., delirium sec-
ondary to drug interactions). Finally, it is helpful to have a willingness to ex-
plore one’s own feelings about aging, as well as to be open to discussing older
patients’ reservations about the wisdom of youth. Elderly patients may be in-
clined to view younger therapists as similar to their children, and the thera-
pist, in response, may experience the reactivation of unresolved conflicts with
parents or grandparents or unresolved issues related to his or her own personal
aging (Meador and David 1994).

References
Administration on Aging: A Profile of Older Americans: 2004. Washington, DC, Ad-
ministration on Aging, 2004. Available at: http://www.aoa.gov/prof/Statistics/
profile/2004/profiles2004.asp. Accessed March 9, 2006.
Areán PA, Unützer J: Inequities in depression management in low-income, minority,
and old-old adults: a matter of access to preferred treatments? J Am Geriatr Soc
51:1808–1809, 2003
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 INDICE DEI CAPITOLI.

La quarta guerra civile Pag. 1

I Flavi (69-96) 17
La repubblica di Traiano e gli ultimi splendori
del Romanesimo 39
Adriano e gli ultimi splendori dell’Ellenismo
(117-138) 57
I primi segni del decadimento (138-193) 83
I principii della monarchia assoluta — Settimio
Severo (193-211) 107
Il caos del terzo secolo (211-284) 123
Diocleziano (284-305) 159
Costantino il Grande (306-337) 179
Le grandi lotte religiose (337-363) 207
L’invasione (363-393) 229
La catastrofe (395-476) 249

Indice alfabetico analitico 275

 FINITO DI STAMPARE A FIRENZE
NELLA TIPOGRAFIA ENRICO ARIANI
IL XX FEBBRAIO MCMXXII
 Nota del Trascrittore

Ortografia e punteggiatura originali sono state

mantenute, correggendo senza annotazione minimi errori
tipografici.
Copertina creata dal trascrittore e posta nel pubblico
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