Gabe J. Maletta

Schizophrenia and Older Adults: An Overview: Directions for Research and Policy

The Group for the Advancement of Psychiatry, Committee on Aging, believes that a crisis has emerged with respect to the understanding of the nature and treatment of schizophrenia in older persons. Moreover, critical gaps exist in clinical services for this population. In this article, we examine the epidemiology of aging and schizophrenia; life-course changes in psychopathology, cognitive function, social functioning, and physical health; and various concerns regarding treatment, services, and financing. Finally, we propose six research and policy recommendations and suggest methods for addressing the research questions that we have posed.

Personality disorders in late life. Understanding and overcoming the gap in research.

A review of the literature on personality disorders (PD) in late life reveals fewer research papers than those found for PD in younger adults and for other major late-life psychiatric diagnoses. The authors suggest that this gap is largely due to the difficult and inconsistent diagnostic process for late-life PDs. Diagnosis is complicated by the frequent unavailability and/or unreliability of longitudinal data, lack of age-adjusted diagnostic instruments, and failure of the current Axis II nosology to account for age-related issues, including changes in social functioning, and the effects of comorbid illness and cognitive impairment. They propose that the development of a geriatric subclassification for PD, along with improved clinical documentation of personality and data from dimensional instruments for both normal and pathologic personalities, would provide a more reliable, valid, and geriatric-friendly diagnostic process.

Reversal of Anorexia by Methylphenidate in Apathetic, Severely Demented Nursing Home Patients

Low-dose methylphenidate was prescribed in an attempt to reverse the anorexia secondary to the gradual onset of apathetic behavior in three severely demented, long-term institutionalized geriatric patients. The anorexia was alleviated quickly in each case without appreciable side effects, and the benefit lasted for a prolonged period after cessation of the psychostimulant.

Choice Reaction Time Modifiability in Dementia and depression

The effects of cognitive impairment resulting from either dementia of the Alzheimer type (DAT) or major depression (pseudodementia) on choice reaction time were examined in two conditions hypothesized to influence group performance selectively. Elderly controls had shorter reaction times than depressed patients who, in turn, were faster than dementia patients in the standard choice reaction time test. Elderly control and depressed subjects responded more quickly under conditions designed to reduce task demands. However, no effect was detected for DAT patients, presumably due to the neural constraints imposed on cognitive functioning in dementia. These results highlight the different etiologies for the intellectual decline in dementia and pseudodementia.

Treatment of behavioral symptomatology of Alzheimer's disease, with emphasis on aggression: current clinical approaches.

A scientific information base is developing which focuses on understanding and managing behavior problems in geriatric populations, especially those with dementing illnesses such as Alzheimers disease. Many of these behavior problems occur in long-term care settings, which have a high prevalence of residents exhibiting emotional and behavioral disorders, often secondary to psychiatric illness. Prior to beginning treatment, behavior disorders must be systematically evaluated and understood to insure optimum care planning. One approach to effectively treating these disorders is to first separate them into two categories: those not amenable to psychotherapeutic medication treatment (nonpsychiatric disorders) and those that are amenable (psychiatric disorders). Specific nonpharmacological treatments may benefit those nonpsychiatric behavioral disorders and include behavioral and environmental paradigms. The psychiatric disorders, especially aggression and assaultive behavior, may be treated beneficially using a variety of psychopharmacological agents, including antianxiety agents, neuroleptics, carbamazepine, beta-blockers, and lithium. The most effective approach toward treating the psychiatric behavior disorders often combines both medication and nonmedication strategies.

The concept of "reversible" dementia. How nonreliable terminology may impair effective treatment.

Although good clinical and research information continually appears in the dementia literature, there is the disconcerting sense that, in some areas, a lack of clarity and rigor exists regarding terminology. Although definitions in the field of dementia initially seem reasonably straightforward, specific problem areas exist. This multidisciplinary field encompasses a variety of physician specialists, as well as other diverse professionals and brings not only the benefit of a rich mix of backgrounds, but also provides a medium for potential misunderstanding due to miscommunication. The variety of definitions of dementia, and especially the label, “reversible dementia,” exemplifies this problem. Disease‐specific dementias, pseudodementia, and delirium are three clinical situations that may or may not be classified as “reversible dementias,” depending on individual training, custom, and jargon. Use of the term “reversible dementia” may cause misunderstanding and inefficiency and benefits neither patient nor caregiver. It is suggested that the term be replaced. Further, all diagnostic labels should be clearly understood and explained. Emphasis must be placed on promoting the fact that all patients with cognitive/functional decline, no matter how defined or what the cause, are eminently treatable individuals.

ACCESS TO HOSPICE PROGRAMS IN END-STAGE DEMENTIA

To the Editor: Hanrahan and Luchins’ found that inability to predict survival was a barrier to provision of hospice care for demented patients. Managed care plans may bar access to hospice care even when the medical complications of dementia clearly limit life expectancy. An 8 1 -year-old male with long-standing dementia was referred to our physician housecall program because of increasing difficulty leaving home. He did not walk and was completely dependent in activities o f daily living. He had a neurogenic bladder with indwelling suprapubic cystostomy tube and had been treated as an outpatient for urinary tract infection. The patient had required a colostc~my for intractable constipation and had symptomatic degenerative joint disease. He had no other life-threatening illnesses. Six weeks later, during an upper respiratory infection, examination showed lower extremity spasticity, dysphagia, weight loss, and pain on being moved. His serum albumin was 3.3 g/dL. The patient’s family reported poor pain control, sleep disturbances, and verbal and physical aggression. The patient had signed a durable power of attorney for health care, naming his “beloved son” and his daughter-in-law, who had been caring for him, as surrogate decision-makers. They declined feeding tube placement and wished to provide palliative care at home for the remainder of the patient’s life.

Progressive supranuclear palsy

Progressive supranuclear palsy has been recognized as a distinct nosological entity for about three decades now. Typically, this progressive neurological disease manifests itself late in the sixth decade with a terminal course of approximately four to six years. Well over one hundred cases have been described in the literature and the heterogeneous nature of progressive supranuclear palsy includes the characteristic vertical ophthalmoplegia, frequent falling and a profound nuchal rigidity. Other features are similar in many respects to those found in Parkinsons disease. The present article reviews the literature on progressive supranuclear palsy with particular reference to its clinical manifestations including the ophthalmoplegia, characteristic sleep disturbances and unique dementia. Also addressed, are neuropathological and epidemiological findings. Finally, conclusions and recommendations for further investigation are offered especially with regard to the neuropsychological nature of this neurological disorder.

The Assessment of Competency in the Older Adult

Although an individual’s competence can come into question at any stage during the life cycle, each stage brings with it certain developmental tasks and vulnerabilities that can change the nature of the questions and the implications of the answers. In this chapter we attempt to outline the issues that are likely to arise with respect to competence during late adulthood. We review some of the basic physiological changes that comprise normal aging and the disorders that can occur with increasing probability in the later years. The primary focus, however, is on how these changes can affect cognitive and emotional processes in ways that would undermine the ability of individuals to act in their own best interest or in the best interest of others. We also review some of the issues that arise in assessing the competence of older adults given that the results of such assessments could affect the status of the individual before the law.