Julie Young

Geriatric Psychiatry Study Guide

ions Appreciate similarities (train and bicycle are modes of transportation); meaning of proverbs (“People in glass houses...”) Stable From: Hirsch CH, Hategan A: Physiology and Pathology of Aging. In: Hategan et al. (eds). Geriatric Psychiatry: A Case-Based Textbook, Springer; p. 7. 2018; used with permission Question 1.3

End-of-Life Care

This summary provides clinicians with information about anticipating the end of life (EOL); the common symptoms patients experience as life ends, including in the final hours to days; and treatment or care considerations. Psychiatrists can help patients to navigate emotionally charged issues associated with EOL care, as well as to facilitate discussions among patients and other clinicians. As patients cope with progressively debilitating chronic illnesses, psychiatrists will be increasingly involved in diagnosing and treating common syndromes associated with the EOL such as delirium, anxiety disorders, and depressive disorders. They will also be consulted on difficult cases as patients, family members, and clinical staff struggle with other issues beyond psychiatric illness, per se.

Personality Disorders in Late Life

The social, physical, and cognitive challenges of aging may be particularly difficult for those with maladaptive patterns of thinking, feeling, and behaving. For example, older individuals with lifelong patterns of maladaptively relating to the world may have had social and interpersonal support networks and other resources in their younger years to function relatively well. However, as spouses and siblings die, health problems mount, and overall functional status declines, those with personality “traits” may manifest as full-blown personality disorders in late life. Due to the scarcity of research in the area of personality disorders in older adults, the clinical care of older patients with personality disorders is currently comprised of adapting clinical strategies gleaned from studies of younger adults onto their older counterparts.

Neuropsychiatric Symptoms Due to Major and Mild Neurocognitive Disorders

The management of mild and major neurocognitive disorders often involves the assessment and management of neuropsychiatric symptoms, also known as behavior and psychological symptoms of dementia (BPSD), as these symptoms commonly occur during the course of the neurocognitive disorders. Because neuropsychiatric symptoms often impact on the ability of a caregiver to manage at home, it is very important that they are assessed and treated promptly. The following section provides a review of the evaluation, assessment, impact, and management of common neuropsychiatric symptoms seen in various neurocognitive disorders.

Ethics and Law

The focus of this section is on the practical application of basic ethical and legal principles to the practice of medicine. After a brief overview, several case studies will illustrate the practical application of pertinent ethical and legal principles in the management of psychiatric illness in the geriatric population.

Emergencies in Geriatric Psychiatry

The emergency department (ED) setting poses challenges in the appropriate diagnosis and treatment of geriatric patients. With an emphasis on emergency medical conditions, including both comorbid and primary presentation of various psychiatric disorders, this section focuses on providing quality geriatric patient care in ED settings. In the emergency setting, primary consideration of delirium is routinely needed, especially in geriatric patients; this can include the episodes of delirium induced as a physical consequence of suicidal acts, such as toxic ingestions.

Substance Use Disorders in Older Adults

Substance abuse is a major class of psychiatric illnesses in all patients but poses specifically greater challenges in geriatric psychiatry. Older patients, especially those with long history of substance use, are at particular risk for chronic systemic medical and psychiatric complications of substance abuse, attributable to the “wear and tear” on body systems from years of abnormal neurophysiology. Psychiatric comorbidity or even “tri-morbidity” (e.g., substance abuse + depressive disorder + personality disorder) presents particular challenges in the geriatric population, as the cumulative effects of multi-morbid psychiatric illness may both obscure the often surreptitious role of substance abuse (masking its clear diagnosis) and complicate other psychiatric treatment. In addition, recovery programming needed to gain control over substance abuse may not be readily available to older patients. Management of substance abuse in geriatric patients therefore calls on sophisticated clinical skills and acumen.

Sexuality and Sexual Dysfunctions in Later Life

Sexual needs appear to be similar in adult life and late life, with variations in mode of expression, frequency, and intensity. However, for older adults, there are a number of factors that can create barriers to achieving sexual expression. Older adults experience multiple age-related physiological changes in sexual functioning. During the aging process, it can be common for both males and females to experience sexual dysfunction relating to any issue that arises during the four stages of the sexual response cycle (excitement, plateau, orgasm, and resolution). Inappropriate sexual behaviors in institutionalized settings are more likely to occur in patients with major neurocognitive disorders. Clinicians working with older adults need to remain knowledgeable of legal and ethical issues related to the right to consensual sexual activity, which are discussed in this section. Assessment, diagnosis, and management of sexual dysfunction in older adults are also reviewed.

Elder Abuse and Neglect

Psychiatrists can play an important role in identifying older adults who may be victims of mistreatment, abuse, and neglect and intervene on behalf of this vulnerable population. This section summarizes the types of elder mistreatment, potential consequences, and physical and behavioral indicators of elder mistreatment.

Aging with Neurodevelopmental Disorders: Intellectual Disability and Autism Spectrum Disorder

Older adults with neurodevelopmental disorders represent a heterogeneous population. Despite the heterogeneity of etiologies, clinical presentations, and comorbid backgrounds of varying physical and neuropsychiatric symptomatologies, common considerations can be found in those aging individuals with intellectual disabilities, particularly intellectual disability and autism spectrum disorder, which are discussed in this section. A systematic approach to management with an emphasis on patient-centered care is necessary. This section reviews the age-related changes pertinent to those diagnosed with intellectual disabilities and the tools and resources necessary to manage aging patients with intellectual disabilities.