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Psychiatric Issues

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Psychiatric Issues 13 Psychiatric Issues MONICA MATHYS and MYRA T. BELGERI Learning Objectives 1. Recognize the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for major depressive disorder, anxiety disorders, and features commonly observed in late-life depression and anxiety. 2. Recommend an appropriate treatment plan for a geriatric patient suffering from depression and/or anxiety. 3. Recognize the changes in sleep that occur with normal aging and the impact of insomnia on an elderly patient’s health and quality of life. 4. Recommend appropriate therapy for insomnia based on published evidence in the elderly patient. 5. Describe the limitations of the DSM-5 criteria when used to diagnose elderly patients with substance-use disorders. 6. List the alcohol drinking limits for geriatric patients and discuss the reasons why guidelines suggest lower limits compared to younger adults. 7. Recommend an appropriate treatment plan for alcohol withdrawal and long-term abstinence for a geriatric patient. Key Terms and Definitions CLINICAL GLOBAL IMPRESSION OF IMPROVEMENT (CGI-I): Seven-point scale that measures how much a patient’s symptoms have improved or worsened compared to baseline. COGNITIVE BEHAVIORAL THERAPY: Therapy to help patients correct negative thoughts associated with depression and to cope with anxiety disorders. The therapy includes breathing retraining, muscle relaxation, cognitive restructuring to focus on the consistent worrying, and graded exposure so the patient can learn how to cope in stressful/phobic situations. 378 | Fundamentals of Geriatric Pharmacotherapy EARLY-ONSET ALCOHOLISM/ABUSE/DEPENDENCE: Alcohol abuse/dependence in which onset occurs before the age of 50. HAMILTON RATING SCALE FOR ANXIETY (HRSA): Fourteen-item assessment tool appropriate for measuring symptom severity and treatment response for generalized anxiety disorder (GAD). INTERPERSONAL PSYCHOTHERAPY: Therapy focused on finding and dealing with interpersonal causes of depression. LATE-LIFE ANXIETY: Anxiety episode that occurs when a patient is older. LATE-LIFE DEPRESSION: Depressive episode that occurs when a patient is older. LATE-LIFE SUBSTANCE USE DISORDER: Substance abuse or dependence in an older adult. LATE-ONSET ALCOHOLISM/ABUSE/DEPENDENCE: Alcohol abuse/dependence in which onset occurs at or after the age of 50. LATE-ONSET DEPRESSION: Major depression in which the first episode occurs when the patient is an older adult. He or she has never had a depressive episode as a younger adult. PARTIAL RESPONSE: A less than 50% reduction in symptoms. PROBLEM-SOLVING THERAPY: Therapy that focuses on helping patients learn strategies for solving everyday problems associated with their depression. RECURRENCE: New episode of depression 6 months or longer after achieving remission. RELAPSE: Increase in depressive symptoms within 6 months from remission. REMISSION: An asymptomatic state. RESPONSE: A 50% reduction in symptoms. SLEEP EFFICIENCY: The amount of time asleep while in bed. SLEEP RESTRICTION: Behavioral therapy that enhances the homeostatic drive for sleep by limiting the time spent in bed to the time spent sleeping. SUPPORTIVE THERAPY: Therapy that focuses on providing an environment in which patients can discuss and be straightforward about their symptoms and causes of depression. Sleep architecture and sleep physiology Introduction change with aging; comorbidities and the envi- ronment contribute to insomnia in the elderly sychiatric disorders discussed in this chapter patient. If underlying factors cannot be corrected, include depression, anxiety, insomnia, and comorbidities are not treated and controlled, substance abuse. Although diagnostic criteria and nonpharmacologic therapy is ineffective, Pare the same as for younger adults for these medications may help the patient achieve sleep disorders, it is sometimes difficult to elicit clear goals. However, it is important to choose drug symptoms of depression or anxiety from older therapy that will minimize adverse events and for patients, especially if they have underlying the patient to understand how these agents work dementia. Fortunately, newer pharmacologic to set proper expectations. agents add options that are better tolerated in individuals with comorbidities, multiple medica- Finally, substance and alcohol use should tions, and altered pharmacodynamics. not be dismissed as a possible health issue .
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