Handbook of Consultation-Liaison Psychiatry

25. The Geriatric Patient

Lori Murayama and Iqbal Ahmed

CONTENTS

25.1 Principles of Geriatric Assessment and Treatment

25.2 Pharmacologic Issues in the Elderly

25.3 Specific Disorders in the Elderly

25.3.1 Dementia

25.3.2 Delirium

25.3.3 Mood Disorders

25.4 Specific Issues in Caring for the Elderly

25.4.1 Palliative Care/End of Life Issues

25.4.2 Capacity

25.4.3 Functional Ability and Disposition Planning

25.4.4 Elder Abuse and Undue Influence

The elderly or geriatric population, composed of people ages 65 years and over, is rapidly growing in the United States and throughout the world. According to the United Nations World Prospects published in 2005, the global population of people over age 60 years in 2005 was estimated to be 672 million out of a total of approximately 6.5 billion and is expected to reach 1.9 billion by 2050 (cited in: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. The World Population Prospects: the 2004 revision. http://wwwun.orglesalpopulation/publications[WPP2004/2004 Highlights_ finalrevised.pdf). In 2005, the U.S. Census Bureau estimated that the elderly population over age 65 years was 36.8 million, or 12% of the total U.S. population. Of this group, those over the age of 85 were the fastest growing segment.

This growing elderly population correlates with the increasing utilization of health services by the elderly. The 2004 National Hospital Discharge Survey conducted by the U.S. Department of Health and Human Services (DeFrances and Podogornik, 2004) found that 38% of inpatient beds were occupied by patients ages 65 and older compared to 20% in 1970. Of the geriatric inpatients, a prospective study (Fulop et al., 1998), found that 44.5% of these patients met the criteria for a psychiatric comorbidity. Studies have shown that treatment of these psychiatric comorbidities can actually impact health care spending because of the correlation between psychiatric comorbidities and length of stay in the hospital (Fulop et al., 1998; Saravay et al., 1991). Levitan and Kornfeld (1981) also found that elderly patients receiving psychiatric consultations after being admitted for hip fractures not only spent 12 fewer days in the hospital but were also more likely to be discharged home rather than to a nursing home.

25.1 Principles of Geriatric Assessment and Treatment

The geriatric population on the consultation-liaison (CL) service is a distinct and challenging group because of the higher rate of medical comorbidity and biologic changes associated with aging, both of which can impact treatment. Most elderly patients have at least one or more chronic medical conditions (Table 25.1). In addition, they utilize more health care dollars through higher rates of medication use, hospitalizations, and health care spending in the last year of their lives (DeFrances and Podgornik, 2004; U.S. Department of Health and Human Services, 2002). The geriatric population is also unique because of issues related to death, dying, and palliative care. In addition, the psychiatric problems and stressors elderly patients deal with are vastly different from their younger counterparts (Table 25.2), with higher rates of dementia, delirium, and depression (Grossberg et al., 1990; Levitte and Thomby, 1989; Mirowsky and Ross, 1992; Ruskin, 1985; Scott et al., 2004; Small and Fawzy, 1988).

Many of the unique developmental issues facing the geriatric patient can be broken down into a biopsychosocial perspective (Table 25.3) (Ahmed and Takeshita, 1997). From a biologic perspective, it is important to understand what are considered normal age-associated changes in order to distinguish these from pathologic changes. In addition, the concept of young-old (65-75) versus old-old (85+) emphasizes the point that elderly patients cannot all be categorized as one homogeneous group. The old-old tend to have more comorbidities, functional problems, and poor prognostic conditions. From a psychological perspective, there are changes in self-concept in addition to changes in cognition. As one ages, there are changes in the speed of mental processing, perceptual-motor tasks, and the performance of novel tasks, whereas there should be no changes in vocabulary, comprehension, knowledge, reasoning, and judgment (Albert and Moss, 1988). From a sociologic perspective, there are significant changes in the attitudes toward the elderly and the roles they play in society.

Data from Grossberg et al., 1990; Levitte and Thornby 1989; Ruskin, 1985; Scott et al., 2004.

The assessment of the geriatric patient should pay attention to the developmental issues, as well as comorbidities, cognition, and level of function. The evaluation of the geriatric patient should also recognize that because of the age-associated changes, the elderly are more vulnerable (biologically, psychologically, and socially) to psychiatric disorders. In addition, geriatric patients are more likely to have medical illnesses that coexist with or cause psychiatric symptoms. The presentation of psychiatric disorders may also be different from that seen in the younger population, with more cognitive symptoms and higher rates of comorbid dementia or delirium (Ahmed and Takeshita, 1997). Geriatric patients also present with more somatic complaints, and they may report psychiatric symptoms less often (Jeste et al., 2005).

25.2 Pharmacologic Issues in the Elderly

Pharmacokinetic changes occur with both normal aging and with the diseases that are more likely to be associated with aging such as cardiac, renal, and liver diseases (Table 25.4). In addition, age-related changes in the various organ systems render them more susceptible to the adverse effects of the medications in general. The changes in the brain with aging are significant (Table 25.5) and have an impact on both the therapeutic and adverse effects of the drugs. It is important to consider the interplay of physical disease, psychiatric disorders, and psychosocial interactions in this special population.

Adhering to the principles of pharmacotherapy outlined in Table 25.6 should help ensure the optimal therapeutic benefit of medications in the elderly while avoiding the risks of adverse reactions. Specific considerations in choice of agents should include caution in the use of drugs with anticholinergic effects and those with cardiovascular effects. Because of increased medical comorbidities, the elderly are at increased risk for adverse outcomes with medications. In addition, with the increased use of both prescribed and over-the-counter medications, there is a greater risk of drug-drug interactions. The choice of agents used factor in the associated medical/neurologic comorbidity. For example, in patients with specific disorders such as Parkinson's disease, agents with minimal extrapyramidal effects such as quetiapine may be preferred.

The Beers criteria have been developed (Fick et al., 2003) to evaluate for potentially inappropriate medication use in the older adults. It is estimated that 30% of geriatric hospital admissions are associated with problems related to drugs or their toxic effects. Examples of potentially inappropriate medications in the elderly include long-acting benzodiazepines, which can increase fall risk and produce prolonged sedation and diminished cognition; short-acting benzodiazepines at higher doses; amitriptyline, doxepin, thioridazine, and diphenhydramine, due to anticholinergic effects; and daily fluoxetine due to the long half-life and the risk of increasing agitation and sleep disturbances. Selective serotonin reuptake inhibitors (SSRIs) receive a low severity rating, but even they need to be monitored because they can cause or exacerbate the syndrome of inappropriate antidiuretic hormone (SIADH).

25.3 Specific Disorders in the Elderly

25.3.1 Dementia

Because of the rapidly growing elderly population, dementia is a commonly encountered issue in the medical unit. According to Geldmacher and Whitehouse (1996), the prevalence of dementia at age 60 is 1%, with this percentage doubling every 5 years thereafter to the point that by the age of 85, this number reaches 30% to 50%. The presence of dementia can directly affect the care of an elderly patient in the hospital setting. A study conducted by Erkinjuntti et al. (1986) reported that patients suffering from dementia not only had increased lengths of stay but also requires more daily nursing care upon discharge than did those without dementia.

The distinction between delirium and dementia is a frequent subject of inpatient consults. Taking a proper history of patients' cognitive symptoms from a reliable caregiver and recognizing the fluctuating level of consciousness that characterizes delirium may help distinguish between the two conditions. Using a cognitive screening instrument such as the Mini-Mental State Examination (MMSE) (Folstein et al., 1975) may be helpful in both the diagnosis of cognitive impairment and in the differential diagnosis by determining if the cognition is stable or fluctuating from day to day on serial examinations. (See Chapter 7 for MMSE and additional discussion of delirium and dementia.)

Additionally, assisting the treatment team with problematic behaviors that arise in the severely demented patients is also a common role for CL psychiatrists. Some of these behavioral problems are included in (Table 25.7). Psychosis and wandering, which is common in the midcourse of dementia, was noted to be less problematic in the later stages because of impairments in language and ambulation. It is in these later stages of dementia that neuropsychiatric symptoms of agitation/aggression, "aberrant motor behavior," and hallucinations become more prominent (Goy and Ganzini, 2003).

25.3.1.1 Treatment of Dementia

When planning the treatment of behavioral problems, it is important first to investigate (1) new medical problems, (2) medication side effects, (3) pain issues, (4) sleep deprivation, (5) environmental changes, and (6) antecedent - behavior - consequence (ABC) (American Psychiatric Association, 1997). Considering these factors not only can aid in determining the etiologies for these problematic behaviors, but also can give clues as to what interventions can help in the future.

Before considering the pharmacologic treatment of behavioral problems, nonpharmacologic interventions first must be attempted. Some general recommendations in dealing with agitated dementia patients that could be implemented are listed in Table 25.8 (American Psychiatric Association, 1997; Cohen-Mansfield, 2001; Wyszynski and Wyszynski, 2005).

Although medical treatments for the medically ill elderly individual may not differ significantly from those used by their healthy counterparts, side effects and drug interactions must be considered when administering medications for patients with medical comorbidities. Acetylcholinesterase inhibitors such as donepezil, rivastigmine, and galanthamine are routinely used for those with mild to moderate dementia (Agronin and Maletta, 2006). It should be noted that gastrointestinal side effects are common and that these medications should be taken with food. When initiating acetylcholinesterase inhibitor therapy in the hospital, it should be recognized that while improvements will be subtle and should not be expected immediately, they are usually apparent by 6 months and can persist for up to 2 years (Spar and La Rue, 2002). These medications have also been shown to improve noncognitive symptoms such as apathy, agitation, and depression. The decision whether to discontinue these medications in the inpatient setting may be determined by whether the patient has reached the end/severe stage of dementia "or when the patient's degree of decline is to the point where there can be no further improvement in quality of life." (It is the role of the clinician with input from the caregiver and family members to make that assessment.) More recently memantine, an N-methyl-D-aspartate (NMDA) receptor antagonist, has been used to treat moderate to severe dementia by itself and in combination with cholinesterase inhibitors (Reisberg et al., 2003; Tariot et al., 2004).

For the treatment of agitation and psychosis in dementia patients when nonpharmacologic approaches fail, the American Academy of Neurology has recommended the use of antipsychotic medications (Carson et al., 2006). In dementia patients with behavioral problems or psychotic symptoms, there is controversial evidence demonstrating the efficacy of olanzapine and risperidone compared to placebo but limited evidence for the other atypical antipsychotics. Compared to typical antipsychotics, atypical antipsychotics have limited or no data supporting their superiority over typical antipsychotics in terms of efficacy or short-term safety. The Food and Drug Administration (FDA), however, has recently issued warnings with regard to their use in this particular population of patients. In 2003 a safety alert was issued when patients participating in risperidone trials were found to have increased incidence of cerebrovascular accidents. Safety alerts by Health Canada were also issued for risperidone and olanzapine, and a warning for aripiprazole has also been added as well. Later in 2005, the FDA issued an advisory declaring an increase in overall mortality in elderly patients with dementia being treated with any atypical antipsychotic medication. Of note, none of these agents are approved by the FDA for treating psychotic and behavioral symptoms in dementia. Recent clinical trials and meta-analysis of atypical antipsychotics have emphasized that while these agents may be helpful with individual patients, as a group they have significant limitations due to their adverse effects (Schneider et al., 2006a,b). A study in the New England Journal of Medicine in 2006 also showed that this risk applied to typical antipsychotics as well (Wang et al., 2005).

25.3.2 Delirium

Delays in recognizing and treating delirium can have significant complications from both a medical and economic standpoint. Nearly 12.5 million elderly patients are admitted to U.S. hospitals each year. The development of delirium complicates at least 20% of these hospitalizations, contributing to over 49% of all hospital days and increasing hospital costs by as much as $2500 per patient (Inouye, 2006). These effects in the elderly are further magnified in the postoperative setting (15% to 53%), in the intensive care setting (70% to 87%), and in the end of life setting where the incidence is estimated at nearly 83%. Mortality rates among hospitalized patients with delirium are comparable to those of acute myocardial infarction or sepsis ranging from 22% to 76% (American Psychiatric Association, 1999; Curyto et al., 2001; Inouye, 2006).

Elderly patients are more prone to delirium because of the increased prevalence of risk factors such as chronic medical illness, dementia/cognitive impairment, sensory impairment (visual and hearing), structural brain disease, age-related central nervous system changes, and changes in pharmacokinetics and pharmacodynamics (Goy and Ganzini, 2003; Inouye, 2006) The presentation of delirium in the elderly shares many of the same characteristics as delirium in the younger population.

Although the priority should always be placed on treating the underlying etiology, symptomatic treatment can be addressed with high potency antipsychotics such as haloperidol when patients are agitated or displaying psychotic symptoms. Haloperidol is often the antipsychotic of choice because of its minimal anticholinergic effects, its wide therapeutic window, and its multiple routes of delivery. To date, there is a lack of studies demonstrating the efficacy of atypical antipsychotics such as risperidone and olanzapine, with early reports indicating increased risks of problematic side effects as well as higher costs (Goy and Ganzini, 2003). In the elderly patients, haloperidol is commonly administered at 0.5 to 2 mg and can be re-dosed or doubled every 30 minutes (Jacobson, 1997; Jacobson and Schreibman, 1997). Patients typically respond after one to two doses. Because agitation likely occurs again within 6 to 12 hours after the initial dose, standing doses of haloperidol should be given with half of the initial dose on the subsequent day and then tapered over the next 3 to 5 days. While there is less likelihood of dystonia with intravenous haloperidol, there is a higher rate of QT prolongation.

Although the role of benzodiazepines is often minimized in the setting of delirium, they can be used as an adjunctive agent once the haloperidol doses reach 5 to 10 mg (Jacobson, 1997; Jacobson and Schreibman, 1997). Lorazepam would be the benzodiazepine of choice because of its rapid onset, shorter halflife, more predictable bioavailability, lack of active metabolites, and decreased risk of accumulation. In the elderly patient, lorazepam can be given at doses between 0.5 and 1 mg. It should be noted that for delirium attributed to seizures or alcohol/sedative withdrawal, benzodiazepines are the first-line agents for therapy.

25.3.3 Mood Disorders

25.3.3.1 Depression

The combined effects of depression and medical illness in elderly patients can lead to increases in not only mortality but also nursing home placement, rate of readmission, and cost of inpatient services as well (Shanmugham et al., 2005). While the estimated prevalence of geriatric major depression is 1% to 2% in the general population, approximately 15% of elderly adults have depressive symptoms that do not meet the criteria for major depression. In primary care and hospital inpatient settings, the prevalence is approximately 10% to 12% (Shanmugham et al., 2005).

The geriatric population carries with it unique risk factors, which are discussed in Table 25.9. It is also important to recognize that the clinical presentation of depression can be different in the elderly, and patients may complain of more somatic symptoms and actually deny feeling depressed (Table 25.10).

Some medical illnesses have been implicated in causing depression in the elderly, including cerebral vascular disease and dementia. A cerebral vascular event can precipitate major depression in nearly 25% to 50% of stroke patients (Burke and Wengel, 2003). Studies have suggested that depression that occurs shortly after a stroke may be more structurally related to the location of the lesion than depression that occurs later on. Although evidence is inconclusive, some studies have suggested that lesions occurring in the anterior pole of the left hemisphere or the left basal ganglia are more likely related to depression (Burke and Wengel, 2003). Distinguishing features of vascular depression include greater involvement of executive dysfunction, anhedonia, and functional disability; less family history; and fewer psychotic features (Jeste et al., 2005).

Major depression has been found in 20% to 25% of those with dementia, with another 20% categorized as having other depressive syndromes (Burke and Wengel, 2003). The difficulty in diagnosing depression in dementia patients lies in the fact that the diagnostic process can often be hindered by poor cognitive functioning, and many of the symptoms of dementia and depression overlap. Further complicating early detection is the fact that depressive symptoms may not fit the diagnostic criteria for a major depressive disorder and may be more intermittent and associated with other psychological and behavioral disturbances. Because of this diagnostic dilemma, alternative approaches have been aimed at (1) using an inclusive approach, whereby symptoms are counted regardless of the presumed etiology of those symptoms; or (2) focusing primarily on the psychological symptoms of depression (Burke and Wengel, 2003). The Geriatric Depression Scale (Sheikh and Yesavage, 1986) can be useful because it puts less emphasis on the somatic symptoms of depression when compared to the Beck Depression Inventory (Burke and Wengel, 2003). In addition, features that are more suggestive of depression rather than dementia include (1) acute onset of symptoms, (2) improvement with antidepressants, and (3) complaints of memory problems exceeding actual memory impairment during neuropsychological testing (Small et al., 1986). While it is helpful to make the distinction of cognitive impairment due to depression because of potential treatment with antidepressants, from a long-term perspective these patients remain at an increased risk of developing irreversible dementia later on (Ownby et al., 2006).

25.3.3.1.1 Treatment of Depression in the Elderly: Overall, there are limited data on the treatment of depression in the medically ill elderly patient (Burke and Wengel, 2003). While SSRIs have been widely used as first-line agents, there is no specific evidence demonstrating the superior efficacy of any particular class of antidepressants. Expert recommendations suggest that SSRIs are better tolerated than tricyclic antidepressants (TCAs) by the elderly. Empirical studies, however, reveal similar tolerability profiles. The potential adverse effects, however, may be more serious for TCAs including higher risk of anticholinergic and cardiovascular side effects (Shanmugham et al., 2005). Citalopram and escitalopram are often used because they carry the lowest risk of drug interactions (Burke and Wengel, 2003). In terms of atypical antidepressants such as venlafaxine, bupropion, mirtazapine, and nefazodone, there are limited data dealing with treatment of the elderly (Burke and Wengel, 2003). Nefazodone has also been implicated in rare cases of liver failure (Bristol-Myers Squibb Company, 2002).

Treatment of nonmajor depression such as dysthymia and minor depression has been shown to have moderate benefits (Burke and Wengel, 2003). In terms of treatment of geriatric psychotic depression, expert consensus guidelines recommend the use of an antidepressant medication in addition to an antipsychotic medication or electroconvulsive therapy (ECT) (Shanmugham et al., 2005).

In the elderly ECT has been recommended as an initial treatment for those with (1) psychotic depression, (2) catatonia, (3) severe depression with functional impairment, (4) medical comorbidities, or (5) acute suicidality or inadequate nutrition where a quick response is needed (Shanmugham et al., 2005). Although there are no absolute contraindications, relative contraindications in the elderly are similar to those in younger patients, including cerebrovascular conditions such as aneurysms, recent stroke, space-occupying lesions, and cardiovascular comorbidities, as well as patients who are deemed high anesthetic risks (Greenberg and Kellner, 2005).

In patients with shortened life expectancy (<2 months), psychostimulants such as methylphenidate are recommended (Goy and Ganzini, 2003). Psychostimulants can also be used adjunctively for 2 to 3 weeks in the depressed apathetic medically ill geriatric patient until the primary antidepressant can reach maximal efficacy. Occasionally, however, it has been used as a sole antidepressant for up to several months (Jacobson et al., 2002; Rosenberg et al. 1991). Response to psychostimulants can be seen in 2 days, and discontinuation side effects are uncommon (10%), although blood pressure and pulse should be monitored because of the possibility of tachycardia and hypertension (Goy and Ganzini, 2003; Rosenberg et al., 1991). The starting dose can be methylphenidate 2.5 mg every morning with breakfast and can be increased by 2.5 to 5 mg every 2 to 3 days (Jacobson et al., 2002). A typical daily dose is between 5 and 10 mg b.i.d. Drug interactions have been noted with warfarin, TCAs, monoamine oxidase inhibitors (MAOIs), and venlafaxine. Tachycardia and hypertension can occur when combined with the latter agents.

25.3.3.1.2 Elderly Suicide: It has been estimated that 20% to 50% of elderly patients who commit suicide see their general practitioner within the week preceding their suicide (Cattell, 2000). The difficulty in evaluating elderly patients for suicide is that they give fewer warnings, use deadlier methods (71% using firearms), and have smaller attempts to completion ratios (4:1 versus 200:1 in adolescence). Because of these alarming statistics, earlier detection and treatment can decrease the rates of suicide (see Table 25.11 for risk factors for elderly suicide).

25.3.3.2 Bipolar Disorder

When an elderly patient presents with manic symptoms but has an unclear history of bipolar disorder, it is important to first rule out medical etiologies for those manic symptoms such as those listed in Table 25.12. For those with a prior diagnosis, the natural history of bipolar disorder is for the frequency and duration of affective symptoms to increase with age. Elderly bipolar patients with manic symptoms frequently present differently from their younger counterparts, often typified by a mixed state (Burke and Wengel, 2003). They tend to be more irritable and argumentative, with less euphoria and racing thoughts. Geriatric patients also have higher rates of psychotic symptoms and cognitive deficits, often mimicking delirium.

In terms of treatment of bipolar, lithium, valproic acid, and carbamazepine are the primary mood stabilizers used in the elderly (Burke and Wengel, 2003; Young, 2005). (For dosing of these medications in the elderly, see Jacobson et al., 2002.) Newer anticonvulsants, such as gabapentin, lamotrigine, oxcar- bazepine, and topiramate, have little empiric data to support their use in the geriatric population. Antipsychotics have been used for adjunctive control of acute mania and are starting to show promise as a monotherapy (Dunner, 2005; Glick et al., 2001; McDonald and Wermager, 2002). Electroconvulsive therapy is used in severe mania that is unresponsive to medications or in those who are acutely suicidal or nutritionally compromised.

25.3.3.3 Psychosis

In a geriatric patient without a history of psychosis, it is important to rule out medical or medication etiologies of psychosis by reviewing medication lists, performing a neurologic exam, and performing laboratory tests such as blood counts, liver function tests, basic chemistry panel, vitamin B12/folate levels, serum thyroid-stimulating hormone (TSH), rapid plasma reagent (RPR), and imaging studies such magnetic resonance imaging (MRI) or computed tomography (CT) scan of the brain.

For the elderly patient with schizophrenia, a major difference when compared with younger patient with schizophrenia lies in the reduction of positive symptoms (see Chapter 10) and an increase in negative symptoms and cognitive deficits (referred to as "burning out").

For those patients without a prior history or evidence of a medical etiology, the diagnosis of late-onset psychosis can be entertained. Symptoms often begin after 40 years of age and present with delusions (mostly persecutory) and hallucinations. There is a higher prevalence in women, and these patients are known to have functioned moderately well in the past (Agronin and Maletta, 2006). They present with less thought disorders, fewer negative symptoms, and less severe cognitive impairments, and they require lower doses of antipsychotics (Jeste et al., 2005).

Patients with various dementias can also develop psychotic symptoms. In these cases, the onset of psychosis usually occurs after or coincides with the onset of dementia (Jeste et al., 2005). While patients with schizophrenia do have generalized cognitive impairments, their learning capacity is relatively intact, unlike patients with dementia.

25.3.3.3.1 Treatment of Psychosis in the Elderly: Compared to typical antipsychotics, atypical antipsychotics are the treatment of choice due to efficacy and superiority of side-effect profiles. Atypical antipsychotics can be used to treat negative symptoms and have less extrapyramidal side effects (EPSs) (which the elderly are more susceptible to) but require vigilance for orthostatic hypotension, sedation, and impaired glucose tolerance/diabetes. There have also been recent FDA warnings implicating atypical antipsychotics in increased mortality and cerebrovascular accidents in patients with dementia (Carson et al., 2006). See Jacobson et al. (2002) for dosing in the elderly as well as side effects specific to each antipsychotic.

25.3.3.4 Anxiety Disorders

Common themes of anxiety in the geriatric medically ill patient include worries about physical illness and its impact on quality of life, including pain, disability, and the possibility of death. These fears can often be exacerbated by feelings of isolation and dependence in the hospital environment.

In certain instances it is in the hospital setting that an underlying anxiety disorder is exacerbated. In other instances, anxiety symptoms are secondary to a medical etiology including various diseases, medications, or substances. It is therefore important to differentiate the causes by (1) looking for a history of anxiety symptoms; (2) assessing the current medications, especially analgesics, cold remedies, anticholinergics, herbal medications, and vitamins; (3) looking for a history of drug or alcohol use; (4) looking for a medical history that includes endocrine diseases (thyroid/diabetes), pheochromocytoma, or cardiac/ pulmonary disease; and (5) looking for a family history of anxiety. Various rating scales including the Hamilton Anxiety Scale (HAM-A), the Beck Anxiety Inventory, the Hospital Anxiety and Depression Screen, and the Brief Symptom Inventory are tools to help confirm a diagnosis. (Agronin and Maletta, 2006; Goy and Ganzini, 2003).

A combination of psychotherapy (cognitive-behavioral approach) and medications are appropriate interventions for those motivated to, and have the cognitive capacity to, engage in therapy. For those receiving palliative care, the focus of therapy is teaching anxiety management skills such as progressive muscle relaxation, controlled respiration, and guided imagery rather than insightoriented psychotherapy. Reassuring patients that their symptoms will be addressed, that familiar nursing staff members will be available, and that their spiritual needs will be met by offering pastoral services can help alleviate anxiety in the medically ill elderly (Goy and Ganzini, 2003). In addition to therapy, benzodiazepines are considered first-line treatment, but caution is suggested because they can cause confusion and falls in the elderly and can potentially suppress respiration in patients with pulmonary disease or those on high doses of narcotics (Goy and Ganzini, 2003). If longer term anxiety treatment is needed, then the traditional use of SSRIs or serotonin and norepinephrine reuptake inhibitors (SNRIs) would be appropriate.

25.3.3.5 Substance Abuse! DependencelMisuse

Alcohol and substance abuse is often unrecognized in the elderly. According to community-based epidemiologic studies, the 1-year prevalence rate for alcohol abuse and dependence is 2.75% for elderly men and 0.51% for elderly women. The prevalence rates are higher, however, in primary care settings, where at-risk drinking has been estimated to be 5% to 15% (Oslin, 2005).

The prevalence of substance use disorders, however, actually may be underestimated because of the limited applicability of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria to the geriatric population. For example, elderly patients may have difficulty fitting the tolerance criteria of dependence because age-related changes in pharmacokinetics and pharmacodynamics lower drugs tolerance. In addition, the criteria addressing the inability to fulfill occupational obligations may be less applicable because a large portion of these patients no longer work (Jeste et al., 2005). At-risk drinking may also go unrecognized because physicians may not realize that the allowable intake for an elderly patient is different from that for a middle-aged adult. The National Institute on Alcohol Abuse and Alcoholism and the Center for Substance Abuse Treatment recommend that patients of ages 65 and older should consume no more than one standard drink per day or seven standard drinks per week (Oslin, 2005).

While the geriatric population can face similar substance abuse problems as their younger counterparts, a particularly unique problem facing the elderly is the misuse of prescription and over-the-counter medications. The two most commonly misused prescribed drugs by geriatric patients are benzodiazepines and narcotics, both of which can cause problems of tolerance, withdrawal, and cognitive changes. According to Oslin (2005), approximately 32% of community-dwelling geriatric patients take analgesics and 10.4% take benzodiazepines. In addition, geriatric patients often use over-the-counter cold and allergy medications, which can increase the risk of delirium because of their anticholinergic effects.

Helpful diagnostic tools to assess alcohol abuse in the elderly include (1) the CAGE (composed of 4 questions to screen for alcohol abuse) questionnaire (Ewing, 1984) in which one positive response can be an indicator of a disorder (Buchsbaum et al., 1992), and (2) the short Michigan Alcoholism Screening Instrument-Geriatric version. In addition to assessing for substance use, it is important to assess for alcohol-related problems such as (1) medication interactions, particularly warfarin and digoxin; (2) medical problems such as uncontrolled diabetes, poor nutrition, cardiovascular disease, hypertension, osteoporosis, hyperuricemia, and peripheral neuropathy; (3) insomnia; (4) withdrawal; and (5) accidents and falls (Agronin and Maletta, 2006). To assess for potential abuse of narcotics or benzodiazepines, the Dupont Checklist is a useful tool (Blow et al., 1992).

Treatment of alcohol and substance withdrawal in the elderly is similar to regimens used in younger populations. Although elderly patients have been shown to have a longer duration of withdrawal symptoms, there is no evidence suggesting that older patients are more prone to alcohol withdrawal or need a longer duration of treatment for withdrawal symptoms (Oslin, 2005). According to Beresford et al. (1988), initial treatment with a smaller than usual dosage of benzodiazepine is recommended in treating alcohol withdrawal in the elderly because of its increased half-life in the geriatric population. With patients in clear withdrawal in the absence of liver disease, start with chlordiazepoxide 25 to 50 mg orally and repeat every 2 hours until withdrawal symptoms abate. Over the next 3 (or occasionally 4) days, the dosage can be tapered. For those with significant liver disease, lorazepam (oral or intramuscularly) may be used with a starting dose of approximately 1 mg.

For the treatment of opiate withdrawal, symptomatic treatment is used for mild to moderate withdrawal, and methadone or buprenorphine can be used with caution in elderly patients with significant opiate addiction. (Agronin and Maletta, 2006).

For nonpharmacologic maintenance treatment of substance abuse, day programs and senior centers can be useful. According to Agronin and Maletta (2006), age-related group activities have been found to be superior to mixed-aged group activities. In terms of pharmacologic agents for alcohol, naltrexone has been shown to be safe and beneficial in older adults and is now available in a decanoate injection (Agronin and Maletta, 2006). However, it should be avoided in opiate-dependent patients or those currently taking opiates for pain. Treatment can be initiated at 25 mg daily and can either be maintained or increased to 50 mg daily. Recent studies on acamprosate have indicated some efficacy in adults; however, there are no studies focused on the elderly (Oslin, 2005). Disulfiram is also used occasionally in the adult population; however, its use in the elderly is limited, especially in those with hepatic or cardiovascular disease.

25.4 Specific Issues in Caring for the Elderly

25.4.1 Palliative Care/End of Life Issues

Palliative care has been extensively covered in Chapter 17, but it is an important topic when working with the medically ill geriatric population. It is important to recognize that progressively ill patients also have progressively higher rates of major depressive disorder. The prevalence of depression during terminal illness has been estimated to range from l% to more than 40%, with approximately 25% of cancer patients developing a significant mood disturbance (Goy and Ganzini, 2003). Addressing depression even in this setting is crucial because patients who are depressed tend to make more restricted advance directives and change them after remission of their depression (Ganzini et al., 1994).

Attention also should be paid to caregiver stress, and support can be provided through inpatient staff (social workers, pastoral care, nurses, and psychiatrists) and community resources. Preparing family members by guiding them through each stage of the patients' course leading up the final hours of life will help to alleviate some of their distress and can also serve to improve communication with the primary care provider (Goy and Ganzini, 2003).

25.4.2 Capacity

Capacity is a common consultative question concerning geriatric patients on the medical and surgical unit. To be deemed as having capacity, patients must demonstrate that they have sufficient understanding to make or communicate responsible decisions concerning one's condition (Appelbaum and Grisso, 1988). This is not to be confused with competence, which is legally determined.

Prior to interviewing the patient, it is important to learn the facts of the situation from the treatment team and whether the patient has been informed of these facts. The treatment team should also understand that just because patients lack capacity does not mean that they cannot later regain capacity. This is particularly true with reversible conditions such as delirium, psychoses, and mood disorders.

For a person to have capacity, there are four basic principles that state that the patient must (1) communicate a choice, (2) understand the information given, (3) understand the situation and its consequences, and (4) manipulate the information rationally (Applebaum and Grisso, 1988). Table 25.13 lists specific question to address these principles. A sliding scale approach can be taken to making a determination of capacity. This means that a lower standard can be used if a patient refuses a high-risk/low-benefit procedure, but a higher standard is used if a patient refuses a low-risk/high-benefit procedure.

If a patient has been determined to lack capacity, then advanced directives can be activated such as reviewing the living will or individual preferences, and having the durable power of attorney (DPOA) involved in making decisions for the patient. If there are no advanced directives, then a surrogate decision maker can be sought, either by having a capable patient designating someone, or by having involved parties (such as family members) stepping in. If a surrogate decision maker is not available, then a guardian can be appointed by the court once there is a legal determination of incompetence.

25.4.3 Functional Ability and Disposition Planning

In the elderly, a key focus is the evaluation and optimization of function and quality of life, and not just illness. Even in the hospital every effort should be made to optimize functional ability, as the elderly are very vulnerable to loss of function due to aging, physiology, medical, psychiatric, and iatrogenic reasons in the hospital (Creditor, 1993). This can ultimately lead to failure to thrive (Robertson and Montagnini, 2004). The level of function is determined by assessment of activities of daily living (ADLs), both the basic ADLs and the instrumental ADLs (IADLs). Basic ADL evaluation focuses on activities such as feeding, bathing, toileting, and grooming, and evaluation of IADLs focuses on cooking, shopping, use of telephone, and maintaining a checkbook. Instruments are available to make such determination (Applegate et al., 1990). The ADL capacity often determines the level of care an older person may need. In addition, it is critical to involve family and other formal and informal caregivers in the patient's life in making decisions about future living arrangements and assistance needed. Focus should be on both patient safety and respect of patient autonomy. Decisional capacity determination may need to be made if it appears that the patient does not appear to show good judgment in making decisions about future living arrangements and follow through of medical recommendations.

25.4.4 Elder Abuse and Undue Influence

A possible reason for consultation to psychiatry may be to provide an evaluation of elderly abuse. According to the U.S. House of Representatives Select Committee on Aging, an estimated 1 to 2 million older Americans are abused each year (Subcommittee on Health and Long-term Care of the Select Committee on Aging, 1990). Although reporting of suspected elder abuse was mandated in 43 states as of 1990, actual reporting remains rare. In one survey, only 18% of all elder abuse cases were actually reported by health care professionals and physicians (Kleinschmidt, 1997).

Based on Appelbaum and Grisso, 1988.

According to the National Aging Resource Center on Elder Abuse (NAR- CEA), there are seven suggested categories of elder abuse, which include those listed on Table 25.14. Undue influence is another concern when dealing with the elderly, particularly those who are dependent or impaired. Undue influence becomes an issue when "caregivers use their role or power to exploit the trust, dependency, or fear of another to gain psychological control over the patient's decision-making, usually for financial gain" (Quinn, 2002).

Physicians should be aware of signs of elderly abuse (Table 25.15) and report any incidents accordingly to state laws.

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