Geriatric Psychiatry - A Case-Based Textbook, 2e (Mar 30, 2024)_(3031478010)_(Springer) 9783031478017, 9783031478024

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Ana Hategan James A. Bourgeois Calvin H. Hirsch Caroline Giroux Editors

Geriatric Psychiatry A Case-Based Textbook Second Edition

Geriatric Psychiatry

Ana Hategan  •  James A. Bourgeois  •  Calvin H. Hirsch Caroline Giroux Editors

Geriatric Psychiatry A Case-Based Textbook Second Edition

Editors

Ana Hategan Division of Geriatric Psychiatry Department of Psychiatry and Behavioural Neurosciences McMaster University Hamilton, ON, Canada Calvin H. Hirsch Division of General Medicine University of California, Davis Medical Center Sacramento, CA, USA

James A. Bourgeois Department of Psychiatry and Behavioral Sciences, University of California Davis Medical Center Sacramento, CA, USA Caroline Giroux Department of Psychiatry and Behavioral Sciences, University of California Davis Medical Center Sacramento, CA, USA

ISBN 978-3-031-47801-7    ISBN 978-3-031-47802-4 (eBook) https://doi.org/10.1007/978-3-031-47802-4 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2018, 2024 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

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Foreword 1 In 2018, there were 52.4 million adults in the United States, ages 65 years and older, representing 15.6% of the country’s population. By 2030, the percentage of Americans 65 years or older will increase by 20%; and they will outnumber children under the age of 5. This is the first time ever in the entire human history that the number of older adults will exceed that of young children. Another striking aspect of this older population growth will be a marked increase in its heterogeneity. The proportion of older Americans from racial and ethnic minorities will increase by 135% between 2017 and 2040, compared with only 36% for the non-Hispanic White population. Yet, the aging of the population continues to be accompanied by prevalent ageism, driven by a common misperception that old age is associated with an inevitable decline in brain functioning. Actually, aging is characterized by considerable heterogeneity among older adults, and also within an older adult. Different organ systems in the same body age at different rates, and different parts of the same brain age differently. Research during the last 30 years has provided clear evidence of plasticity of the aging brain in people who stay active physically, cognitively, and socially. Positive psychosocial determinants of health such as quality of social connections, resilience, wisdom, and positive attitude are also associated with healthier aging of the brain. Many health-­ promoting strategies that are useful for the older adults in the general population can also be used, with appropriate modifications, in older adults with mental illnesses. A sadly biased and irrational phrase to describe the increase in numbers of older adults is “a silver tsunami.” In reality, many older adults remain high functioning, industrious, and creative into the eighth, ninth, and even tenth decade of their lives. I, therefore, label the demographic shift in the population a “golden wave.” At the same time, there is a nearly uniform consensus that the aging of the population will have a major impact on our already dysfunctional healthcare system, especially in the area of mental health. The current system is unprepared for the complexity of caring for a rapidly growing and increasingly heterogenous population of older adults. The inadequacy of the overall healthcare was magnified by the COVID-19 pandemic, which produced a 27.6% increase in the global prevalence of major depressive disorder across the lifespan. The pandemic has further exposed fundamental problems in the US healthcare system that specifically affect older people. The National Academies of Science, Engineering, and Medicine (NASEM) has published major reports that stress an urgent need for creating an expanded, well trained, and adequately prepared medical and social workforce for older adults, taking into account growing disparities and inequities, developing pragmatic and valid assessments of parameters of aging, and implementing new approaches to care delivery. The NASEM recommendations include enhancing the competence of all providers who deliver healthcare, increasing the recruitment and retention of geriatrics specialists, and redesigning models of care for more efficient deployment of the existing workforce. Creative educational and training approaches can help accelerate mastery of geriatric care principles by students and practitioners in relevant fields. There is also a need for more personalized care and growing sophistication in the use of electronic health records (EHRs) to identify risk, classify subpopulations, and direct appropriate interventions applicable to older adults with mental illnesses. This second edition of Geriatric Psychiatry: A Case-Based Textbook edited by four distinguished experts in the field—Drs. Ana Hategan, James A.  Bourgeois, Calvin H.  Hirsch, and Caroline Giroux, is an excellent model for helping to develop and expand an adequately prepared geriatric workforce. The first edition of this textbook was published in 2018 and became the best-selling book among the top 10 books in psychiatry and neurology combined; a likely contributor to this success was that it was case-based. It is a well-known fact that trainees learn more about diseases from case presentations and case conferences than from theoretical lectures. Every chapter in the

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Foreword 1

book included several clinical case reports, helping the readers understand the pragmatic principles of care at an individual patient level. For this second edition, the Editors have modified the original chapters and some of the titles to reflect current state of health and healthcare in geriatric psychiatry—e.g., inclusion of neuropsychiatric symptoms of COVID-19, the care of aging LGBTQ+ population, and other matters related to diversity, equity, and inclusion. The Editors have updated diagnostic guidelines using DSM-5-TR and ICD-11, and also added more recent data and references. This textbook has three parts. The first part focuses on basic principles in the assessment and treatment of late-life neuropsychiatric syndromes, including physiology, biology, psychotherapy, pharmacotherapy, and ethics. The second part describes common clinical characteristics of mental illnesses in late life including depressive, anxiety, bipolar, psychotic, trauma-related, neurocognitive, sleep, and personality disorders. The final part is devoted to special topics in old age such as consultation-liaison psychiatry, forensic psychiatry, emergencies, palliative care, caregivers, virtual care, and two new important chapters on climate change and the health of older adults and contemporary clinical care models. Each chapter contains a summary of the topic area, case histories with case analysis, key points, teaching points, and questions and answers. The chapters include basic aspects of the various conditions including their epidemiology, clinical features, course, and treatment. What makes the book unique is detailed descriptions and discussions of real-world clinical cases and information necessary for students and clinicians in training, including key features of symptomatic presentation, practical guidelines for diagnosis and treatment, and clinical pearls. With the latest DSM and ICD guidelines and key points, review questions, tables, and illustrations, this textbook is an excellent resource for readers worldwide for credentialing and practice guidance. An example of the comprehensive coverage of a critical area in geriatric psychiatry relates to neurocognitive disorders, the most common and serious neuropsychiatric disorders in older adults. There are seven well written and highly informative chapters on delirium, major or mild neurocognitive disorder due to Alzheimer disease, major or mild frontotemporal neurocognitive disorder, major or mild neurocognitive disorders with Lewy bodies, major or mild vascular neurocognitive disorder, neuropsychiatric symptoms of major or mild neurocognitive disorders, and neuropsychiatric manifestations of systemic medical conditions. Alzheimer disease is the single most common and fatal chronic brain disorder in older adults. Major or mild neurocognitive disorders due to Alzheimer disease exist on a spectrum of cognitive and functional impairment. While cognitive impairment is its pathognomonic feature, it is commonly accompanied, and sometimes preceded, by other neuropsychiatric symptoms like agitation, depression, and psychosis. The authors present diagnostic guidelines, typical and atypical clinical presentations, differential diagnosis, and treatment options. What I found particularly useful are tables on topics that are not usually discussed in the clinical literature, such as non-modifiable and potentially modifiable risk factors for Alzheimer disease, comparison between typical and rapidly progressive Alzheimer disease, cognitive differences between Alzheimer disease and major depressive disorder, and strategies for side effects, lack of response, and treatment discontinuation of cholinesterase inhibitors. The value of this textbook extends beyond geriatric psychiatry to clinicians, researchers, and educators in overall geriatric medicine. The best illustration of this point is the chapter on neuropsychiatric manifestations of systemic medical conditions, which include complex patients, high utilizers, and patients with psychiatric as well as general medical illnesses such as HIV and COVID-19. Systemic medical conditions presenting with neuropsychiatric symptoms are often misdiagnosed as primary psychiatric illnesses or disturbances. The most common “medical mimics” include autoimmune, endocrine, infectious, metabolic, iatrogenic, and neoplastic processes, which tend to be much more common in older than in younger populations. The authors appropriately point out the need for a wider differential diagnosis in evaluating older adults presenting with neuropsychiatric symptoms, so as to avoid incorrect and ­potentially danger-

VII Foreword 1

ous misdiagnosis of primary psychiatric disorders. The authors also recommend involvement of colleagues from appropriate medical specialties in the evaluation and care of this type of patients. Another laudable feature of this textbook is the attention paid to palliative and end-of-life care as well as care of the caregivers. The United Nations has declared 2021–2030 as the Decade of Healthy Aging. Notably, definitions of both health and aging are changing. Very recently, the NASEM published a report titled “Achieving Whole Health” that described whole health as physical, behavioral, spiritual, and socioeconomic wellbeing as defined by each individual and their family and community for themselves. Whole healthcare is characterized as an interprofessional, team-based approach anchored in trusted relationships, aligning with a person’s life mission, aspiration, and purpose. Furthermore, the report emphasized ensuring the wellbeing and whole healthcare team members. Thus, the whole healthcare model seeks to shift the focus to a model that prioritizes disease prevention, health, and wellbeing. The traditional perspective on aging must change too. Aging is not a disease to be cured or prevented. Aging is an active and ongoing life process that begins at conception and is associated with a dynamic balance between growth/development and degeneration. A sizable minority of the patients with serious mental illnesses like schizophrenia and major depressive disorder have levels of wellbeing in the normative range. This has been called “wellness within illness” by Elyn Saks. Wellbeing correlates with levels of resilience, optimism, and social support. Our therapies should enable the patients to enhance their positive attributes that would increase their chances of recovery. Readers will be pleased to see that the chapters on individual diseases in this textbook discuss not only psychopathology, relapses, and risk factors but also positive aspects such as wellbeing, remission, and protective factors. This textbook meets the needs of the future with its coverage of the most frequently encountered challenges, including neuropsychiatric syndromes, psychopharmacology, the law, substance misuse, mental health following a physical condition, “medical psychiatry,” and palliative care. Written by internationally recognized authorities in the field, Geriatric Psychiatry: A Case-Based Textbook is an invaluable guide for graduate and undergraduate medical and other healthcare professional students, as well as clinicians, educators, and researchers interested in mental healthcare for older adults, including psychiatrists, psychologists, geriatricians, neurologists, primary care and family practice physicians, social workers, nurses, pharmacists, and others. Publications of such books will help improve healthcare for older adults with mental illnesses and promote their wellbeing. Dilip V. Jeste

Global Research Network on Social Determinants of Mental Health and Exposomics La Jolla, CA, USA World Federation for Psychotherapy La Jolla, CA, USA Healthy Aging and Senior Care, Psychiatry and Neurosciences University of California San Diego La Jolla, CA, USA American Psychiatric Association Washington, DC, USA American Association of Geriatric Psychiatry McLean, VA, USA

Foreword 2 According to the United Nations, by the year 2050, one in six persons will be an older adult (65 years old or over) [1]. In the United States alone, by 2050, the number of older adults will climb to almost 84 million people, which will be over 20% of the population [2]. Among older adults in the US population, mental health and substance use conditions (including dementia-related behavioral and psychological symptoms) are common, occurring in 14–20% of the older population [3]. Despite this “aging mental health tsunami,” the workforce to help manage the psychiatric needs of older adults has not grown in kind. In fact, the number of psychiatrists trained in geriatric psychiatry fellowships has decreased over the past decade. Despite a peak of 106 geriatric psychiatry fellows in the United States in 2002–2003, the number has declined in intervening years, with only 48 such fellows nationally in 2020–2021, a 55% drop in fellowship enrollment [4]. The American Psychiatric Association has extrapolated that this decline will worsen the ratio of geriatric psychiatrists/ older Americans from 1/23,000 to 1/27,000 by the year 2030 [5]. An oft-quoted proverb, attributed to several African cultures, is that it “takes a village to raise a child,” meaning that to care for and nurture our progeny, society must pool our resources and take responsibility for our children. This concept is also very apt for the care and quality of life for older adults. To adequately manage the aging of the world’s population, we will collectively have to come together and invest in the education and training of our workforces, and expansion of services for older adults, particularly those with mental health conditions. Increasingly emphasized and recommended is the development of geriatric mental health curricula aimed at interprofessional learners [6]. Thus, the new edition of this textbook is particularly welcome, given the need to provide a tremendous amount of education for those outside of geriatric psychiatry, including those in general psychiatry and medicine as well as other disciplines such as psychology, nursing, and social work who are likely to see the bulk of geriatric mental health conditions in the next few decades. Late-life neuropsychiatric syndromes occur in the context of changes associated with the physiology of aging, medical, and neurological issues. By covering the landscape of geriatric psychiatry in three broad categories (Basic Principles in the Assessment and Treatment of Late-Life Neuropsychiatric Syndromes; Common Clinical Manifestations in Late Life; and Special Topics), the text helps the reader to organize the complexity of these syndromes. In the Basic Principles section, readers may find the chapter on somatic therapies particularly useful as the use of these therapies are likely to continue to grow in the aging population and practitioners will need to be able to explain the basis of, indications for and outcomes of these treatments to patients and their families. Within the Common Clinical Manifestations section, the chapter on trauma is important as adverse childhood experiences can continue to echo in the mental health issues of later life. Within the Special Topics section, the chapter on sexuality and sexual dysfunction is welcome as an area that, because of ageism, is too often ignored or given short-­shrift in medical settings. The organization of the text with highlighted teaching points, case histories, and questions and answers is particularly helpful for more active learning. Timely updates to this edition including linking to DSM-5-TR terminology, inclusion of the neuropsychiatric symptoms of COVID-19, and discussion of the aging LGBTQ+ population as well as two new chapters: Climate Change and the Health of Older Adults and Contemporary Clinical Care Models. In summary, the workforce that will assess and treat older adults in the coming years is in need of the resources that will help them to care for this population. This text is a welcome and comprehensive resource for this important mission.

IX Foreword 2

Helen C. Kales

Department of Psychiatry and Behavioral Sciences University of California, Davis Sacramento, CA, USA

References 1. United Nations Department of Economic and Social Affairs. World population ageing 2019. New York: United Nations; 2020. 2. U.S. Department of Commerce, Economics and Statistics Administration, U.S. Census Bureau. An aging nation: the older population in the United States: population estimates and projections, current population reports, issued May 2014. Available at: 7 https://www.­census.­gov/prod/www/population.­ html. 3. Eden J, Maslow K, Le M, et al., editors. The mental health and substance use workforce for older adults: in whose hands?  Washington, DC: Institute of Medicine of the National Academies, The National Academies Press; 2012. 4. Conroy ML, Meyen RA, Slade MD, Forester BP, Kirwin PD, Wilkins KM. Predictors for matriculation into geriatric psychiatry fellowship: data from a 2019–2020 National Survey of U.S.  Program Directors. Acad Psychiatry. 2021;45(4):435–9. 7 https://doi.org/10.1007/s40596-­021-­01413-­2. Epub 2021 Mar 15. 5. American Psychiatric Association. APA supports institute of medicine report calling for increased mental health workforce capacity to care for growing geriatric population. Press release 16 Jul 2012. [email protected]. 6. Conroy ML, Wilkins KM, van Dyck LI, Yarns BC. Geriatric psychiatry across the spectrum: medical student, resident, and fellow education. Psychiatr Clin North Am. 2022;45(4):765–77. 7 https://doi. org/10.1016/j.psc.2022.07.008. Epub 2022 Oct 14.  

 

 

Preface Geriatric Psychiatry: A Case-Based Textbook, Second Edition is a comprehensive volume. Under the close aegis of the editors, the authors have updated the original chapters and some of the titles to reflect recent developments and state-of-the-art knowledge in the field of geriatric psychiatry and have brought their references up to date. The Second Edition has added information about the neuropsychiatric symptoms of COVID-19; the care of the aging LGBTQ+ population; and other topics related to diversity, equity, and inclusion as well as climate change, and their impact on the care of older adults. The Second Edition has updated diagnostic guidelines using the more recent Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR), and the International Classification of Diseases, 11th edition (ICD-11). Similar to the First Edition, the Second Edition aims to facilitate the learning and consolidation of skills and the integration of concepts. This textbook is aimed both at trainees and seasoned clinicians, who need to learn how the complicated physiologic, medical, social, and environmental challenges facing older adults influence the development and presentation of psychiatric conditions. A likely contributor to the success of this book’s first edition (published in 2018) was that it was case-based. Problem-­ based learning, a widely adopted teaching model during medical training, has been shown to have positive effects on physician competency after graduation, both in cognitive and social domains [1], and to promote competencies in the “real-world” clinical practice of physicians [2]. Since nothing is static in the area of curricular development, medical institutions continuously experience multiple effects of a curricular change, with an accelerating shift from problem-based learning to case-based learning. Case-­ based learning, a newer modality of teaching in many healthcare disciplines [3], is preferred because it is a structured approach, enhances clinical skills, and keeps the learning relevant. Contemporary trainees must continue to have access to instructors who serve as the inspirational role models that traditional curriculum offers. Case-based learning emerges as a promising teaching method for trainees in all medical fields, including geriatric psychiatry. Teaching through integrative cases, with its patient-centered approach, promotes learning and the adoption of programmatic assessment, and fosters the ability to integrate knowledge from across the medical curriculum. It promotes an appreciation of inter-specialty and multidisciplinary collaborative care while building self-efficacy to tackle challenging, authentic, and relevant clinical problems. These skills are all pertinent to the needs of modern medical students, postgraduate trainees, and established physicians who seek to expand or update their field of expertise. Trainees in the medical specialty of psychiatry and the subspecialty of geriatric psychiatry need exposure to high-yield, real-world cases in order to master core competencies in geriatric psychiatry. This textbook is ideal not only for trainees studying for the basic geriatric psychiatry rotation in psychiatry residency training, but also for those studying for subspecialty qualifying examinations in geriatric psychiatry. This book is similarly intended for those training in other disciplines, such as advanced practice nursing and clinical psychologists, not just medical specialties. We hope that many clinicians will find the cases a useful addition to their resources for mastering the care of older patients. Beyond the needs of trainees (e.g., residents and fellows in psychiatry and psychiatric subspecialties), the volume is intended to be equally valuable to practicing physicians. We envision two groups of practicing physicians who may benefit from the comprehensive and case-based approach we have taken. Psychiatrists who have the need for periodic specialty recertification will find this book an efficient review of topics in geriatric psychiatry to facilitate validation of clinical currency and to enhance examination preparation. Perhaps more importantly, psychiatrists who wish to further their knowledge and skills in geriatric psychiatric practice, and other specialty physicians whose work verges on geriatric psychiatry (e.g., geriatricians, internists,

XI Preface

­ eurologists, physiatrists) will find this volume a needed resource to enhance clinical n problem-solving skills and to give these other specialists a pragmatic grounding in the clinical aspects of geriatric psychiatry that relate to their work within the framework of other medical specialties. Therefore, this textbook has an innovative, cutting-edge format that melds two concepts together: the traditional textbook and the case-based learning style. This approach has several advantages: 55 Trainees learn from the case-based approach. The argument is that this demographic needs to employ learning skills that will resonate longer and provide more learning support. 55 This concept sets this textbook apart from others; it is not nearly as abstract as a standard textbook, and the editors believe that learning by example is the way of the future. 55 The reader can approach the material in two ways. The first way is to study the cases before reading the body of the chapter in order to identify gaps in clinical knowledge and confidence that will allow the content of the chapter to have more immediate relevance and thus promote retention. The second, more conventional, approach is to read the content of the chapter first and then to study the cases in order to assess assimilation of the material. Each chapter is meant to be a complete stand-­ alone learning module, but each can also be used as a reference to refresh and enhance clinical skills. 55 This textbook offers the engagement level of a case studies book, while it has the learning tools that will reinforce the concepts, including charts, graphics, teaching points, key objectives, and review questions with referenced answers. The advantages of this case-based textbook format are manifold: it is learner-­ focused, allows for active and self-directed learning, and enhances content knowledge, while simultaneously fostering the development of communication, critical thinking, problem solving, and collaboration. This positions trainees to function using real-­ world clinical experiences. This novel breed of case-based textbook aims to be a comprehensive reference (as conventional texts also aim to be) and also retain the ability to serve as a quick reference for readers. As such, the chapter authors have utilized quality reviews and meta-analyses that have systematically synthesized the literature that has come before and have provided bibliographies that are comprehensive, relevant, and valuable to the interested reader, while not being as exhaustive as found in textbooks of the past. Geriatric Psychiatry: A Case-Based Textbook, Second Edition retains the relevance of the textbook in this era of exponential growth of the Internet and PubMed. This volume covers main topics in geriatric psychiatry, whereas topics such as substance use disorders and sexuality and sexual dysfunction in later life are becoming even more relevant now that the baby boomers are beginning to age. This volume is practical and concise, featuring 37 chapters on geriatric psychiatry topics, each comprising clinical background, followed by a question-and-answer section format accompanying cases designed to carry on teaching while enhancing the reader’s diagnostic ability and clinical understanding. The majority of the chapters include two cases of various clinical complexities, highlighting teaching points and reviewing ­ multiple choice questions. The text is arranged in three sections covering basic principles in assessment and management of geriatric neuropsychiatric syndromes, common psychiatric diagnoses in late life, and a collection of specialized topics. The material matches the existing postgraduate curricula in geriatric psychiatry and will prepare candidates for their specialty and subspecialty certification examinations. The cases map well to the American Association for Geriatric Psychiatry and Canadian Academy of Geriatric Psychiatry and other international postgraduate curricula in geriatric psychiatry. Written and edited by geriatric psychiatrists, consultation-liaison psychiatrists, general psychiatrists, geriatricians, and other physician specialists in the care of older adults, as well as authors from allied health professions, this book will provide the editors’ and authors’ clinical experience with evidence-based information, expert opin-

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Preface

ions, and contemporary clinical guidelines for geriatric neuropsychiatric syndromes. Key features consist of being an easy-to-reference, heavily illustrated, specialty-specific guidance on how to diagnose and manage problems that arise in clinical practice, and it should be as succinct and clinically relevant as possible. The chapters present the main DSM-5-TR categories with reference to later life illness presentations. The cases and their explanations stress clinical reasoning and underpinning evidence-based mechanistic principles, rather than emphasizing memorization and the selection of right and wrong answers to questions. The clinical cases are written to be representative of typical, though at times complex, patient presentations. Furthermore, cases presented are composites based on authors’ experience and are not individual/separate cases. As the case examples illustrate throughout the textbook, psychiatric complexity and comorbidity are the rule (especially in aging patients). In evaluating such patients, the reader might be tempted to “simplify the complexity” by applying a more reductionistic and illness-focused nomenclature of the diagnostic classification systems. Although both DSM and ICD classification systems continue to adapt as scientific advances in psychiatric phenomenology progress over time, they endeavor to capture the complex interactions of psychiatric illness, systemic medical comorbidity, multiple pharmacologic agents, the processes of normal aging, and the patient’s unique functional and psychosocial status. Thus, the psychiatric care of older patients must strive to be holistic and patient-centered in its scope. An “atypical” clinical presentation might be evocative of some cultural or generational factors that modify the “textbook” presentations on which illness classifications are based. Hippocrates is reputed to have said [4], “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” We believe that our elaborate cases in each chapter underscore the challenges of diagnosing and managing psychiatric morbidity in older adults and encourage an integrative approach that acknowledges the dynamic interplay among psychiatric, systemic medical, pharmacologic, cultural, and social factors. We hope that this book fosters an interest in understanding the specific patient’s unique narrative and clinical presentation. We also hope that the cases presented in this volume serve to encourage the reader to stretch beyond “habitual zones of clinical comfort” while advancing pragmatic clinical knowledge and judgment. The authors and editors of this book have endeavored to use the latest DSM-5-TR nomenclature to describe psychiatric illnesses, both regarding broad categories and specific illnesses. The DSM-5-TR was published in 2022, and much of the research and clinical literature based on data acquired before 2022 was written in DSM-5 (and earlier DSM versions) style. Therefore, the chapter authors/editors quoted sources by using the terminology in force at the time of the original publications, while, when writing about the current state, they use the DSM-5-TR nomenclature. When needed for clarity, “transduction” language, for example, “major neurocognitive disorder (DSM-­ 5-­TR), formerly dementia (DSM-IV),” is used to assist the reader to manage this admittedly sometimes semantically awkward period of transition. This is accomplished in the service of clarity of thought, and the authors/editors hope that such terminology assists the reader. The editors have built their careers on their balanced roles as clinicians and educators, which has led to shaping this curriculum. It is their hope that this book is intended as a hands-on, real-world approach to learning that will keep readers engaged and able to understand the key factors that drive the medical decision-making process. Readers will also be able to cover the bioethical aspects, presentation, management, and biopsychosocial treatment of the most common neuropsychiatric illnesses in older adults. We hope this academic textbook remains on bookshelves during training and beyond, well into the years of postgraduate medical practice.

XIII Preface

Ana Hategan

Hamilton, ON, Canada James A. Bourgeois

Sacramento, CA, USA Calvin H. Hirsch

Sacramento, CA, USA Caroline Giroux

Sacramento, CA, USA

References 1. Koh GC, Khoo HE, Wong ML, Koh D. The effects of problem based learning during medical school on physician competency: a systematic review. CMAJ. 2008;178(1):34–41. 2. Schlett CL, Doll H, Dahmen J, et al. Job requirements compared to medical school education: differences between graduates from problem-based learning and conventional curricula. BMC Med Educ. 2010;10:1. 7 https://doi.org/10.1186/1472-­6920-­10-­1. 3. McLean SF.  Case-based learning and its application in medical and health-care fields: a review of worldwide literature.  J Med Educ Curric Dev. 2016;3:JMECD.S20377. 7 https://doi.org/10.4137/ JMECD.S20377. 4. Egnew TR. Suffering, meaning, and healing: challenges of contemporary medicine. Ann Fam Med. 2009;7(2):170–5.  

 

XV

Contents I 1

Basic Principles in the Assessment and ­Treatment of Late-Life Neuropsychiatric ­Syndromes Physiology and Pathology of Aging.......................................................................................3 Calvin H. Hirsch and Ana Hategan

1.1 Background.................................................................................................................................................4 1.1.1 Normal Versus Normative Aging.................................................................................................................4 1.1.2 Loss of Resilience...............................................................................................................................................4 1.1.3 Construct of Frailty...........................................................................................................................................5 1.1.4 Multimorbidity...................................................................................................................................................6 1.1.5 Telomere Length, Inflammation, and Multimorbidity.........................................................................8 1.1.6 Aging in Individual Organ Systems and Implications for Disease and Treatment.....................9 1.1.7 Age-Related Changes in the Heart.............................................................................................................11 1.1.8 The Aging Lung..................................................................................................................................................13 1.1.9 The Aging Endocrine System........................................................................................................................13 1.1.10 Clinically Relevant Age-Associated Changes in Kidney and Liver Function................................17 1.1.11 Sarcopenia of Aging.........................................................................................................................................18 1.2 Case Studies................................................................................................................................................18 1.2.1 Case 1.................................................................................................................................................................... 18 1.2.2 Case 2.................................................................................................................................................................... 21 1.3 Key Points: Physiology and Pathology of Aging.............................................................................24 1.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................25 References............................................................................................................................................................ 26 2

Comprehensive Geriatric Assessment..................................................................................31 Calvin H. Hirsch and Tricia K. W. Woo

2.1 Background.................................................................................................................................................32 2.1.1 Overview..............................................................................................................................................................32 2.1.2 Cognition and Mood........................................................................................................................................32 2.1.3 Functional Ability..............................................................................................................................................32 2.1.4 Physical Health...................................................................................................................................................32 2.1.5 Medication Review...........................................................................................................................................37 2.1.6 Social Supports..................................................................................................................................................38 2.1.7 Focused Geriatric Physical Examination...................................................................................................38 2.1.8 Special Challenges with Geriatric Patients...............................................................................................45 2.2 Case Studies................................................................................................................................................46 2.2.1 Case 1.................................................................................................................................................................... 46 2.2.2 Case 2.................................................................................................................................................................... 48 2.3 Key Points: Comprehensive Geriatric Assessment.........................................................................50 2.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................51 References............................................................................................................................................................ 52 3

Neuroimaging in Clinical Geriatric Psychiatry................................................................55 Amer M. Burhan, Niharika Soni, Matthew Kuo, Udunna C. Anazodo, and Jean-Paul Soucy

3.1 Background.................................................................................................................................................56 3.1.1 Introduction........................................................................................................................................................56 3.1.2 Brain Structure and Networks......................................................................................................................56 3.1.3 Age-Related Changes in Brain Structure and Brain Networks..........................................................61 3.1.4 Overview of Brain Imaging Modalities......................................................................................................62 3.2 Case Studies................................................................................................................................................74 3.2.1 Case 1.................................................................................................................................................................... 74

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Contents

3.2.2 Functional Imaging Brief Cases....................................................................................................................78 3.2.3 Sampler CT Scan Cases...................................................................................................................................95 3.3 Key Points: Neuroimaging in Clinical Geriatric Psychiatry..........................................................97 3.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................98 References............................................................................................................................................................ 98 4

Neuropsychology in Late Life.....................................................................................................103 Heather E. McNeely and Jelena P. King

4.1 Background.................................................................................................................................................104 4.1.1 Rationale..............................................................................................................................................................104 4.1.2 Neuropsychology of Normal Aging............................................................................................................104 4.1.3 Neurocognitive Disorder................................................................................................................................105 4.1.4 Neuropsychological Assessment Procedures.........................................................................................105 4.2 Case Studies................................................................................................................................................112 4.2.1 Case 1.................................................................................................................................................................... 112 4.2.2 Case 2.................................................................................................................................................................... 115 4.3 Key Points: Neuropsychology in Late Life.........................................................................................119 4.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................120 References............................................................................................................................................................ 121 5

Pharmacotherapy: Safe Prescribing and Adverse Drug Events...........................123 Calvin H. Hirsch, Shyam Maharaj, and James A. Bourgeois

5.1 Background.................................................................................................................................................124 5.1.1 General Principles of Pharmacotherapy in Old Age.............................................................................124 5.1.2 Epidemiology of Polypharmacy and Adverse Drug Events...............................................................124 5.1.3 Prescription Complexity.................................................................................................................................126 5.1.4 Drug-Food/Nutrient Interactions................................................................................................................127 5.1.5 Dietary Supplements and Drug-Supplement Interactions................................................................128 5.1.6 Potentially Inappropriate Medications (PIMs)........................................................................................129 5.1.7 Medications of Special Concern for Older Adults..................................................................................130 5.1.8 Adverse Reactions Meriting Special Consideration..............................................................................137 5.1.9 Deprescribing: A Clinical Approach to Polypharmacy.........................................................................142 5.2 Case Studies................................................................................................................................................143 5.2.1 Case 1.................................................................................................................................................................... 143 5.2.2 Case 2.................................................................................................................................................................... 145 5.3 Key Points: Pharmacotherapy: Safe Prescribing and Adverse Drug Events..........................146 5.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................150 References............................................................................................................................................................ 151 6

Neuromodulation Therapies I: Electroconvulsive Therapy.....................................155 Carole Lazaro, Lisa A. McMurray, Milena Rogan Ducic, and Timothy E. Lau

6.1 Background.................................................................................................................................................156 6.1.1 Introduction........................................................................................................................................................156 6.1.2 History of Electroconvulsive Therapy (ECT).............................................................................................156 6.1.3 The Electrical Stimulus....................................................................................................................................156 6.1.4 Electrode Placement........................................................................................................................................157 6.1.5 Stimulus Dosing.................................................................................................................................................158 6.1.6 Seizure Monitoring...........................................................................................................................................158 6.1.7 Mechanism of Action.......................................................................................................................................159 6.1.8 Cardiovascular Response to ECT.................................................................................................................159 6.1.9 Pre-ECT Evaluation...........................................................................................................................................159 6.1.10 Informed Consent.............................................................................................................................................160 6.1.11 Management of Medications........................................................................................................................160 6.1.12 Use of ECT in Geriatric Psychiatry................................................................................................................161 6.1.13 Diagnostic Indications and Efficacy............................................................................................................161

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6.1.14 Side Effects in Geriatric Patients..................................................................................................................163 6.1.15 Continuation ECT and Maintenance ECT.................................................................................................165 6.1.16 Electroconvulsive Therapy Versus Repetitive Transcranial Magnetic Stimulation.....................166 6.1.17 Electroconvulsive Therapy Plus Ketamine and ECT Versus Ketamine............................................167 6.2 Case Studies................................................................................................................................................167 6.2.1 Case 1.................................................................................................................................................................... 167 6.2.2 Case 2.................................................................................................................................................................... 171 6.3 Key Points: Neuromodulation Therapies I: Electroconvulsive Therapy..................................176 6.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................177 References............................................................................................................................................................ 178 7

Neuromodulation Therapies II: Repetitive Transcranial Magnetic Stimulation and Deep Brain Stimulation............................................................................181 Lisa A. McMurray, Sara Tremblay, Carole Lazaro, and Timothy E. Lau

7.1 Background.................................................................................................................................................182 7.1.1 Neuromodulation Therapies.........................................................................................................................182 7.1.2 Repetitive Transcranial Magnetic Stimulation (rTMS)..........................................................................182 7.1.3 Deep Brain Stimulation (DBS).......................................................................................................................193 7.2 Case Studies................................................................................................................................................194 7.2.1 Case 1.................................................................................................................................................................... 194 7.2.2 Case 2.................................................................................................................................................................... 197 7.3 Key Points: Neuromodulation Therapies II: rTMS and DBS.........................................................199 7.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................199 References............................................................................................................................................................ 201 8

Psychotherapy in Late Life............................................................................................................205 Caroline Giroux and W. Edwin Smith

8.1 Background.................................................................................................................................................206 8.1.1 Generalities..........................................................................................................................................................206 8.1.2 Procedural Adaptations..................................................................................................................................211 8.1.3 Types of Psychotherapies...............................................................................................................................212 8.1.4 Experiential Psychotherapies........................................................................................................................217 8.1.5 Corporal Mediation Therapies......................................................................................................................218 8.1.6 Systemic Family Therapy................................................................................................................................218 8.1.7 Combination (or Second- and Third-­Generation) Therapies.............................................................219 8.1.8 Psychotherapy Formats..................................................................................................................................221 8.1.9 Other Forms of Therapy..................................................................................................................................222 8.1.10 Special Considerations....................................................................................................................................222 8.2 Case Studies................................................................................................................................................222 8.2.1 Case 1.................................................................................................................................................................... 222 8.2.2 Case 2.................................................................................................................................................................... 225 8.3 Key Points: Psychotherapy in Late Life..............................................................................................228 8.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................229 Appendix......................................................................................................................................................231 References............................................................................................................................................................ 231 9

Ethics, Mental Health Law, and Aging...................................................................................233 Daniel L. Ambrosini, Calvin H. Hirsch, and Ana Hategan

9.1 Background.................................................................................................................................................234 9.1.1 Demographic and Epidemiological Factors............................................................................................234 9.1.2 Ethical Theories and Frameworks................................................................................................................234 9.1.3 Legal Overview..................................................................................................................................................237 9.1.4 Informed Consent.............................................................................................................................................237 9.1.5 Mental Capacity.................................................................................................................................................238 9.1.6 Advance Directives...........................................................................................................................................239

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9.1.7 Decision-Making for Older Adults Without Family and Guardianship ( The “Unbefriended Patient”).........................................................................................................................241 9.1.8 Involuntary Commitment and Long-Term Care.....................................................................................242 9.1.9 Elder Abuse.........................................................................................................................................................242 9.1.10 Managing Risk of Violence in Older Adults with Psychiatric Disorders.........................................243 9.1.11 End-of-Life Discussions...................................................................................................................................243 9.1.12 Physicians’ Roles and Responsibilities.......................................................................................................244 9.2 Case Studies................................................................................................................................................245 9.2.1 Case 1.................................................................................................................................................................... 245 9.2.2 Case 2.................................................................................................................................................................... 246 9.3 Key Points: Ethics, Mental Health Law, and Aging.........................................................................249 9.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................249 References............................................................................................................................................................ 250

II 10

Common Clinical Manifestations in Late Life Late-Life Depressive Disorders..................................................................................................255 Emma Gregory, Tracy Cheng, and Ana Hategan

10.1 Background.................................................................................................................................................256 10.1.1 Definition.............................................................................................................................................................256 10.1.2 Epidemiology.....................................................................................................................................................256 10.1.3 Etiology.................................................................................................................................................................257 10.1.4 Clinical Description...........................................................................................................................................258 10.1.5 Diagnostic Evaluation......................................................................................................................................259 10.1.6 Differential Diagnosis......................................................................................................................................260 10.1.7 Treatment.............................................................................................................................................................261 10.2 Case Studies................................................................................................................................................264 10.2.1 Case 1.................................................................................................................................................................... 264 10.2.2 Case 2.................................................................................................................................................................... 268 10.3 Key Points: Late-Life Depressive Disorders......................................................................................271 10.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................271 References............................................................................................................................................................ 273 11

Late-Life Bipolar Disorders..........................................................................................................277 Ana Hategan, Tracy Cheng, and Karen Saperson

11.1 Background.................................................................................................................................................278 11.1.1 Definition.............................................................................................................................................................278 11.1.2 Epidemiology.....................................................................................................................................................278 11.1.3 Etiology.................................................................................................................................................................279 11.1.4 Clinical Description...........................................................................................................................................279 11.1.5 Diagnostic Evaluation......................................................................................................................................281 11.1.6 Differential Diagnosis......................................................................................................................................283 11.1.7 Treatment.............................................................................................................................................................283 11.2 Case Studies................................................................................................................................................286 11.2.1 Case 1.................................................................................................................................................................... 286 11.2.2 Case 2.................................................................................................................................................................... 290 11.3 Key Points: Late-Life Bipolar Disorders..............................................................................................293 11.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................293 References............................................................................................................................................................ 294 12

Late-Life Anxiety Disorders.........................................................................................................297 Claire Slavin-Stewart, Ana Hategan, Sachin Sarin, and Zainab Samaan

12.1 Background.................................................................................................................................................298 12.1.1 Definition of Anxiety Disorders....................................................................................................................298

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12.1.2 Epidemiology and Diagnostic Criteria.......................................................................................................298 12.1.3 Evolutionary Considerations.........................................................................................................................300 12.1.4 The Interplay Between Anxiety and Depressive Disorders................................................................300 12.1.5 Association Between Cognitive Impairment and Anxiety.................................................................300 12.1.6 Etiology.................................................................................................................................................................300 12.1.7 Diagnostic Evaluation......................................................................................................................................301 12.1.8 Treatment.............................................................................................................................................................302 12.2 Case Studies................................................................................................................................................304 12.2.1 Case 1.................................................................................................................................................................... 304 12.2.2 Case 2.................................................................................................................................................................... 308 12.3 Key Points: Late-Life Anxiety Disorders.............................................................................................309 12.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................310 References............................................................................................................................................................ 310 13

Obsessive-Compulsive and Related Disorders...............................................................313 Puja Chadha and Shannon Suo

13.1 Background.................................................................................................................................................314 13.1.1 Definitions and Clinical Description...........................................................................................................314 13.1.2 Epidemiology.....................................................................................................................................................319 13.1.3 Etiology.................................................................................................................................................................319 13.1.4 Diagnostic Evaluation......................................................................................................................................320 13.1.5 Treatment.............................................................................................................................................................322 13.2 Case Studies................................................................................................................................................324 13.2.1 Case 1.................................................................................................................................................................... 324 13.2.2 Case 2.................................................................................................................................................................... 328 13.3 Key Points: Obsessive-Compulsive and Related Disorders.........................................................331 13.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................331 References............................................................................................................................................................ 332 14

Trauma- and Stressor-Related Disorders............................................................................335 Caroline Giroux and Andrés F. Sciolla

14.1 Background.................................................................................................................................................336 14.1.1 Trauma: Generalities and Definitions.........................................................................................................336 14.1.2 Epidemiology.....................................................................................................................................................337 14.1.3 Etiology.................................................................................................................................................................338 14.1.4 Phenomenology................................................................................................................................................339 14.1.5 Prevention and Treatment Approaches....................................................................................................345 14.2 Case Studies................................................................................................................................................348 14.2.1 Case 1.................................................................................................................................................................... 348 14.2.2 Case 2.................................................................................................................................................................... 351 14.3 Key Points: Trauma- and Stressor-­Related Disorders....................................................................355 14.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................356 References............................................................................................................................................................ 358 15

Late-Life Psychotic Disorders.....................................................................................................361 Emma Gregory, Jessica E. Waserman, and Karen Saperson

15.1 Background.................................................................................................................................................362 15.1.1 Definition.............................................................................................................................................................362 15.1.2 Epidemiology.....................................................................................................................................................362 15.1.3 Etiology and Differential Diagnosis............................................................................................................362 15.1.4 Clinical Description...........................................................................................................................................363 15.1.5 Diagnostic Evaluation......................................................................................................................................364 15.1.6 Treatment.............................................................................................................................................................365 15.2 Case Studies................................................................................................................................................369 15.2.1 Case 1.................................................................................................................................................................... 369

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15.2.2 Case 2.................................................................................................................................................................... 372 15.3 Key Points: Late-Life Psychotic Disorders.........................................................................................375 15.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................375 References............................................................................................................................................................ 376 16

Substance Use Disorders...............................................................................................................379 Jeffrey DeVido, Calvin H. Hirsch, Nitika Sanger, Tea Rosic, Zainab Samaan, and James A. Bourgeois

16.1 Background.................................................................................................................................................380 16.1.1 Definition.............................................................................................................................................................380 16.1.2 Epidemiology.....................................................................................................................................................380 16.1.3 Etiology.................................................................................................................................................................387 16.1.4 Clinical Description...........................................................................................................................................388 16.1.5 Diagnostic Evaluation......................................................................................................................................388 16.1.6 Differential Diagnosis......................................................................................................................................392 16.1.7 Treatment.............................................................................................................................................................392 16.2 Case Studies................................................................................................................................................394 16.2.1 Case 1.................................................................................................................................................................... 394 16.2.2 Case 2.................................................................................................................................................................... 398 16.3 Key Points: Substance Use Disorders.................................................................................................402 16.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................402 References............................................................................................................................................................ 403 17

Delirium.....................................................................................................................................................407 Ana Hategan, Calvin H. Hirsch, James A. Bourgeois, and Deborah ­Francis

17.1 Background.................................................................................................................................................408 17.1.1 Definition.............................................................................................................................................................408 17.1.2 Epidemiology.....................................................................................................................................................408 17.1.3 Etiology and Risk Factors................................................................................................................................408 17.1.4 Pathophysiology................................................................................................................................................410 17.1.5 Motor Subtypes of Delirium and Clinical Presentation.......................................................................411 17.1.6 The Neuropsychiatric Symptoms of Delirium.........................................................................................412 17.1.7 Diagnosis, Assessment, and Workup..........................................................................................................413 17.1.8 Medical Evaluation...........................................................................................................................................420 17.1.9 Essential Role of Nurses, Other Health Professionals, and Family Caregivers.............................422 17.1.10 Prevention and Management.......................................................................................................................425 17.1.11 Post-delirium, Aftercare Interventions......................................................................................................430 17.2 Case Studies................................................................................................................................................430 17.2.1 Case 1.................................................................................................................................................................... 431 17.2.2 Case 2.................................................................................................................................................................... 432 17.3 Key Points: Delirium.................................................................................................................................435 17.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................435 References............................................................................................................................................................ 436 18

Major or Mild Neurocognitive Disorder Due to Alzheimer Disease..................441 Ana Hategan, Glen L. Xiong, and Kimberley M. Bender

18.1 Background.................................................................................................................................................442 18.1.1 Definitions, Diagnostic Criteria, and Reclassification Systems.........................................................442 18.1.2 Epidemiology.....................................................................................................................................................444 18.1.3 Pathophysiology................................................................................................................................................446 18.1.4 Risk Factors and Prognostic Factors in Alzheimer Disease.................................................................448 18.1.5 Clinical Description...........................................................................................................................................449 18.1.6 Diagnostic Evaluation......................................................................................................................................452 18.1.7 Comorbidity and Differential Diagnosis...................................................................................................456 18.1.8 Treatment.............................................................................................................................................................457

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18.2 Case Studies................................................................................................................................................459 18.2.1 Case 1.................................................................................................................................................................... 459 18.2.2 Case 2.................................................................................................................................................................... 471 18.3 Key Points: Major or Mild Neurocognitive Disorder Due to Alzheimer Disease..................474 18.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................475 References............................................................................................................................................................ 476 19

Major or Mild Frontotemporal Neurocognitive Disorder........................................479 James A. Bourgeois, Ana Hategan, Calvin H. Hirsch, and Briana Howarth

19.1 Background.................................................................................................................................................480 19.1.1 Definition.............................................................................................................................................................480 19.1.2 Epidemiology.....................................................................................................................................................481 19.1.3 Etiology.................................................................................................................................................................481 19.1.4 Clinical Description...........................................................................................................................................482 19.1.5 Diagnostic Evaluation......................................................................................................................................483 19.1.6 Differential Diagnosis......................................................................................................................................488 19.1.7 Treatment.............................................................................................................................................................491 19.2 Case Studies................................................................................................................................................492 19.2.1 Case 1.................................................................................................................................................................... 492 19.2.2 Case 2.................................................................................................................................................................... 500 19.3 Key Points: Major or Mild Frontotemporal Neurocognitive Disorder.....................................505 19.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................506 References............................................................................................................................................................ 507 20

Major or Mild Neurocognitive Disorders with Lewy Bodies...................................511 Poh Choo How and Glen L. Xiong

20.1 Background.................................................................................................................................................512 20.1.1 Definition.............................................................................................................................................................512 20.1.2 Differential Diagnosis......................................................................................................................................513 20.1.3 Epidemiology.....................................................................................................................................................515 20.1.4 Etiology.................................................................................................................................................................515 20.1.5 Clinical Description...........................................................................................................................................515 20.1.6 Diagnostic Evaluation......................................................................................................................................517 20.1.7 Treatment.............................................................................................................................................................519 20.2 Case Studies................................................................................................................................................521 20.2.1 Case 1.................................................................................................................................................................... 521 20.2.2 Case 2.................................................................................................................................................................... 522 20.3 Key Points: Major or Mild Neurocognitive Disorder with Lewy Bodies..................................524 20.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................524 References............................................................................................................................................................ 525 21

Major or Mild Vascular Neurocognitive Disorder..........................................................527 Adrian I. Espiritu, Kishana Balakrishnar, Manoosh Moradizadeh, Nicole E. Marlatt, and Amer M. Burhan

21.1 Background.................................................................................................................................................528 21.1.1 Definition.............................................................................................................................................................528 21.1.2 Epidemiology.....................................................................................................................................................531 21.1.3 Etiology.................................................................................................................................................................531 21.1.4 Clinical Description...........................................................................................................................................534 21.1.5 Diagnostic Evaluation......................................................................................................................................534 21.1.6 Differential Diagnosis......................................................................................................................................541 21.1.7 Treatment.............................................................................................................................................................542 21.2 Case Studies................................................................................................................................................548 21.2.1 Case 1.................................................................................................................................................................... 548

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21.2.2 Case 2.................................................................................................................................................................... 551 21.3 Key Points: Major or Mild Vascular Neurocognitive Disorder....................................................554 21.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................554 References............................................................................................................................................................ 555 22

Neuropsychiatric Symptoms of Major or Mild Neurocognitive Disorders..................................................................................................................................................561 Adrian Espiritu, Carl Frolian Leochico, Calvin H. Hirsch, Nicole E. Marlatt, and Amer M. Burhan

22.1 Background.................................................................................................................................................562 22.1.1 Introduction........................................................................................................................................................562 22.1.2 Definitions...........................................................................................................................................................562 22.1.3 Epidemiology.....................................................................................................................................................564 22.1.4 Etiology and Mechanism................................................................................................................................568 22.1.5 Clinical Description...........................................................................................................................................570 22.1.6 Treatment.............................................................................................................................................................571 22.2 Case Studies................................................................................................................................................582 22.2.1 Case 1.................................................................................................................................................................... 582 22.2.2 Case 2.................................................................................................................................................................... 586 22.3 Key Points: Neuropsychiatric Symptoms of Major or Mild Neurocognitive Disorders............................................................................................................589 22.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................590 References............................................................................................................................................................ 591 23

Neuropsychiatric Manifestations of Systemic Medical Conditions...................599 Mariam Abdurrahman

23.1 Background.................................................................................................................................................600 23.1.1 Definition.............................................................................................................................................................600 23.1.2 Epidemiology.....................................................................................................................................................600 23.1.3 Approach to Neuropsychiatric Presentations.........................................................................................609 23.2 Case Studies................................................................................................................................................610 23.2.1 Case 1.................................................................................................................................................................... 610 23.2.2 Case 2.................................................................................................................................................................... 613 23.3 Key Points: Neuropsychiatric Manifestations of Systemic Medical Conditions...................616 23.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................617 References............................................................................................................................................................ 618 24

Sleep-Wake Disorders......................................................................................................................621 Zahida Meghji, Ana Hategan, Melina Maclean, and Akua ­Amoako-­Tuffour

24.1 Background.................................................................................................................................................622 24.1.1 Definition and Diagnostic Criteria..............................................................................................................622 24.1.2 Epidemiology of Sleep Disorders in Older Adults.................................................................................623 24.1.3 Age-Related Sleep Changes..........................................................................................................................624 24.1.4 Disorders Contributing to Poor Sleep........................................................................................................625 24.2 Case Studies................................................................................................................................................634 24.2.1 Case 1.................................................................................................................................................................... 634 24.2.2 Case 2.................................................................................................................................................................... 638 24.3 Key Points: Sleep-Wake Disorders.......................................................................................................642 24.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................642 References............................................................................................................................................................ 646 25

Personality Disorders.......................................................................................................................649 Caroline Giroux and W. Edwin Smith

25.1 Background.................................................................................................................................................650 25.1.1 Generalities and Definitions..........................................................................................................................650 25.1.2 Adult Development: Attachment, Mentalization, and Individuation............................................652

XXIII Contents

25.1.3 Epidemiology.....................................................................................................................................................653 25.1.4 Etiology.................................................................................................................................................................654 25.1.5 Phenomenology................................................................................................................................................655 25.1.6 Treatment Approaches...................................................................................................................................660 25.1.7 Special Considerations....................................................................................................................................663 25.2 Case Studies................................................................................................................................................663 25.2.1 Case 1.................................................................................................................................................................... 663 25.2.2 Case 2.................................................................................................................................................................... 668 25.3 Key Points: Personality Disorders........................................................................................................671 25.4 Comprehension Multiple Choice Questions (MCQ) Test and Answers....................................671 References............................................................................................................................................................ 673

III 26

Special Topics in Old Age Consultation-Liaison Psychiatry...............................................................................................677 James A. Bourgeois and Caroline Giroux

26.1 Background.................................................................................................................................................678 26.1.1 Definition of Consultation-Liaison Psychiatry........................................................................................678 26.1.2 Clinical Practice in Consultation-­Liaison Psychiatry.............................................................................678 26.1.3 Consultation-Liaison Psychiatry in Geriatric Patients..........................................................................681 26.2 Case Studies................................................................................................................................................684 26.2.1 Case 1.................................................................................................................................................................... 684 26.2.2 Case 2.................................................................................................................................................................... 687 26.3 Key Points: Consultation-Liaison Psychiatry....................................................................................689 26.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................690 26.4.1 For the Following MCQs, Consider the Patient in Case 1 Presentation..........................................690 26.4.2 For the Following MCQs, Consider the Patient in Case 2 Presentation..........................................691 26.4.3 Additional Comprehension Multiple Choice Questions.....................................................................691 References............................................................................................................................................................ 692 27

Aging with Intellectual and Developmental Disabilities.........................................695 Kerry Boyd and Veronique Baril

27.1 Background.................................................................................................................................................696 27.1.1 Intellectual and Developmental Disabilities...........................................................................................696 27.1.2 Aging Issues........................................................................................................................................................699 27.1.3 Etiology and Comorbidities...........................................................................................................................700 27.1.4 Communicate CARE and HELP.....................................................................................................................701 27.2 Case Studies................................................................................................................................................704 27.2.1 Case 1: Merle.......................................................................................................................................................704 27.2.2 Case 2: Leonard..................................................................................................................................................708 27.3 Key Points: Aging with Intellectual and Developmental Disabilities......................................712 27.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................713 27.5 Additional Resources...............................................................................................................................714 References............................................................................................................................................................ 714 28

Psychiatric Emergencies.................................................................................................................717 Timothy E. Lau, Sarah Russell, Elizabeth Kozyra, and Sophiya Benjamin

28.1 Background.................................................................................................................................................718 28.1.1 Introduction........................................................................................................................................................718 28.1.2 Confusion.............................................................................................................................................................718 28.1.3 Suicidality.............................................................................................................................................................723 28.1.4 Aggression...........................................................................................................................................................727 28.1.5 Abuse of Older Adults Including Neglect.................................................................................................727 28.1.6 Adverse Medication Side Effects.................................................................................................................729

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Contents

28.2 Case Studies................................................................................................................................................735 28.2.1 Case 1.................................................................................................................................................................... 735 28.2.2 Case 2.................................................................................................................................................................... 737 28.3 Key Points: Psychiatric Emergencies...................................................................................................739 28.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................739 References............................................................................................................................................................ 740 29

Geriatric Forensic Psychiatry: Risk Assessment and Management...................743 Joseph C. Ferencz, Gary A. Chaimowitz, and Caroline Giroux

29.1 Background.................................................................................................................................................744 29.1.1 What Is Forensic Psychiatry?.........................................................................................................................744 29.1.2 Evaluating the Geriatric Offender...............................................................................................................745 29.1.3 Risk Assessment.................................................................................................................................................748 29.2 Case Studies................................................................................................................................................751 29.2.1 Case 1.................................................................................................................................................................... 751 29.2.2 Case 2.................................................................................................................................................................... 752 29.3 Key Points: Geriatric Forensic Psychiatry: Risk Assessment and Management...................754 29.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................754 References............................................................................................................................................................ 755 30

Sexuality and Sexual Dysfunction...........................................................................................757 Daniel L. Ambrosini, Rosemary Chackery, and Ana Hategan

30.1 Background.................................................................................................................................................758 30.1.1 Sexual Functioning and Sexual Rights......................................................................................................758 30.1.2 Epidemiology.....................................................................................................................................................759 30.1.3 Diagnostic Evaluation......................................................................................................................................759 30.1.4 Sexual Expression in Later Life.....................................................................................................................762 30.1.5 Legal and Ethical Issues..................................................................................................................................765 30.2 Case Studies................................................................................................................................................768 30.2.1 Case 1.................................................................................................................................................................... 768 30.2.2 Case 2.................................................................................................................................................................... 769 30.3 Key Points: Sexuality and Sexual Dysfunction................................................................................771 30.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................771 References............................................................................................................................................................ 772 31

 alliative Care for Geriatric Psychiatric Patients with P Life-­Limiting Illness...........................................................................................................................773 Margaret W. Leung, Eilann C. Santo, Lawrence E. Kaplan, and James A. Bourgeois

31.1 Background.................................................................................................................................................774 31.1.1 Description of Palliative Care........................................................................................................................774 31.1.2 Establishing Goals of Care with Advance Care Planning....................................................................774 31.1.3 Major Neurocognitive Disorder as a Terminal Diagnosis....................................................................775 31.1.4 Delirium in the Palliative Care Setting.......................................................................................................777 31.1.5 Depressive Disorders in the Palliative Care Setting..............................................................................779 31.1.6 Anxiety Disorders in the Palliative Care Setting.....................................................................................783 31.1.7 Substance Use Disorders in the Palliative Care Setting.......................................................................784 31.1.8 Off-Label Use of Psychiatric Medications in Palliative Care Setting................................................786 31.1.9 Medical Aid in Dying........................................................................................................................................787 31.2 Case Studies................................................................................................................................................790 31.2.1 Case 1.................................................................................................................................................................... 790 31.2.2 Case 2.................................................................................................................................................................... 791 31.3 Key Points: Palliative Care for Geriatric Psychiatric Patients with Life-Limiting Illness..................................................................................................................................794 31.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................794 References............................................................................................................................................................ 795

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32

Caregiver Interventions in Geriatric Psychiatry.............................................................801 Kurtis S. Kaminishi, Susie Morris, Renee Garcia, Reza Safavi, and Calvin H. Hirsch

32.1 Background.................................................................................................................................................802 32.1.1 Definition.............................................................................................................................................................802 32.1.2 Epidemiology.....................................................................................................................................................802 32.1.3 Etiology.................................................................................................................................................................802 32.1.4 Clinical Presentation........................................................................................................................................802 32.1.5 Diagnostic Evaluation......................................................................................................................................805 32.1.6 Interventions......................................................................................................................................................807 32.2 Case Studies................................................................................................................................................811 32.2.1 Case 1.................................................................................................................................................................... 811 32.2.2 Case 2.................................................................................................................................................................... 814 32.3 Key Points: Caregiver Interventions in Geriatric Psychiatry.......................................................819 32.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................819 References............................................................................................................................................................ 820 33

Public Health Perspectives on Aging in Displacement..............................................823 Mariam Abdurrahman and Ana Hategan

33.1 Background.................................................................................................................................................824 33.1.1 Public Health Perspectives on the Aging Population..........................................................................824 33.1.2 Displacement and the Associated Burden on Mental Health...........................................................826 33.1.3 Globalization at the Local Level: Resettlement and Culturally Informed Care...........................828 33.2 Case Studies................................................................................................................................................829 33.2.1 Case 1.................................................................................................................................................................... 829 33.2.2 Case 2.................................................................................................................................................................... 831 33.3 Key Points: Public Health Perspectives on Aging in Displacement..........................................834 33.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................834 References............................................................................................................................................................ 835 34

Climate Change and the Health of Older Adults............................................................837 Anna C. Gunz, Emma Gregory, Jennifer Do, Mark A. Cachia, Myles Sergeant, and Ana Hategan

34.1 Background: What Is Planetary Health?............................................................................................838 34.2 Exploring Planetary Health and Impact on Healthcare...............................................................838 34.2.1 Defining the Climate Crisis and Healthcare Impacts............................................................................838 34.2.2 Health and Social Inequity.............................................................................................................................838 34.2.3 Health Impacts of Climate Change for Geriatric Populations...........................................................839 34.3 Practical Interventions in Psychiatric Education and Practice...................................................843 34.3.1 In the Exam Room.............................................................................................................................................843 34.3.2 In the Workplace................................................................................................................................................848 34.3.3 Promoting Planetary Health Using a Systems Approach...................................................................850 34.4 Case Study...................................................................................................................................................852 34.4.1 Case History........................................................................................................................................................852 34.4.2 Case Questions and Answers........................................................................................................................852 34.5 Key Points: Climate Change and the Health of Older Adults......................................................855 34.6 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................856 References............................................................................................................................................................ 858 35

Equity, Diversity, and Inclusion in the Care of Older Adults..................................861 Albina Veltman and Tara La Rose

35.1 Background.................................................................................................................................................862 35.1.1 Anti-oppressive Practice.................................................................................................................................862 35.1.2 Culture...................................................................................................................................................................864 35.1.3 LGBTQ+ Communities.....................................................................................................................................865

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Contents

35.1.4 Racialized and Immigrant Communities..................................................................................................867 35.1.5 People with Intellectual/Developmental Disabilities..........................................................................869 35.1.6 Homeless Populations.....................................................................................................................................870 35.2 Case Studies................................................................................................................................................872 35.2.1 Case 1.................................................................................................................................................................... 872 35.2.2 Case 2.................................................................................................................................................................... 873 35.3 Key Points: Equity, Diversity, and Inclusion in the Care of Older Adults................................875 35.4 Comprehension Multiple Choice Question (MCQ) Test and Answers......................................875 References............................................................................................................................................................ 876 36

Virtual Care Delivery: Opportunities, Models, and Outcomes.............................879 Melanie T. Gentry, Shilpa Srinivasan, Terry Rabinowitz, and Donald M. Hilty

36.1 Background.................................................................................................................................................880 36.1.1 Definition and Healthcare Context.............................................................................................................880 36.1.2 Epidemiology.....................................................................................................................................................880 36.1.3 Virtual Care Evolution......................................................................................................................................880 36.1.4 Objectives............................................................................................................................................................880 36.2 Case................................................................................................................................................................881 36.2.1 Presentation........................................................................................................................................................881 36.2.2 Case Analysis.......................................................................................................................................................881 36.3 Telepsychiatry Evidence Base for Geriatric Medical and Psychiatric Populations..............881 36.3.1 Evaluation of Geriatric Telepsychiatry: Synchronous Audio/Visual Visits.....................................881 36.3.2 Patient Evaluation by Video...........................................................................................................................882 36.3.3 Types of Geriatric Telepsychiatry Interventions and Settings...........................................................882 36.4 Telepsychiatry Models: Pros and Cons...............................................................................................889 36.4.1 Introduction to Models...................................................................................................................................889 36.4.2 Studies of Older Adults and Technology..................................................................................................890 36.4.3 Health Equity in Telepsychiatry....................................................................................................................890 36.5 How to Employ Telepsychiatry: Basic Information, Implementation, and Training...........891 36.5.1 Basic Considerations........................................................................................................................................891 36.5.2 The Telepsychiatry Interview........................................................................................................................891 36.5.3 Implementation Intangibles.........................................................................................................................891 36.5.4 Training for Clinicians......................................................................................................................................892 36.5.5 Skills and Competencies.................................................................................................................................893 36.6 Key Points: Virtual Care Delivery: Opportunities, Models, and Outcomes............................893 References............................................................................................................................................................ 894 37

Systems of Care: Contemporary Clinical Care Models in Geriatric Psychiatry...........................................................................................................................897 Sandy Ngo Moubarek and Lorin Scher

37.1 Background and Rationale.....................................................................................................................898 37.2 Integrating Behavioral Health Care Model Within a Health Care System..............................900 37.2.1 Development of Integrated Behavioral Health (IBH) Services at the University of California, Davis Health System.........................................................................................900 37.3 Case Studies................................................................................................................................................901 37.3.1 Case 1 (Case Management/Embedded Psychiatric Consultation)..................................................901 37.3.2 Case 2 (Case Management/E-Consult Case)............................................................................................902 37.4 Implementation and Workforce Development...............................................................................903 37.5 Key Points: Systems of Care: Contemporary Clinical Care Models in Geriatric Psychiatry..............................................................................................................905 References............................................................................................................................................................ 905

Index ......................................................................................................................................................................... 909

XXVII

Contributors Mariam  Abdurrahman, MD, MSc, FRCPC  Department of Psychiatry, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada Department of Psychiatry, Unity Health Toronto—St. Joseph’s Health Centre, Toronto, ON, Canada Daniel L. Ambrosini, LLB/BCL, MSc, PhD  Department of Psychiatry and Behavioural Neurosciences, DeGroote School of Business, McMaster University, Hamilton, ON, Canada Akua Amoako-Tuffour, BSc (Pharm), RPh  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Udunna C. Anazodo, PhD  Medical Biophysics, Western University, Lawson Health Research Institute, London, ON, Canada Kishana Balakrishnar, HBSc (Can.)  Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada Véronique Baril, MA (Psychology)  West Niagara Psychology Centre, Beamsville, ON, Canada Kimberley M. Bender, MD  Department of Family Medicine, McMaster University, Hamilton, ON, Canada Sophiya  Benjamin, MBBS, Dip ABPN  Department of Psychiatry and Behavioral Neurosciences, McMaster University, Kitchener, ON, Canada James A. Bourgeois, OD, MD  Department of Psychiatry and Behavioral Sciences, University of California, Davis Medical Center, Sacramento, CA, USA Kerry Boyd, MD, FRCPC  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Amer  M.  Burhan, MBChB, MSc, FRCPC  Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada Psychiatry Department, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada Mark A. Cachia, MD, MPH  Public Health and Preventive Medicine Residency Program, Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada Rosemary Chackery, MD, FRCPC  Department of Inpatient Psychiatry, Royal Victoria Regional Health Centre, Barrie, ON, Canada Puja Chadha, MD  Department of Psychiatry and Behavioral Sciences, University of California, Davis Medical Center, Sacramento, CA, USA Gary A. Chaimowitz, MB, ChB, FRCPC  Division of Forensic Psychiatry, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Tracy Cheng, BSc, MD  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada

XXVIII

Contributors

Jeffrey DeVido, MTS, MD  Department of Health and Human Services, Behavioral Health and Recovery Services, Marin County, CA, USA Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA Jennifer Do, BSc (Pharm), RPh  Medication Information, Quality, and Safety (MedIQS), Pharmacy Department, Sunnybrook Health Sciences Centre, Toronto, ON, Canada Milena Rogan Ducic, MD  Department of Psychiatry, Queen’s University, Kingston, ON, Canada Adrian I. Espiritu, MD  Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada Division of Neurology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila, Philippines Joseph C. Ferencz, MD, PhD, FRCP  Division of Forensic Psychiatry, Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, McMaster University, Hamilton, ON, Canada Deborah Francis, RN, MSN, GCNS (Ret.)  Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA Renee Garcia, MD  Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA Melanie T. Gentry, MD  Mayo Clinic, Rochester, MN, USA Caroline Giroux, MD  Department of Psychiatry and Behavioral Sciences, University of California, Davis Medical Center, Sacramento, CA, USA Emma Gregory, MD, FRCPC  Department of Psychiatry, University of Toronto, Toronto, ON, Canada Anna  C.  Gunz, MD  Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada Children’s Health Research Institute, London, ON, Canada Children’s Environmental Health Clinic Ontario, Children’s Hospital—London Health Sciences Center, London, ON, Canada Ana  Hategan, MD, FRCPC  Division of Geriatric Psychiatry, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Donald M. Hilty, MD  Department of Psychiatry and Behavioral Sciences, University of California, Davis Medical Center, Sacramento, CA, USA Calvin H. Hirsch, MD  Division of General Medicine, University of California, Davis Medical Center, Sacramento, CA, USA Briana Howarth, MD, FRCPC  Geriatric and Consultation Liaison Psychiatry, Halton Healthcare, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada

XXIX Contributors

Poh Choo How, MD, PhD  Department of Psychiatry and Behavioral Sciences, University of California, Davis Medical Center, Sacramento, CA, USA Kurtis  S.  Kaminishi, MD, MBA  Department of Psychiatry, San Francisco Veterans Affairs, University of California at San Francisco, San Francisco, CA, USA Lawrence E. Kaplan, DO  Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA Jelena P. King, PhD  Department of Psychology, St. Joseph’s Healthcare, Hamilton, ON, Canada Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Elizabeth  Kozyra, BSc (Hons), BSc (Pharm), PharmD  Pharmacy Department, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada Matthew Kuo, MD, HBSc (Can.)  Department of Psychology, University of Toronto Scarborough, Toronto, ON, Canada Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada Tara La Rose, BSW, MSW, PhD  School of Social Work, McMaster University, Hamilton, ON, Canada Timothy E. Lau, MD, MSc, FRCPC  Division of Geriatric Psychiatry, Department of Psychiatry, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada Carole  Lazaro, MBBS, FRCPC  Division of Geriatric Psychiatry, Department of Psychiatry, Royal Ottawa Mental Health Centre, Ottawa, ON, USA Carl Froilan D. Leochico, MD  Psychiatry Department, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada Department of Rehabilitation Medicine, Philippine General Hospital, University of the Philippines, Manila, Philippines Department of Physical Medicine and Rehabilitation, St. Luke’s Medical Center, Quezon City, Philippines Margaret  W.  Leung, MD, MPH  Department of Supportive Care Services, The Permanente Medical Group, Kaiser Permanente, Roseville, CA, USA Melina Maclean, MD  Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada Shyam  Maharaj, BSc, RPh, PhD  Department of Medicine, McMaster University, Hamilton, ON, Canada Nicole  E.  Marlatt, PhD, HBSc  Department of Psychiatry, St. Joseph’s Health Care London, Parkwood Institute, London, ON, Canada Lisa  A.  McMurray, MD, FRCPC  Department of Geriatric Psychiatry, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada

XXX

Contributors

Heather E. McNeely, PhD, CPsych  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Zahida Meghji, MD, MSc, BSc, FRCPC  Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada Manoosh Moradizadeh, MD  Department of Geriatric Psychiatry, Parkwood Institute-­Mental Health, London, ON, Canada Susie Morris, MD, MA  Riverside University Health System, Moreno Valley, CA, USA Sandy Ngo Moubarek  Department of Psychiatry and Behavioral Sciences, University of California, Davis Medical Center, Sacramento, CA, USA Terry  Rabinowitz, MD, DDS  Telemedicine, Department of Psychiatry and Family Medicine, University of Vermont College of Medicine, Burlington, VT, USA Tea Rosic, MD  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Sarah Russell, MD, FRCPC  Department of Psychiatry, The Ottawa Hospital, Ottawa, ON, Canada Reza Safavi, MD  Baylor College of Medicine, Houston, TX, USA Zainab  Samaan, MBChB, MSc, PhD, MRCPsych  Department of Psychiatry and Behavioural Neurosciences, McMaster University and St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada Nitika  Sanger, HBSc  Medical Science Graduate Program, McMaster University, Hamilton, ON, Canada Eilann C. Santo, MD, MPH  Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute and Brigham and Women’s Hospital, Boston, MA, USA Karen Saperson, MBChB, FRCPC  Department of Psychiatry and Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada Sachin Sarin, MSc, MD  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Lorin Scher, MD  Department of Psychiatry and Behavioral Sciences, University of California, Davis Medical Center, Sacramento, CA, USA Andrés F. Sciolla, MD  Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento, CA, USA Myles  Sergeant, P.Eng., MD, FCFP  Department of Family Medicine, McMaster University, Hamilton, ON, Canada Claire Slavin-Stewart, MD  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada W.  Edwin  Smith, MD, FRCPC  Department of Psychiatry, Saint John Regional Hospital, Dalhousie University, Memorial University, Saint John, NB, Canada

XXXI Contributors

Niharika Soni, MCISc  Western University, London, ON, Canada Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada Jean-Paul  Soucy, MD, MSc  PET Unit, McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada Shilpa  Srinivasan, MD  Prisma Health-University of South Carolina School of Medicine, Columbia, SC, USA Shannon Suo, MD  LifeStance Health, Inc., Sacramento, CA, USA Sara Tremblay, PhD  Royal’s Institute of Mental Health Research, Affiliated with the University of Ottawa, Ottawa, ON, Canada Albina Veltman, BSc (Hons), MD, FRCPC  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Jessica E. Waserman, MD, FRCPC  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Tricia K. W. Woo, MD, MSc, FRCPC  McMaster University, Centre for Healthy Aging, St. Peter’s Hospital, Hamilton, ON, Canada Glen L. Xiong, MD  Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento, CA, USA

1

Basic Principles in the Assessment and ­Treatment of Late-Life Neuropsychiatric ­Syndromes Contents Chapter 1

Physiology and Pathology of Aging – 3 Calvin H. Hirsch and Ana Hategan

Chapter 2 Comprehensive Geriatric Assessment – 31 Calvin H. Hirsch and Tricia K. W. Woo Chapter 3

Neuroimaging in Clinical Geriatric Psychiatry – 55 Amer M. Burhan, Niharika Soni, Matthew Kuo, Udunna C. Anazodo, and Jean-Paul Soucy

Chapter 4

Neuropsychology in Late Life – 103 Heather E. McNeely and Jelena P. King

Chapter 5 Pharmacotherapy: Safe Prescribing and Adverse Drug Events – 123 Calvin H. Hirsch, Shyam Maharaj, and James A. Bourgeois Chapter 6 Neuromodulation Therapies I: Electroconvulsive Therapy – 155 Carole Lazaro, Livsa A. McMurray, Milena Rogan Ducic, and Timothy E. Lau Chapter 7 Neuromodulation Therapies II: Repetitive Transcranial Magnetic Stimulation and Deep Brain Stimulation – 181 Lisa A. McMurray, Sara Tremblay, Carole Lazaro, and Timothy E. Lau

I

Chapter 8

Psychotherapy in Late Life – 205 Caroline Giroux and W. Edwin Smith

Chapter 9

Ethics, Mental Health Law, and Aging – 233 Daniel L. Ambrosini, Calvin H. Hirsch and Ana Hategan

3

Physiology and Pathology of Aging Calvin H. Hirsch and Ana Hategan Contents 1.1

Background – 4

1.1.1 1.1.2 1.1.3 1.1.4 1.1.5 1.1.6

1.1.11

 ormal Versus Normative Aging – 4 N Loss of Resilience – 4 Construct of Frailty – 5 Multimorbidity – 6 Telomere Length, Inflammation, and Multimorbidity – 8 Aging in Individual Organ Systems and Implications for Disease and Treatment – 9 Age-Related Changes in the Heart – 11 The Aging Lung – 13 The Aging Endocrine System – 13 Clinically Relevant Age-Associated Changes in Kidney and Liver Function – 17 Sarcopenia of Aging – 18

1.2

Case Studies – 18

1.2.1 1.2.2

 ase 1 – 18 C Case 2 – 21

1.3

Key Points: Physiology and Pathology of Aging – 24

1.4

 omprehension Multiple Choice Question C (MCQ) Test and Answers – 25

1.1.7 1.1.8 1.1.9 1.1.10

References – 26

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 A. Hategan et al. (eds.), Geriatric Psychiatry, https://doi.org/10.1007/978-3-031-47802-4_1

1

4

1.1 

Background

while preventive and disease-specific health-care attempts to push it to the right. The gap between survival free of multimorbidity and length of life (see . Fig. 1.1) represents a period of comorbidity that can diminish quality of life, result in higher health-­care costs, and lead to prolonged disability, i.e., dependence on others for activities involved in independent living. The overarching goal of preventive and disease-­specific health care is to compress this period of comorbidity while simultaneously “rectangularizing” the survival curve to resemble normal (ideal) survival. Preventing, recognizing, and correctly treating systemic medical and psychiatric conditions prevalent in old age depend on an understanding of the physiology underpinning both normal and normative aging. Understanding common physiologic pathways during the aging process can provide insight into how seemingly unrelated conditions can co-occur. For example, anxiety and depressive disorders in geriatric patients can be independently associated with the development of urinary incontinence, falls, and functional dependence [2].  

1.1.1 

Normal Versus Normative Aging

The conventional paradigm of human aging involves an ineluctable decline in function culminating in death. Ideal survival, whether it is survival free from disability, diseasefree survival, or total longevity, would be expected to depend on genetic variation within the population that tends to be expressed later in life. The ideal, or speciesspecific, survival curve (see . Fig. 1.1) shows a rectangular shape, with a narrow downward slope due to attrition from accidents and congenital disease until advanced old age, when genetically programmed longevity theoretically leads to a rapid decline in population survival that accelerates near the species-specific maximum. This ideal survival is referred to as “normal aging.” By contrast, “normative aging” is the actual survival of a population due to the interaction of environment (e.g., air pollution, infectious agents), behavioral factors (e.g., smoking, diet), and societal factors (e.g., socioeconomic status, education) at the level of the host’s genome (epigenetics) and at the macro level through interactions with individual cells and entire organs. Epidemiological and demographic research has attributed only 15–30% of longevity to heritable factors [1], but these low percentages are affected by the paucity of studies of exceptional survivors, i.e., individuals living to 100  years and beyond. Nonetheless, the gap between normal and normative aging remains large. Chronic disease arising congenitally or from host-­ environment or host-behavioral interactions pushes the curve to the left,  

Loss of Resilience

1.1.2 

Changes in structure and function occur in all organ systems during normal aging, but accelerated aging can result from behavioral and environmental stressors. For example, excess exposure to UV radiation because of tanning can prematurely age the skin, causing permanent solar damage and predisposing to skin cancer. While organ systems do not age uniformly, they all experience a decline in physiologic reserve, or resilience [3], such that stressors to homeostasis (e.g., acute or chronic

100 75 Percent survival

1

C. H. Hirsch and A. Hategan

50

Normal (ideal) aging Survival free from disability or multimorbidity

Normative aging Survival with comorbidity

25

0 Age

90

120 years

Exceptional aging

..      Fig. 1.1  Theoretical survival curves. The solid black curve represents normal or ideal aging, with mortality related largely to accidental death and trauma until the genetically determined maximum life expectancy. Some premature mortality also would be expected due to genetically determined diseases. The red curve reflects norma-

tive aging, i.e., the survival of individuals within a society due to the interaction of the host’s genome, cells, and organs with environmental and behavioral factors. The dotted line represents survival free of disability or multimorbidity. The orange area represents the interval of life spent with comorbidity

5 Physiology and Pathology of Aging

PNA

eostasis Hom

eostasis Hom

eostasis Hom

eostasis Hom

eostasis Hom

Compensated

PNA

Decompensated

e Ag

55 Weakness (defined as difficulty carrying 10 pounds [4.5 kg]) 55 Low body weight (BMI ≤ 18.5 kg/m2) Individuals meeting 3–4 of the frailty characteristics are considered frail, those with 1–2 characteristics are prefrail, and those with none of the criteria are considered robust [4]. Notably, the Fried index does not equate frailty either with multiple comorbidities (“multimorbidity”) or with disability, although in observational studies, there is considerable overlap among the three (see . Fig. 1.3) [5]. The Rockwood Frailty index is based on the age-related accumulation of comorbidities, functional impairment, clinical signs and symptoms (e.g., visual loss), specific laboratory values associated with poor outcomes, and factors such as health-care utilization, number of medications, and self-reported health. The index has been modified over time and for different usages, ranging from 70 items to under 30 [6, 7]. Both frailty models predict mortality, disability, and health-­ care utilization [5–8], and the accumulated deficits model predicts cardiovascular events [6]. Psychiatrists caring for frail seniors should recognize that frail older adults have as much as a threefold greater likelihood of developing a depressive disorder, compared to non-frail seniors [9, 10], and that frailty predicts neurocognitive decline. For example, in the Honolulu-Asia Aging Study, a 10% increase in frailty based on the deficits frailty index was associated with a 5.0-point decline on the Cognitive Abilities Screening Instrument, and both baseline and within-person changes in frailty predicted cognitive trajectories [11]. Other studies have linked physical frailty with increased risk for major or mild neurocognitive disorder due to Alzheimer disease or vascular disease [12].  

..      Fig. 1.2 The narrowing homeostatic cylinder of aging. PNA  pneumonia. As physiological resilience declines with age, stressors to normal homeostasis, such as pneumonia, become more likely to exceed the ability of the individual to compensate, resulting in generalized dysfunction that may affect more than one organ system

illness) can exceed the compensatory capacity. This loss of resilience can lead to decompensation that spreads from the affected organ to the entire organism (see . Fig.  1.2). For example, a patient with severe weakness, urinary incontinence, atrial fibrillation, and heart failure develops delirium related to acute multi-organ decompensation precipitated by an episode of pneumonia brought on by a virus that merely caused sniffles and a day or two of fever in her grandchild. That patient’s comorbidities, and, to some extent, their treatment, contributed to her decompensation.  

Teaching Point Normative aging refers to survival within a society as a result of the interactions of the individual’s genome, cells, and organ systems with environmental and behavioral factors.

6% 21%

46%

1.1.3 

27%

Construct of Frailty

Although most clinicians think that they recognize frailty when they see it, only in recent years have investigators attempted to develop systematic, valid, and reproducible definitions of frailty that provide meaningful constructs for clinical and epidemiological research. The Fried and Rockwood indices are the two most commonly used. The Fried index, modified for use in the clinical setting, is based on a phenotype consisting of four components: 55 Self-reported exhaustion (defined by difficulty walking from one room to another) 55 Low physical activity

Frailty + Disabilityy Frailty + Disability + Multimorbidity Frailty alone Frailty + Multimorbidity

..      Fig. 1.3  The overlap among frailty, disability, and comorbidity

1

6

Teaching Points

a

55 With aging, there is a loss of physiological resilience to perturbations to organ-system and organismal homeostasis, which can result in the dysfunction of organ systems unrelated to the diseased organ. Thus, for example, pneumonia can precipitate falls, urinary incontinence, and delirium. 55 Frailty can now be characterized by objective, validated indices, and objective measures of frailty have been linked to neurocognitive disorders and depression.

Percent

1

C. H. Hirsch and A. Hategan

90 80 70 60 50 40 30 20

81.5 64.9 30.4

12.4

0

30.8

17.5

45–64

65–84 Age group

≥85

% with both physical & psychiatric comorbidity % with multimobidity

1.1.4 

b 80

Multimorbidity

70

 revalence of Multimorbidity in P Older Adults Differences in the number and selection of chronic conditions used to define multimorbidity (usually ≥2 or ≥ 3 conditions) and the populations studied have resulted in a prevalence ranging from 15% to 93% [13]. Both the incidence and prevalence rise with age. Barnett et  al. selected 40 common conditions to study based on consensus about their importance from a public-health perspective [14], and collected data on the prevalence of these conditions from 1,751,841 residents drawn from 314 medical practices in Scotland in 2007. . Figure 1.4a shows their findings for adults 45 years and older. Both the percentage of individuals with multimorbidity and average number of comorbidities increased with age. The combined prevalence of psychiatric disorders with physical morbidity also rose with age, and the co-­ occurrence of psychiatric comorbidities increased with the total number of disorders (see . Fig.  1.4b).1 The prevalence of subjective memory complaints and neurocognitive impairment in older adults also rise with the number of comorbidities [15–17]. Multimorbidity in older adults has been associated with lower socioeconomic status, even in societies with a national health-­ care system and low barriers to accessing health care [14, 18].  

 

Percent

60 50 40 30 20 10 0

2

3

4

5 6 No. of comorbidities

7

≥8

% with both physical & psychiatric comorbidity

..      Fig. 1.4  Demographics of multimorbidity in Scottish primary care patients in 2007. Panel a The percentage with multimorbidity (red bars) and the percentage of individuals whose multimorbidity includes both physical and psychiatric comorbidities (blue bars). Panel b The percentage of individuals with combined physical and psychiatric comorbidity as a function of the total number of comorbidities [14]

Teaching Point

1

The authors used a standardized definition for psychiatric disorders but did not disclose the conditions included in the definition.

Multimorbidity and disability precede death, and the goal of prevention and medical therapy is to compress the duration of morbidity by moving the morbidity-­ free survival curve closer to normative survival and, in so doing, potentially moving normative survival closer to ideal, or normal, survival.

7 Physiology and Pathology of Aging

 hysiological Mechanisms Underlying P Multimorbidity and Functional Decline

and women (mean age, 77 years) with systolic heart failure [27]. Across different chronic illnesses, CRP and Research has provided varying levels of evidence to interleukin-6 (IL-6) have been independently associated explain how numerous pathways might lead to organ-­ with worse scores on a composite measure of function system changes and dysfunction. In practice, multiple (Short Physical Performance Battery), showing lower interacting pathways likely contribute to cellular aging grip strength, longer time to complete five chair stands, within organ systems. These include epigenetic effects and longer time to complete a 4-m walk [28]. In the caused by environmental and behavioral factors (e.g., Health, Aging, and Body Composition (ABC) study, smoking); dysregulation of cell proteins; genetic 2081 men and women (mean age, 74  years) were folchanges, such as telomere shortening; altered cell lowed for up to 30  months for incident self-reported communication; and attrition of stem cells. Chronic mobility limitation, defined as difficulty walking 0.25 ­ inflammation in one or more organ systems has been mile (403 m) or walking up 10 steps. Baseline laboratory associated with the development of so-called diseases of tests included CRP, IL-6, and tumor necrosis factor aging like Alzheimer disease and osteoarthritis [19]. alpha (TNF-α). For each unit increase in standard deviThrough a variety of poorly understood mechanisms, ation in CRP, IL-6, and TNF-α, there was a 19%, 20%, serious psychiatric illness may contribute to accelerated and 9% increased adjusted risk ratio, respectively, of aging and associated multimorbidity [20]. Oxidative mobility limitation. For CRP, IL-6, and TNF-α in the stress appears to be a common pathway to cellular dam- upper tertile (> 2.54 mg/L, 2.42 pg/mL, and 3.72 pg/mL, age and accelerated aging and is itself a by-product of respectively), the adjusted risk ratio increases were 33%, reactive oxygen species produced by dysfunctional mito- 65%, and 13%, respectively. The incidence of severe chondria [21] as well as by activated inflammatory cells. mobility limitation increased linearly with the number Baptista et al. evaluated oxidative stress in 280 men and of concurrent high inflammatory markers [29]. In the women (mean age, 79.9  years) divided into usual gait InCHIANTI study of aging, levels of IL-6 and IL-IRA speed of   5.77  mg/L corresponded to a 2.8-fold relative risk of frailty compared to participants with a normal CRP [25]. The association of biomarkers of inflammation with frailty persists into advanced old age (aged 85  years and over), indicating that survival beyond age 85, considered to be successful aging, is not accompanied by relative immunity to the systemic effects of chronic low-level inflammation [26]. Diminished physical performance is a core component of the frailty phenotype, so it is not surprising that chronic inflammation was linked to worse performance on the 6-min walk test in a research cohort of 60 men

Chronic inflammatory disease may lead to neuroinflammation, which has been linked to incident depression [31]. A possible pathway by which pro-inflammatory cytokines like IL-6 and TNF-α cause depressive symptoms is through the stimulation of the hypothalamic-­ pituitary-­adrenal axis, leading to increased cortisol and resulting fatigue, anorexia, weight loss, sleep disturbances, and reduced psychomotor activity. Among 2879 persons aged 70–79 years, those with a depressed mood had significantly higher levels of TNF-α, IL-6, and CRP.  Having high levels of all three biomarkers was associated with a 2.40 increased odds ratio of a depressed mood, compared to no high markers (95% CI 1.27–4.53) [32]. Depression in older adults also predicts incident disability. In the Health ABC study, older subjects were classified into three trajectories based on annual Center for Epidemiologic Studies Short Depression scale (CES-­ D10) scores: non-depressed, mildly depressed, and depressed. After adjustment for demographic and lifestyle variables and comorbidity, a clear dose-response relationship between longitudinal depression and incident disability was seen in men and women, with depressed individuals more than twice as likely to develop disability than those who were not depressed

1

8

C. H. Hirsch and A. Hategan

1 Chronic disease

Functional impairment Disability

Inflammation

Depressive symptoms Pre-Frail

Frail

AGING

..      Fig. 1.5  The complex interrelationships among aging, ­inflammation, multimorbidity, frailty, and depressive disorder

[33]. Thus, inflammation appears to contribute to disability directly as well as indirectly through its association with depressive symptoms. Future research must tease out whether depression is truly causative or an epiphenomenon of ongoing inflammation. The complex interrelationships between aging, inflammation, multimorbidity, frailty, and depression (see . Fig. 1.5) underscore the importance of multimodal interventions for age-associated depressive syndromes that target comorbid conditions in addition to the depressive disorders.  

Teaching Point A complex web of interactions has been found linking age-associated inflammation and chronic disease to depression, functional impairment, and frailty.

1.1.5 

 elomere Length, Inflammation, T and Multimorbidity

Significance of Telomeres and Aging Repeated nucleotide sequences (TTAGGG) called telomeres form a protective cap at the ends of chromosomes to prevent chromosomal shortening and loss of critical DNA during cell division. Telomeres are protected by the enzyme telomerase, but in most cells telomerase activity is insufficient to prevent loss of the integrity of telomeres, resulting in progressive shortening during the normal aging process. When the shortening reaches

a critical level, errors in DNA transcription result in cellular senescence and cytopathology, in turn contributing to cell death (apoptosis) and increased oncogenic potential [34]. Diseases of accelerated aging that are linked to inflammation, such as cardiovascular disease and type 2 diabetes mellitus, have been associated with greater telomere shortening, as have inflammatory environmental exposures like cigarette smoking. Negative risk factors for cardiovascular disease, such as higher high-density lipoprotein (HDL) and lower blood pressure, have been associated with slower telomere shortening in the longitudinal 1934–1944 Helsinki Birth Cohort Study, whereas unintentional weight loss was associated with relatively accelerated telomere shortening [35]. In meta-analysis, certain psychiatric disorders in adults have shown a robust statistical association with telomere length, including depressive disorders, posttraumatic stress disorder, and anxiety disorders [36, 37]. Persons with late-life depressive disorder have statistically shorter telomeres than their non-depressed peers [38]. The implication is that these psychiatric conditions may independently contribute to accelerated aging through telomere shortening, although establishing a causal link will require large longitudinal studies, and adjustment must be made for potential confounders like smoking. Telomere shortening has been associated with cognitive impairment, hyperphosphorylation of tau, and beta-amyloid deposits in the brain [39]. However, the longitudinal Rotterdam study found longer as well as shorter telomeres associated with the major neurocognitive disorder, Alzheimer disease, in which activated

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9 Physiology and Pathology of Aging

microglia and inflammatory cytokines are also found [40]. The association with both longer and shorter telomeres underscores the continued uncertainty over any causal role that telomere length may have in cognitive decline [41]. Whether the inflammation causes telomere shortening, whether they induce a positive feedback loop to amplify each other, or whether the two independently co-occur remains unsorted.

Teaching Point Telomeres, a protective cap of a repeated sequence of nucleotides at the end of chromosomes, shorten with age, chronic inflammation, and several common chronic diseases. Shortened telomeres have been associated with mood disorders and neurocognitive decline.

type 2 diabetes mellitus [43, 44]. In turn, white matter hyperintensities are linked not only to the risk of ischemic vascular neurocognitive disorder but also to major neurocognitive disorder due to Alzheimer disease, suggesting a relationship between small vessel ischemia and beta-amyloid formation [43]. In healthy individuals, longitudinal MRIs demonstrate the dynamic nature of white matter hyperintensities, which sometimes remain stable, occasionally regress, and often progress, depending in part upon the severity of vascular risk factors and how aggressively they are treated [45]. Functional brain imaging shows reduced brain metabolic activity with aging that is unevenly distributed within brain regions and correlates well with reductions in gray matter volume [46]. Teaching Point

1.1.6 

Gray and white matter decline in advanced old age, leading to a drop in brain volume. White matter hyperintensities accumulate in late life as part of normal aging as well as diseases associated with vascular risk. White matter hyperintensities have been associated both with vascular and Alzheimer disease-related neurocognitive disorder.

 ging in Individual Organ Systems A and Implications for Disease and Treatment

 he Aging Nervous System T Morphological and Metabolic Changes in the Brain In cross-sectional analyses, total brain volume declines in old age, with a 0.45% per year drop in whole brain volume after age 79. Gray matter tends to decline linearly with a loss of 0.11–0.18% per year. White matter declines in a nonlinear fashion [42]. White matter hyperintensities seen on T2 FLAIR MRI brain imaging are believed to reflect small vessel ischemic changes that many consider part of normal advanced aging but which also are associated with vascular risk factors like hyperlipidemia, hypertension, and

Cognitive Changes with Aging In normal aging, general skills and knowledge, procedural (motor) memory, implicit (automatic) memory, memory retention, fund of knowledge, vocabulary, attention, object perception, and the ability to perceive abstractions like similes largely tend to be preserved into advanced old age. However, problem solving, processing speed, episodic memory, rate of learning, memory retrieval, verbal fluency, three-dimensional perception, and most domains of executive functioning tend to decline (. Table 1.1) [47].  

.       Table 1.1  Cognitive changes in normal aging [47] Cognitive domain

Definition

Examples

Trajectory

Crystallized intelligence

Skills, knowledge, abilities that are well practiced and familiar Related to experience

Vocabulary, general knowledge

Stable or slight growth through seventh decade

Fluid intelligence

Problem solving and reasoning for new things

Executive function, judgment

Slow decline from third decade

Processing speed

Speed with which cognitive activities are performed

Slower performance on trails B test

Slow decline from third decade

Intelligence

Attention

(continued)

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.       Table 1.1 (continued) Cognitive domain

Definition

Examples

Trajectory

Selective attention

Ability to focus only on relevant information

Driving

Slight decline in late life

Divided attention

Ability to multitask

Drive and carry on a conversation

Slight decline in late life

Semantic memory

Fund of knowledge

Recall of US presidents after WWII

Late-life decline

Episodic memory

Memory for personally experienced events

Recall of last year’s summer vacation

Slow decline throughout life

Implicit memory

Automatic triggered recall Procedural memory (motor memory)

Recall of tune and lyrics to national anthem How to ride a bicycle, play piano, or type on a keyboard

Generally stable throughout life

Memory acquisition

Learning new things

Studying a foreign language

Rate of acquisition declines with aging

Memory retention

Successful learning

Memory retrieval

Recall

Recalling recently learned new words

Declines

Verbal fluency and vocabulary

Word generation (phonetic and semantic fluency) and lexicon

Carrying on a conversation

Stable; vocabulary may improve with aging

Visual confrontation naming

Correctly naming a previously familiar object when presented with it

Seeing a pencil and calling it “pencil”

Stable with slow decline after age 70

Verbal fluency

Spontaneous word generation within a category

Naming as many words as possible beginning in “S” in 1 min

Declines

Understanding space in two and three dimensions

Assembling a furniture kit, drawing a complex shape

Declines

Object perception

Spatial perception when driving, recognizing faces

Stable

Organize, plan, problem solve, self-monitor, mental flexibility

Planning and preparing a meal

Declines after age 70

Response inhibition

Avoiding patterned responses inappropriate for situation, e.g., connecting 1–2–3, etc. when asked to connect the first number, first letter, and so on (1-A-2-B-3-C, etc.)

Declines

Reasoning

Solving math problems

Declines

Abstractions

Appreciate similarities (train and bicycle are modes of transportation); meaning of proverbs (people in glass houses, etc.)

Stable

Memory

Preserved with aging

Language

Visuospatial abilities

Executive functioning

11 Physiology and Pathology of Aging

Teaching Point In normal aging, problem solving, processing speed, episodic memory, rate of learning, memory retrieval, three-dimensional perception, and many domains of executive functioning decline.

Changes in the Peripheral Nervous System Both antipsychotics and antidepressants have been associated with a nearly 50% increased incidence rate ratio of unexplained falls among older adults [48]. Depressive disorders in the absence of antidepressants also increases the odds ratio of falls [49], which are experienced annually by over one third of adults 65  years and older. Between 2013 and 2018, the reported incidence of falls among hospitalized older psychiatric patients averaged 7.4 per 1000 patient-days [50]. The high incidence of falls stems in part from age-related changes in the central and peripheral nervous systems that affect balance, coordination, and the speed and adequacy of motor response to avert a fall. In older persons, peripheral vibration sense declines more rapidly than touch and pain, and the sensitivity of light touch decreases. In older adults, myelinated nerve fibers conduct signals more slowly, resulting in delay of transmission of sensory information from the feet and joints to the spinal cord, contributing to loss of balance. Mechanoreceptors in the joints, including the knees, hips, and neck, may become damaged from osteoarthritic changes or lost because of joint replacement. This loss of ­peripheral sensation and proprioception substantially hampers postural control in older adults [51]. The response of the brain to postural perturbations requires motor signals to pass through the anterior horn cells of the spinal cord to the muscle. The number and diameter of motor axons in the spinal cord decline with age, as do the number of motor units (each unit representing a single motor neuron and all of its innervated muscle fibers). At the same time, the size of the motor unit increases, meaning that the remaining motor neurons innervate relatively more muscle fibers, resulting in coarser movements. Overall muscle mass declines 20–35% between the ages of 20 and 80, with a corresponding reduction in muscle strength that can be partially reversed with exercise. With aging, rapidly conducting fast-twitch (type II) muscle fibers drop out more quickly than the slower-­conducting slow-twitch (type I) fibers, further retarding the motor response to postural disequilibrium [51]. Motor deconditioning occurs more rapidly in older adults, such that a few days of bedrest from acute illness can result in a substantial decline in muscle strength and gait safety. Both psychiatric and medical hospitalization thus can accelerate loss

of strength as well as balance that is additionally threatened by the wide variety of psychotropic medications that are commonly prescribed (see also 7 Chap. 5).  

Teaching Point Age-associated changes in the peripheral nervous system affect balance, coordination, and motor responses, thereby increasing vulnerability to falls. Psychotropic medications add to this increased risk of falling.

Aging and the Perception of Pain The myelinated A∂ fibers mediate the immediate sensation of pain, whereas the unmyelinated, slower-­conducting C fibers subserve the sustained pain that may follow. The numbers of both types of pain fiber decrease with aging, resulting in a diminished ability to detect pain, but when pain is detected, there is often a reduced pain tolerance. This decreased pain tolerance in older adults is believed to derive from central sensitization, which occurs in part from brain and spinal cord mast cell activation, especially in the thalamus, along with activation of microglia, leading to the release of inflammatory cytokines and a reduction in central inhibition of pain sensitivity [52]. In chronic pain syndromes, this may lead to an earlier requirement for opioids with their associated adverse effects in older patients (see also 7 Chap. 16). Certain psychotropic medications, such as the serotonin norepinephrine reuptake inhibitors (SNRIs) and the gabapentinoids (e.g., gabapentin, pregabalin), and tricyclic antidepressants may help reduce central sensitization [53], notwithstanding their own independent association with falls [53, 54].  

Teaching Point Changes in the central and peripheral nervous systems alter the perception of pain, with decreased peripheral pain sensitivity but greater overall perceived pain once the threshold for pain has been reached. The relatively greater perceived pain (i.e., lower pain tolerance) in older adults results from central sensitization.

1.1.7 

Age-Related Changes in the Heart

Ventricular Function Aging in the absence of cardiovascular disease is accompanied by thickening of the left ventricle and delayed diastolic relaxation (diastolic dysfunction) that reduces passive filling of the ventricles and necessitates greater reliance on atrial contraction. When the contribution of

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early passive filling (E) drops below the atrial component (A), diastolic dysfunction is diagnosed and is reported as an E/A ratio 100 ms, and of these, the majority are men. Over time, individuals with a prolonged QRS duration are more likely than those without prolongation to develop heart failure [70]. Given the prevalence of asymptomatic QRS duration prolongation in seniors, drugs that block the cardiomyocyte sodium channels, especially tricyclic antidepressants, should be used cautiously, if at all. However, selective serotonin reuptake inhibitors (SSRIs) like fluoxetine and citalopram, although weaker sodium-­channel blockers, can prolong the QRS duration and lead to cardiac arrest when doses are excessive [71]. With aging, the QTc lengthens linearly between the ages of 30 and 90, with a slightly higher slope of rise in men, although the QTc is consistently higher in women [72]. Consequently, SSRIs, SNRIs, haloperidol, droperidol, and the “atypical” antipsychotics, which prolong the QTc interval to varying degrees, have the potential for precipitating torsades de pointes and ventricular tachycardia (see also 7 Chap. 5).  

1.1.8 

The Aging Lung

Without the contribution of tobacco or chronic asthma, aging by itself causes changes in pulmonary physiology, architecture, and function that can result in older patients, who are free of clinical lung disease, meeting the criteria for chronic obstructive lung disease stage 1. Emphysematous changes, marked by enlargement of alveoli without destruction of alveolar walls, as well as reduced elastic recoil lead to premature closure of the airways, causing the forced expiratory volume in 1  s (FEV1) and forced vital capacity (FVC) to decrease with age, while the closing volume (CV) increases [73]. The CV increases in the supine position and during general anesthesia. These changes translate into a higher residual volume and functional residual capacity, as seen in chronic obstructive pulmonary disease (COPD). The chest wall stiffens, adding to the work of breathing by the respiratory muscles (principally the diaphragm and intercostals). The age-related change in the proportion of type IIa muscle fibers impairs the strength and endurance of the respiratory muscles. All of these changes affect oxygen transport. The net result of age-associated changes is a greater susceptibility to respiratory failure (i.e., hypoxemia) when acute or chronic pulmonary conditions, as well as pharmaco-

logical interventions that cause sedation or interference with respiratory drive (e.g., opioids, benzodiazepines), are superimposed [74]. Thus, sedating medications should be prescribed cautiously, especially at bedtime, in patients with known lung disease. Older inpatients with lung disease should have oxygen saturation monitored, especially when asleep. Obese patients can experience obesity-related hypoventilation due to the heaviness of their chest wall and should not sleep supine. Similarly, patients with COPD or severe asthma should be encouraged to sleep with their thorax elevated >20° to minimize further increase in closing volume and to maximize the function of their diaphragms. Patients with kyphosis have the added burden of restrictive lung disease and need to sleep more upright or on their sides. Teaching Points 55 Aging itself causes structural and functional changes in the respiratory system that cause mild COPD-like changes, reduced oxygen transport and expiratory airflow, and increased vulnerability to the effects of medical and anatomical conditions that affect lung function. 55 Sedating medications, especially those that can affect respiratory drive (e.g., opioids, benzodiazepines), may affect oxygenation, especially when taken at bedtime. 55 A supine position can be harmful for patients with acute and chronic lung and thoracic disorders, such as: –– Kyphosis –– Morbid obesity –– Moderate to severe COPD –– Pneumonia –– Other conditions that affect oxygen saturation 55 Minimize bedrest for the older hospitalized patient, including: –– Encourage ambulation (supervised if fall risk or needing oxygen). –– Encourage the use of the incentive spirometer if patient is able to cooperate. –– Being up in chair as much as tolerated instead of lying in bed.

1.1.9 

The Aging Endocrine System

Thyroid Disorders This section will focus on age-related changes in the neuroendocrine system that are germane to affective and cognitive changes in older patients. Hypothyroidism is

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not part of normal aging, but it is relatively common. The prevalence of hypothyroidism, defined as a thyroid-­ stimulating hormone (TSH) above the upper limits of normal, begins to rise by age 30, reaches nearly 6% by age 60, and affects approximately 14% of persons over age 79 [75]. It is beyond dispute that severe hypothyroidism impairs cognitive function, and it is considered one of the few “reversible” forms of major or mild neurocognitive disorders. More controversial is the impact of subclinical hypothyroidism, defined as an elevated TSH with normal levels of free thyroxine (T4) and triiodothyronine (T3). Pasqualetti et  al. [76] performed a meta-­ analysis of 13 studies evaluating the effect of subclinical hypothyroidism on a composite endpoint of incident or prevalent major neurocognitive disorder (dementia), reduced MMSE, or reduced scores on intelligence tests in order to maximize statistical power. After stratifying by age (younger than 75 years, 75 years and older), they found that the younger hypothyroid patients were significantly more likely to show cognitive impairment than controls, whereas the older group did not show this effect. The reason for the age effect is unclear, but could reflect a greater prevalence of neurocognitive decline from other causes in the older age group, obscuring the effect of subclinical hypothyroidism. In meta-analysis, hypothyroidism was strongly associated with clinical depression with an odds ratio (OR) of 1.77 (95% CI 1.13–2.77). Subclinical hypothyroidism (elevated TSH but normal T4 and T3) still carried a significant but weaker association with clinical depression with an OR of 1.13 [95% CI 1.01–1.28] [77]. In a large Israeli cohort of persons 65  years and older, 3.8% had subclinical hypothyroidism and 1% had subclinical hyperthyroidism. After adjustment for comorbid conditions, the hazard ratios (HR) for death over 10 years of follow-up, compared to euthyroid controls, were 1.93 for subclinical hypothyroidism and 1.68 for subclinical hyperthyroidism [78]. The physiological basis for this increased mortality remains unclear, but supports the conclusion that subclinical thyroid ­disorders in older adults can have harmful consequences.

Teaching Point Subclinical hypothyroidism has been associated with cognitive impairment in patients under age 75, and both subclinical hypo- and hyperthyroidism are independently associated with an increased risk of mortality. More research is needed to assess the effect of treatment on cognitive outcomes. These associations should be considered in conjunction with other clinical symptoms and medical history before a decision is made to treat.

 ex Hormones, Aging, and Cognition S Estrogen Replacement Therapy in Postmenopausal Women Historically, hormone replacement therapy following menopause was viewed as protective against the development of major neurocognitive disorder based on epidemiologic and laboratory evidence. Most, but not all, case-control studies found a protective effect of supplemental estrogen, with risk reductions ranging from 40% to 60%. Animal studies reinforced the biological plausibility of a protective effect of estradiol, demonstrating facilitation of hippocampal long-term potentiation, showing neuroprotection in models of ischemia and oxidative stress, and showing reduced formation of beta-­ amyloid and the hyperphosphorylation of tau, the signature molecular events underlying Alzheimer disease-­ related neurocognitive disorder [79]. Contradicting this evidence, the landmark Women’s Health Initiative Memory Study (WHIMS) demonstrated a harmful effect of hormone replacement therapy. Among 4532 postmenopausal women with a uterus, aged 65 and older, and free from probable major neurocognitive disorder at baseline, roughly half were randomized to receive oral conjugated equine estrogen (CEE) plus medroxyprogesterone, while the other half received a placebo. During at least 4 years of follow-up, the rate of probable neurocognitive disorder, based on standardized neuropsychological testing, was 45 per 10,000 person-­ years for the hormone replacement group, compared to 22 per 10,000 person-years for the placebo group (HR 2.05, 95% CI 1.21–3.48) [80]. Similar results were found for the 2842 women without a uterus taking unopposed CEE [81]. The greater incidence of neurocognitive decline in the CEE versus placebo group became evident after 2 years and continued for the entire period of extended follow-up to 8 years in both arms of the WHIMS study [81]. Various explanations have been put forward to explain the opposing results from the randomized, controlled trials and the prior observational studies. These have included selection bias (i.e., women with healthier lifestyles might have been more likely to take hormone replacement therapy) and recall bias (i.e., women with unrecognized mild cognitive impairment might not accurately recall hormone use). In addition to WHIMS, several randomized, controlled trials of estrogen replacement therapy in women with major neurocognitive disorder due to Alzheimer disease failed to show any cognitive benefits compared to placebo [79]. An important limitation of WHIMS is that participants received oral estrogen. Randomized, controlled trials of hormone replacement therapy in postmenopausal women have shown that oral estrogen, regardless of the compounds assessed, increases serum markers of

15 Physiology and Pathology of Aging

clotting activation while decreasing antithrombotic clotting factors. In contrast, trials using transdermal estrogen have not shown clotting activation [82]. WHIMS did not differentiate between major neurocognitive disorder due to Alzheimer disease and vascular disease, and thus it remains unknown whether the increased risk of neurocognitive disorder with hormone replacement therapy results from vascular disease, due to increased clotting from the oral formulation, or from an inherent effect of estrogen on the postmenopausal brain. It is unknown whether there is a neuroprotective effect of transdermal estrogen in persons with a major neurocognitive disorder. However, 3  months of transdermal estrodiol in postmenopausal women with Alzheimer disease produced slight but statistically significant improvement in semantic memory and episodic visual memory [83]. The current recommendation is that hormone replacement therapy of any type should not be administered to women over age 65. This blanket recommendation against all hormone replacement therapy in older women because of the increased risk of neurocognitive disorder based on a clinical trial of oral hormone replacement therapy poses a conundrum for the consulting psychiatrist. It is appropriate to recommend discontinuing hormone replacement therapy in women who are being evaluated for mild or major neurocognitive disorder. If the woman is cognitively intact and taking oral hormone replacement therapy, a recommendation for discontinuation also should be made. Given the paucity of data on the long-term neurocognitive effects of transdermal estrogen, it is a matter of clinical judgment whether the potential benefits outweigh the potential risks for the individual patient.

Teaching Point Based on a large randomized, controlled trial, oral estrogen replacement therapy in postmenopausal women has been associated with a roughly twofold increased risk of neurocognitive disorder, compared to placebo. Whether this increased risk is due to the ­activation of clotting factors resulting from hepatic metabolism of the oral estrogen remains unknown. There are insufficient data regarding the risk of neurocognitive disorder in postmenopausal women taking transdermal estrogen, which does not activate clotting factors. Current guidelines recommend against any estrogen replacement therapy in women over age 65 years.

Neurocognitive Effects of Testosterone in Older Men Testosterone and Cognition Data from the Baltimore Longitudinal Study of Aging (BLSA) show that total testosterone and bioavailable testosterone (approximated by the free testosterone index, calculated as total testosterone/sex hormone binding globulin) decline steadily from the third decade onward, such that by the seventh, eighth, and ninth decades, 20%, 30%, and 50% of men, respectively, meet criteria for hypogonadism, defined as a total testosterone of