Geriatric psychiatry has come of age. For example, the guest editors of this edition of Psychiatric Annals have just finished editing the fourth edition of a standard textbook, The American Psychiatric Publishing Textbook of Geriatric Psychiatry (the first edition was published in 1989). The American Association of Geriatric Psychiatry has more than 1,500 members, and nearly this many clinicians and investigators attend their annual meeting. The International Psychogeriatric Association is a strong and vibrant multinational organization. Multiple journals publish articles specific to geriatric psychiatry, such as the American Journal of Geriatric Psychiatry, International Psychogeriatrics, the International Journal of Geriatric Psychiatry, and Aging and Mental Health. More than 1,500 psychiatrists have sat for the boards to obtain a certificate of added qualifications in geriatric psychiatry offered by the American Board of Psychiatry and Neurology.
Of more importance than these external symbols of success has been the rapid and relevant advance of the knowledge base in geriatric psychiatry. Research into understanding aging began more than 50 years ago, with a focus upon normal aging. This research provided the groundwork for a burgeoning of research into the psychopathology of late-life psychiatric disorders during the 1980s, which has continued to this day. These investigations have ranged from studies of brain pathology, which contributes to psychiatric symptoms in the elderly, to studies of psychological and social etiologies, to clinical trials of pharmacologic and nonpharmacologic interventions.
In this edition of Psychiatric Annals, we provide clinically relevant reviews of psychiatric disorders and their management in later life. Much of the focus is on depression, by far the most prevalent cause of emotional suffering among the elderly. In addition, late-life depression has been the focus of an explosion of empirical research over the past 20 years. The research of late-life depression has matured dramatically over these years, and clinicians and clinical investigators have much more fined-tuned understandings of especially biological origins. In addition, biological and psychological therapies have been refined and investigated so that the evidence base for appropriate treatment has expanded dramatically.
Dr. Blazer leads off with an article on the origins of depression. In this article, he emphasizes the biopsychosocial and even spiritual origins and how they interact within the older adult. He also emphasizes the importance of considering protective risk factors, as well as risk factors, especially among psychological and social variables. Drs. Carolina Aponte Urdaneta and Mugdha Thakur follow with a discussion of the treatment of depression in the nursing home. Treating any psychiatric disorder within the constraints of long-term care is a challenge. In addition, psychiatrists do not have the luxury, nor do other specialists, to spend long hours diagnosing and designing therapies for institutionalized older adults. Even so, there is much that can be accomplished by a competent psychiatrist in the nursing home setting.
Next, Drs. Ellen Walker and David Steffens provide a comprehensive overview of the association of geriatric depression and cognitive changes. No finding over the past 20 years has been more important to the understanding of late-life depression than the recognition that many depressed elders also experience cognitive impairment and exhibit vascular lesions in the subcortical regions of the brain. The diagnosis of “vascular depression” vies for inclusion in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), along with a special recognition of the unique characteristics of depression in Alzheimer’s disease.
Dr. Harold Goforth follows with a discussion of pain and pain management in the elderly. Pain and its association with late-life psychiatric disorders is a vastly understudied topic among clinical investigators. Nevertheless, any psychiatrist working with older adults is acutely aware of how chronic pain can complicate the management of depression, anxiety, and other psychiatric disorders. Getting the pain under control is perhaps the first task in managing the underlying psychiatric problem. In addition, psychiatrists should be concerned about physical pain as a symptom worthy of their attention, regardless of its comorbidities.
Finally, Dr. Barbara Kamholz reviews the empirical data relevant to the diagnosis and management of delirium in the elderly. Delirium is a frequent condition among hospitalized older adults, especially those postsurgery and those residing in intensive care units. However, delirium is often overlooked, especially so-called “hypoactive delirium.” When the symptoms are recognized, many clinicians are at a loss as to what steps to take in the management of delirium. Geriatric psychiatrists play a key role in the diagnosis and management of delirium.
We have, of course, omitted many conditions of importance to the mental health of older adults. These include behavioral problems among elders experiencing dementing disorders, psychoses in late life (such as late-onset schizophrenic disorders), anxiety disorders and panic, somatiform disorders, and sleep disorders. However, the articles we present to you should provide a useful overview of this most important psychiatric subspecialty, which will have ever increasing relevance as our population ages and as the care of older people moves center stage through discussions of the future of Medicare, Medicaid, and healthcare reform. Psychiatrists have gained much knowledge and many tools to effectively and efficiently treat older adults — knowledge and tools that should serve elders well, and we are learning more every day.