InternatwnalPsychogeriatrics, Vol.4, No.1.1992 63 1992 Springer Publishing Company

Interntdonal Psychogeriatric Developments

Geriatric Psychopathology: An American Perspective on a Selected Agenda for Research F. M. Baker, Barry D. Lebowitz, Ira R. Katz, and Harold Alan Pincus ABSTRACT.The authors present an overview of research questionsrelated to psychopathology in elderly patients. Specificresearch questionsin the areasof organic mental disorders, affectivedisorders, personality disorders, anxiety disorders, psychotic disorders, and substance abuse are presented. Clinical investigators are encouraged to pursue some of these specific questions in order to facilitate diagnosis and to develop specific effective treatment strategies for psychopathology in older patients.

INTRODUCTION The 1990s will bring an expanded focus upon psychopathology in older persons. Several factors contribute to this. The first is the aging of the United States population. Thirteen percent of the U.S. population will be age 65 or older in 2010 (American Association of Retired Persons, 1988). Today the fastest growing segment of the U.S.population is the “old-old,”persons age 80 and older (National Center for Health Statistics, 1986). A second factor contributing to the expanded focus is the increasing number of psychiatrists specifically addressing the care of the older patient. The American Association for Geriatric Psychiatry (AAGP) is an organization comprised exclusively of geriatric psychiatrists. Currently, its membership is over 1200. A third factor is the ever expanding data based on the evaluation, diagnosis, and treatment of psychiatric symptoms and psychiatric disorders in older persons. Geriatric psychiatric research, as well as the increasing number of textbooks and journals on the topic, has resulted in formal recognition From the Department of Psychiatry, University of Maryland, Baltknore, Maryland, U.S.A. (F. M. Baker, MD, MPH); Mental Disorders of the Aging Research Branch, National Institute of Mental Health, Rockville, Maryland, U.S.A. (B. D. Lebowitz, PhD); the Division of Geriatric Psychiatry. Medical College of Pennsylvar~ia,Philadelphia, PA, U.S.A. ( I R.. Katz,MD, F%D); and the Wice of Research, American Psychiatric Association, Washington, DC,U.S.A. (H. A. Pincus, MD). 141

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of the field of geriatric psychiatry. The successful application by the American Board of Psychiatry and Neurology to the American Board of Medical Specialties has resulted in the approval of a special examination for Added Qualifications in Geriatric Psychiatry. The first examination was given on April 2,1991. There are many examples of important research directions in geriatric psychiatry. Using the best of contemporary approaches in molecular genetics, St. GeorgeHyslop and colleagues (1987) identified an area of chromosome 21 that could hold the genetic key to the familial form of Alzheimer’s disease. Using monoclonal antibody approaches, Davies and associates (Wolozin et al., 1986) succeeded in identifying an antigen that Seems to be a marker with significant specificity for the cellular pathology of Alzheimer’s disease, a finding that could prove to be of considerable value in enhancing the early diagnosis of this disease. While the treatment for the core cognitive symptoms of Alzheimer’s disease remains elusive, many investigators have turned their attention to the management of associated symptoms of depression (Reifler et al., 1989), agitation (Salzman, 1988), and psychosis (Devanand et al., in press) in the demented patient. Such studies may result in strategies for patient management that could well improve both community and institutional care of Alzheimer’s disease patients. A significant aspect of this care is the stress that it places on the family responsible for providing support to the patient. Brody (1989) has highlighted the guilt, demoralization, and depression associated with the burden of caring for the Alzheimer patient. Kiecolt-Glaser (1989) and Blaser (1989) have demonstrated that caregivers of Alzheimer’s disease patients have suppressed immune function on a variety of dimensions (e.g., percentages of total T lymphocytes and helper T cells). A recent NIMH publication edited by Light and Lebowitz summarized the issues involved with caregiving(1989) and reported that 50%of caregiversdevelop a major depressive disorder. In addition to psychiatric disorders, psychiatric symptoms are seen in caregivers as well as in Alzheimer patients. Increasingly,researchersin the field of geriatricpsychiatryhave emphasizedthe importanceof separatingthe olderpopulation intodifferent categories;the “young” old, the “middle” old, and the “old-old” (the frail elderly) .If research studies have included older persons, too often all persons age 60 and older have been combined into only one category. Usually numbers were too small to divide the age groups even into the categories of “young-old” and “frail-elderly,” for example. This remains an ongoing concern in research studies. Data are insufficient regarding specific presentations of psychiatric disorders in the “old-old” to optimally enhance the development of DSM-IV for all diagnostic categories. The age of onset has been shown to be a significantconcern in schizophrenia(Jeste et al., 1988) and in depressive disorder (Meyers & Alexopoulos, 1983). Now investigations are focused upon delineating the impact of a variable age of onset on the clinical presentation, the course of disease, and the outcome of treatment. Research on acute treatment of depression in older patients has shown that treatment response to medications (Georgotas et al., 1986) and psychotherapy (Gallagher & Thompson,, 1988) is substantial. Naturalistic follow-up has shown

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high rates of relapse and recurrence (Murphy, 1983),but the time period in which relapse occurs varies (Myers & Alexopoulos, 1988). Research is now under way to establish protocols for continuation and maintenance treatment of elders. In sum, developments in the basic sciences and clinical investigations in geriatric psychiatry are providing a firm base for treatment and prevention, for educational programs, and for further research. Investigators are using the best of contemporary approaches to address questions concerning the onset, course, and outcome of disease; the interaction of disease with normal age-associatedchanges in adult development; the impact of comorbidity of acute or chronic conditions (Ancoli-Israelet al. 1985;Fisher, 1968;Gurland &Toner, in press; Robinson et al, 1986); and the significance of age of onset for the disorder. This rich body of science has developed a significant momentum with an ever accelerating pace of achievement (Table 1). With this background we present a review of recent work and specific directions for research in six areas of psychopathology: organic mental disorders, affective disorders, personality disorders, anxiety disorders, psychotic disorders, and substance abuse.

DIRECTIONS FOR RESEARCH Organic Mental Disorders Several internationalstudies have detailed the prevalence of Primary Degenerative Dementia of the Alzheimer’s Type (PDDAT) and Multi-Infarct Dementia (MID) (Kay et al. , 1964; Akesson, 1969; Mortimer et al. , 1981; Karasawa et al., 1983; Rocca et al., 1986).Recent studies in community samples in the United Stateshave shownsimilarpattemsofprevalence(Schoenberget al., 1985;Folsteinet al., 1985) and, in one city, an unchanged incidence rate over 15years (Kokmen et al., 1988). One study detailed psychiatricsymptomsduringthe course of PDDAT in a six-year incidence sample (Baker et al., in press). Although the etiology of this progressive deterioration in cognitive functioning remains unclear, recent studies have linked a locus on chromosome 21 with certain familial cases of PDDAT, early onset dementing illness (St. George-Hyslop, 1987). But much remains unknown about cognitive functioning in older persons. A recent study by Matsuyama and Jarvik (1989) suggested a dysfunction in microtubular structure as an etiology of the deterioration in brain architecture. Mild cognitive impairmentwas studied by a work group sponsoredby the Mental Disorders of the Aging Research Branch (MDARB) of the National Institute of Mental Health (NIMH). The term Age-Associated Memory Impairment (AAMI) was used to define the complaint of memory problems without a change in performance, but with documentable changes on neuropsychological testing (Yesavage, 1984; Crook et al., 1986). A series of research questions emerges (Table 2). Although mild cognitive impairment and its course have important implications for public health planning, an understanding of the aging brain is of equal urgency

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(Cohen, 1988). Peripheral neuronal regeneration can occur, but the various cell types of the central nervous system do not regenerate if completely destroyed. Dendritic arborization does occur, and adjacent vascular networks can maintain partial blood flow to an area of ischemia or infarction;however,the central nervous system lacks the regenerative capacity of hepatocytes. Several specific research questions are suggested (Table 3). The complexity of cerebral function is acknowledged (U.S. Department of Health and Human Services, 1989). The progressive development of imaging techniques now makes the noninvasive study of the functioning brain possible. Coupled with the neuropsychological testing and neurochemical techniques, clarification of the changing cerebral functionduring the courseof specificmedical and neuropsychiatric illnesses superimposed upon normal aging can be accomplished. Such information could lead to specific interventions based upon the staging of particular cerebral functional changes characteristic of aging andlor characteristic of aging and superimposed disease states. Currently, behavioral TABLE 1. Mental Disorders in the Elderly Severe dementias (1) Milder dementias Major depression (2) Mixed depression anxiety Dysthymia Symptomatic depression Mild Dysphoria Simple phobia (3) Social phobia Agoraphobia Panic disorder Obsessive-compulsive disorder Generalized anxiety syndrome Schizophrenia (4) Sleep apnea syndromes (5) Nocturnal myoclonus Both Delirium (as a % of elderly medical patients) (6) Suicide (as a % of all deaths by suicide) (7) Alcohol abuse (8)

4.7% 5.8% 1% 1%

2% 4% 19% 10% 1%

5%

Geriatric psychopathology: an American perspective on a selected agenda for research.

The authors present an overview of research questions related to psychopathology in elderly patients. Specific research questions in the areas of orga...
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