Special features of psychiatric treatment for the elderly

Catherine Oppenheimer

Introduction Multiple., problems Sleepprobi.em.s.in,,, thee'derly

Managementof .sleep. .disorders The..useofmedication.. in ..old.. .age. .psychiatry


Mediication.as..an..experimenta,l, .trial

Stopping.. medication Compliance

Psychological.. treatments. .in.old ..age

The.. role .ofspeciajist. se.rYice.s.and.. co-operation. between. agencies

Loss. .of.capacity...and.. dependence on help Ethical.. problems.. in „old.. age .psychiatry

Beneficence .and.non-ma.l.eficence


Medico-leqa!issues Managementof financial .affairs Mediic,al...t,reatm£n.Lan.d... .general.. welfare Driving

Chapter.. References Introduction

There are three linked themes which bind together the topics to be considered in this chapter.

1. Old age is a time of multiple problems Physical, psychological, and social problems often occur together by chance, or precipitate each other in the life of the old person. Very rarely is it feasible to consider the management of one problem in isolation, or to see the patient narrowly as 'the case of disease'. Understanding elderly people and their problems holistically (i.e. from all aspects and in their social contexts) is not just a matter of political correctness, but the only possible way of treating them. It follows that many different sources of expertise or help may be engaged with a single individual. Therefore good co-ordination between different agents or agencies is an essential part of old age psychiatry, both with individual patients and in the overall planning of services. However, success in co-ordination varies greatly between and within countries, depending on economic and political circumstances.

2. Clear boundaries between 'normality' and 'disease' are rare in old age This is partly because of the nature of the pathologies characteristic of old age, many of which are gradual in onset and degenerative in nature, and are due more to failures in processes of repair than to an 'external foe'. Disease often appears to differ quantitatively rather than qualitatively from health. Also, 'normality' is a social construct with fluid borderlines, encompassing the ideas of both 'statistically common' and 'functionally intact'—two meanings which are not the same. To most people the notion of 'normal' old age probably includes ideas of dependence and failing function. Excellent health and vigorous social participation in old age are popularly seen as remarkable and praiseworthy, but not the norm. However, in developed countries excellent health at the age of 65 would nowadays be seen as 'normal middle age' rather than 'exceptional old age', whereas superb health at the age of 95 would still be something noteworthy. Since some degree of physical dependence, forgetfulness, and vulnerability to social exclusion are to be expected in old age, making provision for these needs is also regarded as a 'normal' demand on families, neighbourhoods, and agencies such as social services, rather than the responsibility of health care providers. As the severity of these needs increases, however, so also does the perceived role of health professionals—in making diagnoses, offering treatment, or providing care. The role of specialist services, not only as direct service providers but also in support of other agencies, will be discussed in greater detail later.

3. Lack of competence is common in old age Largely because of the high prevalence of cognitive impairment in old age (especially among the 'older old'), questions frequently arise as to the competence of patients to make decisions and the need to protect them from the consequences of an inability to safeguard their own interests. When old people cannot manage decisions alone, they may either gradually depend more on others or, resisting dependence, become vulnerable through inability to manage their own care or through injudicious decisions. Where competence is lost, mechanisms exist to look after their interests on their behalf. These mechanisms differ from country to country, but the general principles are generally applicable. When an incompetent person depends on a spouse or family member for care, there are fewer dangers of self-neglect or ill-considered decisions. On the other hand, vulnerability to faulty decisions by the caregiver (through ignorance, the caregiver's own incompetence, or malice) is greater, as is the danger to the caregiver from the burden of dependence imposed by the person being cared for.

These three themes will be developed further, and with them the following special topics:

1. multiple problems including sleep disorders in old age, medication in old age psychiatry, and psychological treatments in old age psychiatry;

2. blurred boundaries of normality including the role of specialist services and support between agencies;

3. incapacity and dependence including balancing the needs of patients and caregivers, abuse of older people, ethical issues, and medico-legal arrangements for safeguarding decisions.

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