Geriatric Mental Health Disaster and Emergency Preparedness

Chapter 14 Geriatric Assessment for Differential Diagnosis 289
familiar with the diagnostic categories as outlined in the DSM-IV . The
features of persistent anxiety and dread, re-experiencing of the traumatic
event, avoidance, and increased arousal may be seen in acute and posttraumatic
stress disorder, generalized anxiety disorder, and panic states.
The anxiety disorders are the most commonly diagnosed disorders in the
general population, and older persons are frequently diagnosed with generalized
anxiety disorder, panic disorder, and isolated panic attacks. The
goal of the assessment process is to differentiate the premorbid diagnosis
of anxiety disorder from the effects of a disaster, to understand the baseline
functioning of the person, and to develop a comprehensive treatment
plan that incorporates all the patient’s symptoms and signs of the disorders
in a coherent and workable plan; the ultimate goal is to alleviate suffering
and allow the person to go on with their usual activities as much as
possible.
There are no unique issues for ASD pertinent to the older population.
We must assess the exposure to a traumatic event and the threat of
death, serious injury, or threat to the physical integrity of the patient or his
or her loved ones. Responses may involve intense fear, helplessness, horror,
and dissociative symptoms such as numbing, detachment, absence of emotional
response, reduced awareness of one’s surroundings, derealization,
and depersonalization and dissociative amnesia (Yehuda, et al., 1996). Reexperiencing
the event also occurs as vivid dreams, flashbacks, or daydreams
associated with the intense mood states of anxiety, fear, and dread.
This may recur after a trigger or reminder of the event as in the case of
images of the twin towers. Avoiding places or reminders of the event may
occur. Associated with these symptoms are sleep disturbance, excessive
startle responses, anxiety, poor concentration, and cognitive dulling (Averill
& Beck, 2000). These can easily impair functioning in the usual setting,
and the assessment should include a measure of the patient’s current ability
to perform ADLs and IADLs. The timing of these symptoms according to
the DSM-IV (American Psychiatric Association, 2000) is for onset within
4 weeks of the disaster event, lasting for at least 2 days up to 4 weeks.
Anxiety disorders—such as ASD, PTSD, generalized anxiety disorder,
panic disorder, or obsessive compulsive disorders—invoke intense fear and
threat to self of death, self-harm, or fear of harm or death of a loved one.
Symptoms may be acute, time limited, chronic, or intermittent. PTSD has
many similar features to ASD but the chronicity and timing of onset are different.
PTSD is diagnosed when the symptoms exceed 1 month in duration.
A further categorization into acute PTSD, lasting for less than 3 months,
and chronic PTSD, for symptoms persisting for more than 3 months, is
useful. PTSD is diagnosed when the constellation of symptoms has been