Mohammed T. Abou-Saleh

590 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYknowledge base, research should concentrate on PD clusters andPD with older adults must be conducted using reliable scales tiedto DSM-IV criteria across varied settings (e.g. medical, nursinghome, psychiatric inpatient, psychiatric outpatient) populations(e.g. old-old, females, multicultural) and methodologies (e.g.longitudinal, cross-sectional). The inclusion of age-graded criteriafor Axis II and perhaps also Axis I should be investigated. At thevery least, since all the PD scales currently in use have beendeveloped for younger adults and have yielded generally modestreliability ratings for most PD categories, validity studies must beconducted specifically with older adults 48 . Such studies must takeinto account the effect of cognitive status and medical problemson the responses of older adults. In this way, research concerningthe psychological/developmental history of individuals with PDwill generate valuable prognostic and treatment data. Researchshould also explore those PD features underlying late onset Axis Idisorders. Hopefully, more sophisticated methodologies willprobe the relative and combined merits of pharmacotherapyand different types/modes of psychotherapy (e.g. cognitive–behavioral vs. interpersonal; group vs. individual). Heuristicmodels of the interrelationship between the underlying neuropsychiatricand biological substrate of temperament, genetic factorsand psychosocial changes in personality with aging must begenerated. Finally, the ethical and clinical issues involved in themanagement of ‘‘difficult personality-disordered’’ patients inhospital, rehabilitation and nursing home sites should beexplored, so that the needs of individuals can be balanced withthose of families, staff and patient/resident peers 52–54 .SUMMARYOver the last decade, there has been an increasing amount ofresearch on PD in older adults using structured scales tied toDSM criteria. Major findings are:1. Although still common in older adults, Cluster B pathology isless prevalent than in the young adult population; Cluster Cpathology may be relatively more prominent in older adults.2. Older adults are less likely to receive more than one PDdiagnosis, suggesting that they may finally develop one maincoping strategy to fulfill their interpersonal needs.3. There may be an age-related mellowing of the ‘‘high-energy’’personality characteristic of individuals with PD, and/or thereare ‘‘geriatric variants’’ of PD not tapped by DSM.4. There is a positive association between depression and PDdiagnosis.5. PD in older adults is prognostically useful in outpatientsettings, where the Axis I symptomatology is less severe.6. There are poor concordance rates of PD diagnosis betweenclinical examination, structured interviews and self-reports,suggesting the need for data collection from a variety ofsources.Although age-related changes in PD expression are probably inthe less volatile and impulsive direction, novel PD manifestationscan still create a significant burden in stressful caregiving contextsfor family members, friends, healthcare professionals and administratorsof institutions attempting to support a flawed butvulnerable older adult. Future research guided by conceptualadvances promises to yield exciting progress in assessment andtreatment.ACKNOWLEDGEMENTThe author acknowledges the thoughtful review of a draft of thischapter by Dr Dan Segal.REFERENCES1. American Psychiatric Association. 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