Mohammed T. Abou-Saleh

780 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYPREVENTIVE INTERVENTIONS IN THE CONTEXTOF TREATMENTPrevention of Relapse and RecurrenceEstablishment of the efficacy of treatments is one of the majoraccomplishments of geriatric psychiatry research. As outlined inother sections of this text, many studies have demonstrated thatolder patients respond robustly to treatments that are appropriatelyapplied with adequate intensities. These data are, largely,based on relatively brief, randomized controlled trials addressingthe short-term efficacy of treatments to manage the symptoms ofserious illnesses like depression 8 and Alzheimer’s disease 9,10 . Morerecently, the prevention of relapse and recurrence has emerged asa major orientation in the treatment of the older patient. As therecognition has grown that most mental disorders in late life arechronic, recurring illnesses with substantial residual disability 11 ,sotoo has the acknowledgement that treatment must be approachedwith a much longer-term perspective 12 . An intervention ispreventive if acute treatment response is the starting point, withthe major purpose of preventing relapse or recurrence and notmanaging symptoms.Prevention of Side Effects and Adverse ReactionsCo-morbidity and the associated polypharmacy that comes fromtreatment of multiple conditions are characteristic of olderpatients. New information on the genetic basis of drugmetabolism and on the action of drug-metabolizing enzymesnow provide us with important perspectives on clinicallysignificant alterations in drug concentration levels or on complexdrug interactions 13 . For example, many of the newer antidepressantagents, the selective serotonin reuptake inhibitors (SSRIs),compete for the same metabolic pathway used by b-blockers,type 1 C antiarrhythmics and benzodiazepines.Many older patients require antipsychotic treatment for themanagement of behavioral disturbance in schizophrenia, depressionand Alzheimer’s disease. Movement disorders are commonside effects of the older types of these medications, theconventional neuroleptics. Although doses tend to be quite lowcompared to doses used in young or mid-life adults, age andlength of treatment represent major risk factors for the developmentof movement disorders 14 . Recent data suggest the possibilitythat the newer antipsychotics present a much lower risk and thatthe development of tardive dyskinesia may be preventablethrough use of different medication 15 . Trials of agents (e.g.antioxidants) hypothesized to treat these side effects have beenproposed, although the data from some of the early studies havebeen inconsistent 16,17 .Many drugs affect body sway and postural stability, althoughthere is substantial variability within classes of drugs 18 . In olderpatients, where the prevention of falling is a major concern, apreventive strategy would reflect a differential selection oftreatments or development of fall-specific preventive interventions19 .PREVENTIVE INTERVENTIONS IN THE CONTEXTOF SERVICESPrevention of SuicideRecognition of mental illness in older patients is highly variable.Changes in cognition, affect, thinking, sleep, etc. are oftenattributed to normal processes of age-related change by olderpeople themselves, their spouses and close family members, andeven by their family doctors and primary care physicians. Themost tragic result of the failure to recognize illness is suicide.Suicide rates increase with age, and men always outnumberwomen in suicide completion. In most countries, older mengenerally are at the greatest risk of suicide. In the USA, forexample, old White men have a rate of suicide six times that of thegeneral population. Psychological autopsy studies show thatdepression is common among these men but that it is rarelyrecognized. Nearly 40% of the men who kill themselves see theirprimary care doctors in the week of their death; nearly 70% in themonth of their death 20 . An uncontrolled field experiment on theisland of Gotland in Sweden suggested that a depressionorientatededucational intervention directed toward primarycare physicians could reduce suicide 21 . Other approaches to theprevention of suicide, using aggressive outreach and case-findingtechniques, have been developed in the context of communitybasedmental health or aging services 22,23 .Prevention of Premature InstitutionalizationNursing home placement typically comes at the end of a long anddifficult period of caregiving by the families of patients withAlzheimer’s disease. The burden of this caregiving in terms ofstress, depression and quality of life has been extensivelydocumented 24 . It is only the rare (and very wealthy) family thatcan provide the care necessary to maintain a patient withAlzheimer’s disease at home; institutional care is required forvirtually all patients who survive to the end-stage of the disease.From a public health perspective, delay of institutional placementuntil it was absolutely necessary could have significant impact. Inan important randomized controlled trial of a family-basedcounseling intervention, Mittelman et al. 25 demonstrated clearbenefit: a delay of over 300 days in nursing home admission forpatients whose families were randomized to receive the treatment.The counseling intervention also resulted in a significant reductionin depressive symptoms in these caregivers. Clinical drug trials inAlzheimer’s disease have begun using institutionalization as aprimary outcome 26 or as an outcome from open-label follow-upafter the trial had ended 27 .Prevention of Excess DisabilityThe concept of excess disability is a classic one in geriatrics 28 andrefers at its core to the observation that many older patients,particularly those with Alzheimer’s disease, are more functionallyimpaired than would be expected on the basis of the stage orseverity of their mental disorder. There are many sources of thisexcess disability: some are medical, some are psychosocial andsome are environmental. A generation of research has clearlydemonstrated that attention to these issues, and aggressiveintervention where appropriate, will prevent excess disabilityand will optimize levels of function.MODELS OF ETIOLOGY, PATHOPHYSIOLOGYAND RISKBiological ModelsImproved understanding of the etiology and pathophysiology ofmental disorders can potentially lead to interventions that willprevent the onset or progression of disease. A useful model here isthe large simple trial in a broad population; incident casesrepresent the primary outcome. The state of our knowledge is notyet sufficiently well developed to support this type of research.