Mohammed T. Abou-Saleh

120 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYdiagnosing elderly psychotic disorders. However, many clinicianshave found unreliable the attempt to distinguish betweenschizophrenia and delusional (paranoid) disorder, based uponthe presence of ‘‘bizarre delusions’’. There is no standard by whichone can decide when a delusion becomes ‘‘bizarre’’. Other groundsfor distinguishing delusional disorder from schizophrenia are nowbeing considered. Additionally, current criteria for schizophreniarequire a significant functional decline during the course of thedisturbance, but investigators have noted that many patients withlate-onset psychosis maintain stability in their personal and socialfunctioning.It is rare to encounter elderly patients with pure generalizedanxiety disorders. Mixed anxiety–depression is common, but itdoes not fit easily among mood disorders or among anxietydisorders. Although some continue to advocate consideration of alabel such as ‘‘mixed dysphoric state’’, there has been noconsensus. Growth in the use of serotonin reuptake inhibitors,and compounds such as extended release venlafaxine, hasdampened the debate in practical terms, but their apparenteffectiveness for mixed anxiety–depressive states sheds little lightthat clarifies the nosological confusion.Regarding obsessive–compulsive disorder, post-traumatic stressdisorder and phobias, there are few data available about theiroccurrence among elders to make any salient recommendationsregarding diagnostic classification or modification based on agingrelatedchanges in prevalence, presentation, course, co-morbidityor treatment responsiveness. In a similar vein, there are only asmall number of replicated findings regarding the form orfrequency of adjustment disorders among older patient groups.However, it has been amply clear that the currently employed 6-month time limit for adjustment disorders is inadequate when onefaces a persisting stressful situation, such as a chronic physicaldisability or the need to care for a spouse with Alzheimer’sdisease.While there were some minor text changes in DSM-IVregarding substance use disorders, there has continued to berelatively little attention to specific issues related to older persons.Recent studies 8 have underscored the variety of misconceptionsthat clinicians hold regarding the frequency and impact ofalcohol-related clinical conditions. Many substance abuse problemsamong elders arise from misuse of prescribed medications;older patients often avoid the adverse social consequences of drugseeking and the medical complications of illicit intravenousadministration. Although the abuse/misuse may be physicallyhazardous, especially as it relates to changes in metabolism orpotentials for drug interactions, it is distinct from the jeopardyexperienced by younger abusers. Thus, the diagnostic classificationmust attempt to take into consideration age- and culturerelatedvariations, with an eye to dealing with unsupervised use aswell as frank abuse.Axis IIConsideration of personality factors and related clinical disordershas been hampered by minimal data. Although one mayconjecture about the changing presentation of Axis II psychopathologyacross the age span, there have been remarkably fewrelevant, systematic studies 9 . Clinicians often recognize residualdysfunctional personality features in older, previously diagnosedpatients who later fail to conform to stereotypic descriptions.There are no categories available for denoting such conditions.Similarly, there is no diagnosis of ‘‘emergent’’ personality disorderfor describing those patients who, having suffered marginallyimpairing personality traits throughout their lives, evolve a frankdisorder in old age. For example, such a classification wouldcapture those who, having been supported or buffered by others,become dysfunctional following the death of a spouse or parent.This view stresses the setting-dependent nature of disorderedpersonality. Overall, pre-DSM-IV discussions swerved away fromissues related to personality and aging, leaving them to beresolved in future editions. It is clear, however, that the domain ofpersonality dysfunction—even if not captured by current diagnosticcategories—is a major component of the geriatriclandscape 9 , especially when considering problems such as depressionin primary care settings 10,11 or suicide in elders 12 .Axis IIIAs noted previously, DSM-IV includes guidelines for assisting aclinician in discriminating between a primary Axis I disorder anda symptomatic disorder due to a condition diagnosed on Axis III.When there is an etiologic tie, the general medical disorder shouldbe noted as part of the Axis I diagnosis (e.g. ‘‘mood disorder dueto Alzheimer’s disease’’), in addition to its notation on Axis III.Despite the presence of guidelines, no rule can be used as aninfallible aid to determine whether a condition is truly amanifestation of a fundamental medical disorder or is anunrelated idiopathic (‘‘primary’’) presentation that occurs bycoincidence in the presence of a medical condition that is not tiedetiologically to the Axis I psychiatric disorder. Clinical judgmentmust prevail. Similarly, there are no means available forindicating the current clinical significance of co-morbid conditions,whether they contribute to the patient’s overall disability,are confounds of possible treatments, or are merely incidental,coexisting disturbances that have no therapeutic impact orfunctional implications when considering the primary psychiatricsyndromes.Axis IVAs constituted in DSM-III-R, Axis IV was often unsuitable foruse with elders. Its exemplars failed to account for many of thecommon problems or stresses of later life. Additionally, there wasno method provided in the manual for defining the contributionof positive psychosocial factors that mitigated or diminished thecontribution of stressors to the development of psychopathology.DSM-IV took another approach, defining what might be called‘‘problem areas’’. This approach avoided the shortcomings of theprevious scale, and included a variety of domains relevant toelders, but it too provided no room for an assessment ofcompensatory factors, in addition to its problem-definitionfocus. A psychosocially orientated scale (or set of scales) isnecessary, one that reflects a broad conception that includes socialsupports, occupational and environmental resources, perceivedquality of life, as well as stressors, both acute and chronic.Axis VFunctional ratings may have substantial predictive validity whenused with elders, but also have proved unreliable when not usedcarefully. Current use of Axis V requires an estimation offunctional capabilities based upon psychopathology alone.Many commentators question whether one can reliably separatefunctional deficits due to psychiatric symptoms from those arisingfrom co-morbid physical disorders, especially in elderly patientswith multiple diseases. Presently available global functional healthmeasures are psychometrically robust and are excellent predictorsof subsequent morbidity and mortality in older patient samples.Two separate rating scales, one devoted to overall globalfunctional capability/disability and a second devoted to severity