Geriatric psychiatry subspecialization in Canada: past, present, and future.

OBJECTIVE: To describe the development, future challenges, and directions of geriatric psychiatry in Canada. METHOD: This review and description of geriatric psychiatry was developed in the context of the criteria established by the Royal College of Physicians and Surgeons of Canada for subspecialization applications. Information from key informants, both nationally and internationally, was combined with a review of relevant literature in the field. RESULTS AND CONCLUSIONS: Canada has provided important contributions to the field of geriatric psychiatry in Canada and abroad. The increased needs of older persons with severe mental illness and their families, combined with a significant body of knowledge and therapeutic options, provide an important foundation for further development. Subspecialization in geriatric psychiatry as part of the overall development of psychiatry in Canada is proposed as critical to meeting the challenges of our aging population.

Survivors. A review of the late-life effects of prior psychological trauma.

The author reviews the literature on the epidemiology, symptom picture, and treatment of elderly patients who have encountered serious psychological trauma earlier in life. Data are predominantly derived from studies of aging Holocaust survivors and combat veterans from World War II, the Korean Conflict, and Vietnam, Survivor syndromes persist into old age, but patterns of expression vary. Holocaust survivors appear to have adapted well to instrumental aspects of life, whereas combat warriors may show less functional life-adaptation. Persisting symptoms in all groups include marked disruptions of sleep and dreaming, intrusive memories, impairment of trust, avoidance of stressors, and heightened vulnerability to various types of age-associated retraumatization. There is a deficiency of controlled treatment studies of traumatized elderly patients, but successful group, individual, and family clinical interventions have been described.

Boundary violations and departments of psychiatry.

OBJECTIVE: To explore a number of issues related to boundary violations in psychiatry, including the relationship between the individual physician and his or her patient and broader issues related to various dilemmas arising in academic departments of psychiatry. METHOD: Several potentially troublesome scenarios are presented and discussed in the contexts of 1) the doctor-patient relationship, 2) sexual boundary violations, and 3) nonsexual forms of exploitation, such as finances, confidentiality, dual relationships, and relationships with industry. CONCLUSIONS: A number of examples of boundary problems involving psychiatrists have been explored, and although some of these behaviours are clearly forbidden and harmful, others are less clear and require careful consideration if the profession is to arrive at a thoughtful consensus.

PIP: Trust, integrity, and a commitment to the patient's needs and well-being are essential to effective psychotherapy. Psychiatrists with poor impulse control, exaggerated views of their own specialness, excessive needs for affirmation, or unacknowledged longings for care and nurturance are at risk of succumbing to the intimate enticements of the psychotherapeutic relationship. Academic departments have a responsibility both to prevent and respond to transgressions of professional boundaries and to develop a consensus regarding the parameters of professional conduct. The capability of psychiatrists to serve as effective role models for their trainees may be nullified by the failure to address boundary issues. This article presents examples of boundary problems potentially encountered by psychiatrists. Although sexual contact represents the most extreme and publicized form of boundary violation, nonsexual forms of exploitation involving finances, confidentiality, dual relationships, and relationships with the pharmaceutical industry also are salient. A significant factor in the occurrence of boundary violations is the view that one is "above the rules" and entitled to broaden the parameters of physician privilege and professional conduct.

Treatment of anxiety disorders in late life.

OBJECTIVE: To provide a current review and synthesis of the present state of knowledge of anxiety disorders and symptoms in the elderly. METHODS: Current research derived from a MEDLINE search and references in key textbook articles and other papers were reviewed. These data were combined with the clinical empirical knowledge and experience of the authors. RESULTS: Anxiety disorders and symptoms are a common presenting problem in the elderly. Current knowledge and research findings are limited. Extrapolation from adult studies are of use, but important limitations are evident because of the nature, uniqueness, and complexity of the geriatric psychiatry patient. Comorbidity, especially with depression, medical conditions, drugs, and dementia, remains an important concept in assessment and approach to management of anxiety in the older person. Comprehensive assessment of anxiety symptoms requires consideration of physical, intellectual, environmental, and social determinants. Major anxiety disorders, as defined by DSM-IV, and anxiety symptoms are significant problems in the older adult population and are responsible for significant morbidity and cost to the health care network. CONCLUSIONS: Anxiety disorders and symptoms in old age, although common, have received little research focus to date. A comprehensive, careful approach by the clinician to assessment and management is required because anxiety is often a comorbid condition in the elderly. Effective treatments are available and should be applied in a flexible, integrated, and specific manner.

Integrated psychotherapy for the elderly.

The complexity of interacting variables in the geriatric patient imposes the therapeutic necessity to employ all effective therapeutic modalities in an interactive and integrated fashion. This paper examines the efficacy data on brief and longer term therapies as applied to the elderly, most particularly for treatment of depression and bereavement. In determining the development of an integrated psychotherapy treatment plan, the author suggests a decision pathway which incorporates concurrent utilization of theoretical principles derived from psychodynamic, interpersonal and cognitive behavioural theory. This tripartite approach informs the assessment and diagnosis of the patient as well as the specific choice of therapy. Directions for further research are suggested.

Assessing the protective service needs of the impaired elderly living in the community.

The aim of this paper is to define the guidelines for the preparation of reports on protective service needs of the (impaired) elderly living in the community. Such guidelines are of special importance both because they have not been set down in detail, and because of recent moves to establish adult guardianship legislation in various jurisdictions. Three major areas are addressed in detail: the definition of an adequate assessment; the essential components of each report; and who should have responsibility for the assessment process. Medico-legal issues of guardianship are reviewed.

Analysis of emotional status during the hospital treatment of a borderline patient.

This single case study illustrates a methodology for identifying recurrent pathological emotional states in a hospitalized, borderline patient. Parallel therapeutic inputs are delineated and examined in terms of patient-specific responses. The results indicate that ratings of nursing notes recorded across three periods of hospitalization can reliably isolate the patient's most salient and debilitating emotional states. State-specific therapeutic interventions are extracted and their effectiveness noted. The analyses illustrate clinical phenomena which are congruent with what is known about borderline symptomatology. In addition, the study locates therapeutic errors which often occur when working with difficult patients.

General hospital geriatric psychiatric treatment: a follow-up study.

Fifty-two patients previously treated and discharged from an acute-care general hospital ward were followed up for an average of 30.5 months. The results show that while it is true that depressive episodes in the elderly are often easily and rapidly treated, many of these patients do poorly in the long term for a variety of reasons related to depressive dysphoria, organic brain syndrome, and physical disability. Depressive or dysphoric relapse in the community seems to go largely unrecognized. It is suggested that follow-up must be done soon after discharge to prevent the high level of rejection of the treatment team that may occur once the patient loses contact. Follow-up must in part be done initially through home visits, and a firm institutional liaison established for the large group that will need ongoing care.

The characterologically difficult patient: a hospital treatment model.

A treatment model for the hospitalized borderline patient has evolved from the long-term, intensive treatment of these patients in a psychodynamically oriented setting. Four stages are identified and described. Each has a therapeutic goal and strategy, and repeatedly observable patient responses and staff counter-responses. Although patients vary in the lengths of time in each stage and there is much back and forth between stages, the regularity with which this pattern occurs greatly increases the capacity of the treating personnel to understand and guide the treatment process. The model clarifies perplexing, discouraging, or stale-mating affects and behaviours in the patients, and misleading counter-therapeutic affects and behaviours in the staff. Further, it can predict certain features and, to some extent, probable outcome in any particular course of treatment.

Psychotherapy and the inpatient unit: a unique learning experience.

This paper describes the advantages of an inpatient setting for the teaching and learning of psychotherapy. Contributions to this process derive from the continuous and intense expressions of conscious and unconscious dynamics, transferences, and object relationships by the patients, the obligation on residents to therapeutically engage in a relatively exposed way with all the patients under their care, the availability and familiarity of the staff supervisors who participate in assessments and decisions regarding patient management and psychotherapy, and the collaborative work of all the other team members. Conditions of the setting which make this possible are the strong psychodynamic orientation of all the staff, the resident's role as manager and psychotherapist, the staff psychiatrist's role as supervisor and team leader, and the completely open communication among all the treating personnel.

A Canadian perspective on follow-up of geriatric psychiatric patients in the general hospital.

Institutional follow-up is necessary because relapse, not serious enough to lead to reinstitutionalization but serious enough to impair the individual's quality of life, frequently occurs. The process of aftercare for the geriatric patient discharged from the general hospital psychiatric unit should be coordinated and carried out by an aftercare team within the institution. Aftercare planning should be integrated into the acute treatment phase. The patient should be actively sought out to help forge a strong therapeutic alliance and prevent feelings of abandonment. The dangers of nihilistic feelings, secondary to the burden of care imposed on unsupported community resources, may be lightened by the backup provided by institutional resources.

Psychogeriatric care in the general hospital.

This study examines treatment outcome in 52 psychogeriatric patients to help determine the role of the general hospital in psychiatric care of the elderly. The author reviewed the charts of all patients 65 years of age and over admitted to the psychiatric ward from 1974 to 1978. Approximately 80% of this group showed symptom remission. Treatment failures correlated closely with the presence of major organic brain syndrome. Despite an average age of 73.4 years and a high proportion of widowed patients only 10 patients needed new placements on discharge. The author discusses the reluctance of general hospitals to treat the psychogeriatric patient despite the high success rate, the merits of such an active treatment approach and the effect of short-term therapy programs on the treatment of this group.