Clinical features There are no clear distinctions between the clinical presentation of depr ession in the elderly and that in younger people. However, some symptoms are often more str iking: \200 Severe psychomotor retardation or agitation occurs in up to 30% of depressed elderly patien ts. A degree of cognitive impairment has been detected in 70% (esp. with effortful tasks). Depressive delusions regarding poverty, physical illness, or nihilistic in nature, are comm on (e.g. Cotard \200\231s syndrome, b p. 89). Paranoia is also common, while derogatory and obscene auditory hallucinations may occur. Classic symptoms may not even be evident and th e patient may instead present with somatic, anxiety, or hypochondriacal complaints. A high index of suspicion is required when older patients present with these symptoms, especially abnormal illness behavior. Pseudodementia A minority of retarded depressed elderly present with \200\230pseudodementi a \200\231 (i.e. marked dif \201 culties with concentration and memory). Features suggesti ve of pseudodementia include: previous his- tory of depression; depressed mood; biological symptoms; \200\230islands of nor- mality \200\231; exaggerated symptoms; poor effort on te sting, frequent comments such as \200\230I can \200\231t be bothered \200\231, \200\230it \200\231s too dif \201 cult \200\231 to relatively easy tasks; response to antidepressant medication. For some this may herald/uncover the onset of a dementia syndrome and there is a proven association between depressive pseudodementia and later diagnosis of dementia. 14_Semple_Chap14.indd 520 12/7/2012 3:43:48 PM PSYCHIATRIC ILLNESSES IN THE ELDERLY 2: MOOD DISORDERS 521 Mania or hypomania present a similar clinical picture as in younger patients; however, they are more often followed by a depressive episode in older patients. There is usually a hist ory of bipolar affective disorder. A \201 rst episode of mania in an elderly person requi res careful screening for cerebral or systemic pathology (e.g. stroke or hyperthyroidism). Differential diagnosis Dementia \200\224dif \201 cult to distinguish and can occur togethe r, if in doubt best to treat; paranoid disorder \200\224depressive paranoia and delusions m ay be dif \201 cult to distinguish from psychoses; stroke \200\224especially after left fr ontal CVA or s to the lability, reactive stress, organic apathy, d motivation, or drug side -effects associated with stroke; Parkinson \200\231s disease \200\224drug side-effects in t reating may suggest depressive illness; other physical disorders e.g. infection, hypothyroi dism, tumors, alcohol, drug side-effects. Note: full physical investigation is vital. Management \200 Antidepressants elderly, but care must be exercised in prescribing. ECG and BP monitoring i s important due to postural drops as well as other cardiac problems. First-line is probably SSRIs due to dside-effects and relative safety in OD. Others include: SNRIs such as venlaf axine; and, occasionally, moclobemide (delayed hypotension a problem). General rules includ e: low starting dose; gradual increases; longer maintenance periods (up to 2yrs); beware of suicide risk; consider lithium augmentation. Caution needs to be observed when considering changing/reducing/stopping long-term antidepressants in this group as this not uncommonly may precipitate a relapse even in persons who have been stable for years. ECT where there i s marked agitation, life-threatening stupor, suicidality, or contraindications, failure, or excessive side-effects of drugs. ECT is generally safe and effective. Dementia is not a co ntraindication. Post- ECT confusion may be a problem, in which case treatments should be gi ven at longer intervals. Psychological treatments supportive psychotherapy; bereavement cou nseling. Age-appropriate doses of antipsychotics may be Treatment of mania used, in particu lar haloperidol and risperidone. Lithium is \201 rst-line in prophylaxis but lower dosage s are indicated (levels: 0.4 \200\2230.8 mmol/L) and regular thyroid and renal checks (at l east three monthly) are essential. Also note that levels may easily change in the presence of infection, dehydration, and use of other medications (e.g. diuretics). Levels should be taken at 10 \200\22314hrs after last lithium dose. Following increase in lithium dose, 5 \200\2237 days should be allowed for serum levels to stabilize. TCAs are not absolutely contraindicated in the (b p. 284) First-line treatment for severe illness and speci \201 cally Therapies include: CBT for depression; Prognosis Generally prognosis is good, especially: onset <70yrs; short illness; good previo us adjustment; absent physical illness; good previous recovery. Poor outcome is associated with: severity of initial illness; psy- chotic symptoms; physical illness; poor medication compliance; severe life events during follow-up period. 14_Semple_Chap14.indd 521 12/7/2012 3:43:48 PM CHAPTER 14 Old age psychiatry 522 Speci \201 c aspects of psychiatric illnesses in the elderly 3: psychoses Psychotic illnes s in the elderly may be classi \201 ed as follows: \200 \200 \200 \200\230Old psychosis \200\231 \200\224the \200\230graduate \200\231 population. \200 \230New psychosis \200\231 \200\224late-life schizophrenia or late paraphrenia. Other condi tions with paranoid and/or hallucinatory symptoms (Box 14.1) Old psychosis With the advent of antipsychotic drugs in the 1950s, there followed a progres sive decrease in the numbers of long-stay patients with schizo- phrenia in institutions. Th us more and more ageing patients with chronic schizophrenia moved into the community, and i n countries such as the UK and USA, many of these patients are increasingly referred to psy chogeri- atric services. Caution needs to be observed when considering changing/ redu cing/ stopping long-term antipsychotic in this group as this not uncom- monly may precipitate a r elapse even in persons who have been stable for years. It is advisable that the patient hav e a psychiatric review and opinion in this regard. New psychosis Paraphrenia \200\224a term coined by Emil Kraepelin in 1909; described a psyc hotic illness characterized by delusions and hallucinations, with- out changes in affect (a lthough there may be reactive anxiety), form of thought, or personality. Late paraphrenia \200\224described by Roth and Morrisey in 1952; they noted that this type of illness was the most common form of psychosis in old age (de \201 ned as >60yrs). Epidemiology \200\224relatively rare condition; population studies estimate <1% prevalence. Approximately 10% of admissions to psychiatric wards for the elderly will have the conditi on. One study showed that when ICD-10 cri- teria were used, 60% of cases were classi \201 ed as paranoid schizophrenia, 30% as delusional disorder, and 10% as schizoaffective disord er.1 Gender distribution is estimated at 4 \200\2239:1 female:male predominance. Etiology \200 Genetics The risk of schizophrenia in 1st-degree relatives is 3.4% in late paraphrenics, compared with 5.8% in young schizophrenics, and less than 1% in the general p opulation.2 Premorbid personality characterized by poor adjustment and it is estimated that nearly 45% show lifelong paranoid and/or schizoid traits. Sensory impairments increases ri sk of late paraphrenia. Social isolation Organic factors enlargement; cerebrovascular patho logy is a common comorbid \201 nding. of people with late paraphrenia is such as deafness, of onset in middle life, \200 and major life events may also contribute. Structural imaging demonstrates mild ventricular 14_Semple_Chap14.indd 522 12/7/2012 3:43:48 PM PSYCHIATRIC ILLNESSES IN THE ELDERLY 3: PSYCHOSES 523 Clinical features Persecutory delusions are the most common symp- tom of late paraphrenia ( roughly 90% of patients) and tend to relate to commonplace themes (such as neighbors spying , entering the patient \200\231s home, moving items etc.). Other common delusions include: referential, misidenti \201 cation, hypochondriacal, and religious. Auditory hallucination s (typically third person) occur in approximately 75%, while visual (13%), somatic/tactile (12%), and olfactory (4%) hallucinations are not uncom- mon.3 Schneiderian 1st-rank symptom s are common (46%), while nega- tive symptoms, thought disorder, and catatonia are extremel y uncommon. 10 \200\22320% may present with delusions only. Treatment \200 \200 \200 \200 \200 Relieve isolation and sensory de \201 cits. Establish rapport and develop a therapeutic al liance (often dif \201 cult!). Exclude cognitive or medical disorders. Hospital admission is often required. Low-dose atypical antipsychotics preferred as elderly are very sensitive to side-effects, but non-compliance secondary to lack of insight is often an issue. Box 14.1 Other conditions with paranoid or hallucinatory symptoms These include the following conditions: \200 Secondary paranoid states stances (see b p. 130) Delirium Dementia Affective disorders Schi zoaffective disorder \200\224due to organic disorders or sub- \200 \200 \200 (see b p. 790) (see b p. 132) (see b p. 520) (see b p. 218) Hallucinations of sensory deprivation In the elderly, complex visual hallucinations can occ ur as a non-speci \201 c phenomenon, s to visual impairment \200\224sometimes referred to as Charles Bonnet syndrome. Hal- lucinations may be well-formed, containing animals, people , or scenes. May be partial or complete insight. Differential diagnosis includes: Lewy body dementia (b p. 140), acute confusional state (b p. 790). Reassur- ance may be adequate, bu t in some cases a small dose of antipsychotic medication may reduce distressing symptoms. 1 Howard R, Castle D, Wessely S, et al. (1993) A comparative study of 470 cases of early-on set and late-onset schizophrenia. Br J Psychiat 163: 352 \200\2237. 2 Kay DWK and Roth M (1 961) Environmental and hereditary factors in the schizophrenias of old age (late paraphreni a) and their bearing on the general problem of causation in schizophrenia. J Ment Sci 107: 649 \200\22386. 3 Almeida O (1998) Late paraphrenia. In Butler R and Pitt B (eds), Seminars in old age psychiatry, pp. 148 \200\22363. London: Gaskell. 14_Semple_Chap14.indd 523 12/7/2012 3:43:48 PM CHAPTER 14 Old age psychiatry 524 Other mental health problems in the elderly Alcohol problems With decreasing tolerance for alcohol in advancing age, there is a cor- responding increase in risk of intoxication and a dverse effects. Risk fac- tors for late onset of alcohol problems include: female gender; h igher socioeconomic class; physical ill-health; precipitating life events; neurotic persona lity; psychiatric illness. Principles of management \200 Prognosis is good if alcohol problems commence secondary to practical problems. Encourage a nd facilitate involvement in non-drinking social activities. In extreme cases consider need for supervision of \201 nances. Orientate towards reducing physical problems. Moving to residential care may reduce social isolation. \200 \200 \200 Caution must be displayed when detoxing the elderly from alcohol with benzodiazepines. Ther e may be comorbid cognitive impairment which makes the patient more susceptible to benzodia zepine precipitated deliri- ums (secondary to use of too high doses), rather than alcohol w ithdrawal delirium, and this should always be considered in the differential diag- nosis of , especially elderly, persons with a non-resolving delirium in this context. Drug abuse Generally, illicit substance abuse is not a signi \201 cant problem in the eld- erly although with changing demographics this may become an increasing problem in the futu re. However, misuse of prescription drugs such as benzodiazepines, opiates, and analgesics frequently becomes a problem in this age group. Dependence on these medications may result from care- less prescription of long-term treatments for common problems of age- ing such a s insomnia and arthritis. With the best of intentions, doctors sometimes believe that it is \200\230cruel \200\231 to withdraw patients from these medi- cations, especially if the p atient has been using the drug for years and is advanced in age. Underlying this belief is the common clinically evidenced precipitation of dif \201 cult to treat anxiety states. Ho wever, it is important to consider whether withdrawal may actually enhance quality of life by diminishing chronic side-effects such as depression. Sexual problems Factors in \202 uencing the sexual life of younger adults are relevant to older people too (e.g. social stresses, illness, and side-effects of medications). In addit ion, the elderly may experience added problems related to the speci \201 c physiological c hanges that accompany ageing. Dementia suffer- ers may become sexually demanding as part of the disinhibition that fre- quently characterizes this disorder. Health carers may fail to detect sexual problems experienced by older people as a sexual history is commonly overloo ked. This may result from incorrect assumptions that carers often 14_Semple_Chap14.indd 524 12/7/2012 3:43:49 PM OTHER MENTAL HEALTH PROBLEMS IN THE ELDERLY 525 make regarding sexuality in this age group. The client too may assume that his or her sexua l dysfunction is a \200\230normal \200\231 aspect of ageing. Some practical remedies are: hormone replacement therapy; vaginal lubricants and topi- cal estrogen; and, of course, sil dena \201 l (Viagra). Personality problems Personality traits often become more prominent and rigid in old age; i n particular, traits such as cautiousness, introversion, and obsessionality. Paranoid trait s may intensify, especially in situations where there is increas- ing social isolation. In some cases increasing paranoia may be mistaken for a paranoid psychotic state such as delus ional disorder. Psychopathy is said to burn out with advancing age and criminal behavior is uncommon in the elderly. Roughly 5 \200\22310% of older people exhibit features of persona l- ity disorder and these individuals often come to the attention of health services when t hey are residents in homes for the elderly. Since personal- ity disorder is by de \201 nit ion lifelong, any signi \201 cant change in personal- ity needs explanation. Both organic and functional brain disorders may manifest as \200\230a change in personality \200\231. P ersonality problems are often the cause of Diogenes syndrome \200\224also called senile squ alor syndrome \200\224in which eccentric and reclusive individuals become increasingly isol ated and neglect themselves, living in \201 lthy, poor conditions. They are often oblivi- ous to their condition and resistant to help, necessitating intervention. Suicide Old age is a risk factor for suicide and it is estimated that approximately 20% of all suicides are of the elderly. There is a male predominance of 2:1 in this age group, as suicide rates tend to increase with age in men and decrease with age in women. The rate of elderly suicides declined mark- edly during the 1960s due to the detoxi \201 cation of the mains gas supply. Predictive factors for suicide in the elderly \200 \200 \200 \200 \200 \200 \200 \200 \200 Increasing age. Male. Physical illness (35 \200\22385% cases). Social isolation. Widowed or separated. Alcohol abuse. Depressive illness, current or past (80% cases). Recent contact with psychiatric services. Availability of means. Self-harm Self-harm is relatively uncommon with older people, accounting for only 5% of cas es. Gender distribution is roughly equal. An apparent parasuicide in this age group is much more likely to be a failed suicide and thus all para- suicides should be taken very seriou sly. It is important to exclude depres- sion and also personality disorder as 90% have a de pressive illness. Also 60% are physically ill; 50% have been previously admitted to a psych iatric hospital; and 8% go on to complete a suicide within 3yrs of a parasuicide. 14_Semple_Chap14.indd 525 12/7/2012 3:43:49 PM CHAPTER 14 Old age psychiatry 526 Issues of elder abuse1,2 In recent decades the unfortunate problem of elder abuse has becom e increasingly recognized. It is often overlooked and requires an integrated response from multiple disciplines and agencies, including health and social services, the criminal justi ce system, and government. The need for a uni- \201 ed multidisciplinary approach cannot be emphasized enough as a frag- mented response is fraught with problems. Types of elder ab use Elder abuse is an all-inclusive term representing all types of mistreatment or abusive behavior towards older adults. This mistreatment can be an act of commission (abuse) or omi ssion (neglect), intentional or unintentional, and of one or more types: \200 \200 \200 Physical, sexual, verbal, or psychological abuse. Physical or psychological neglect. Financ ial exploitation. The abuse or neglect results in unnecessary suffering, injury, pain, or loss and leads to a violation of human rights and a decrease in the quality of life. Epidemiology of elder abu se Occurs in both domestic and institu- tional settings: \200 Domestic settings incidents of abuse or neglect in domestic settings. The most common forms of abuse are verbal abuse and \201 nancial exploitation by family members and physical a buse by spouses. Gender distribution (of victims) is equal and economic status and age are unrelated to risk of abuse. Importantly, elder abuse is under-reported \200\224450 000 olde r adults in domestic settings were abused, neglected, or exploited in the USA during 1996, of which only 70 000 were self-reported. Institutional settings institutional settings. How ever, one survey of nursing home staff in a US state disclosed that 36% of staff had witnes sed at least one incident of physical abuse in the preceding year, while 10% admitted havin g committed at least one act of physical abuse themselves. Approximately 4 \200\2236% of elderly people report No data exists for the extent of abuse within Explaining elder abuse The main risk factors for elder abuse are: dependency and social iso lation of the victim; carer has mental or sub- stance misuse problems; absence of a suitabl e guardian. Factors vary according to the type of abuse; for example, dependency is a risk factor for \201 nancial or emotional abuse, but not necessarily for physical abuse. Also the causes of spouse abuse may differ from the causes of abuse by adult offspring. 14_Semple_Chap14.indd 526 12/7/2012 3:43:49 PM ISSUES OF ELDER ABUSE 527 An integrative response to elder abuse Prevention is the best approach and a number of meas ures have proved effective: training and support of carers; reducing isolation of elders; r espite care; CPN visits; etc. Responding to abuse effectively requires a multidisciplinary approach and a proactive system of assessment of suspicious cases (a number of assessment i nstruments have been developed).3,4 There may now also be legislation available to allow as sessment and intervention, e.g. The Adult Support and Protection (Scotland) Act 2007. 1 Payne BK (2002) An integrated understanding of elder abuse and neglect. J Crim Just 30: 5 35 \200\22347. 2 Wolf RS (1999) Suspected abuse in an elderly patient. Am Fam Physician 59: 1319 \200\22320. 3 Fulmer T (2003) Elder abuse and neglect assessment. J Gerontolog Nurs 2 9: 8 \200\2239. 4 Reis M (1998) Validation of the indicators of abuse (IOA) screen. Geronto logist 38: 471 \200\22380. 14_Semple_Chap14.indd 527 12/7/2012 3:43:49 PM CHAPTER 14 Old age psychiatry 528 Psychopharmacology in the elderly1,2 Pharmacokinetics The physiological changes associated with ageing mean that the older patient \200\231s system handles drugs quite differently fr om that of a younger individual. \200 Absorption in gastric pH and mesenteric blood \202 ow. Distribution of drugs is altered, however: reduced body mass, body water, and plasma proteins, together with increased body f at cause increased levels of free drug and longer half-lives (especially of psychotropics). Drug metabolism and loss of ef \201 ciency of liver microsomes. Excretion is reduced with the drop in renal clearance that accompanies old age. Thus drug effects are generally prol onged and cumulative and the risk of toxicity is high. generally remains the same, although there are reductions is reduced due to decreased blood \202 ow to the liver Pharmacodynamics Technology such as PET is enlightening our understanding of the direct eff ects of drugs in the CNS. Speci \201 c differ- ences in these effects in the elderly inclu de: \200 Dopaminergic system thus there is increased sensitivity to the EPSEs of neuroleptics (not d ystonias). Cholinergic system receptors with advancing age. Noradrenergic system \200\224N E levels decrease with age, which may cause this age group to become increasingly vulnerabl e to mood disorders. Narcotics and sedative hypnotics \200\224there is increased sensitivi ty to sedatives in the elderly due to a reduction in the number of available receptors. \200\224there are fewer DA cells in the basal ganglia; \200\224there is a normal reduction in cholinergic The implications of these changes are that elderly patients are more sensi- tive to almost all drugs used in psychiatry. See Box 14.2. 14_Semple_Chap14.indd 528 12/7/2012 3:43:49 PM PSYCHOPHARMACOLOGY IN THE ELDERLY 529 Box 14.2 General principles of prescribing include: \200 \200 \200 Start with a very low dose. Increases should be made slowly. Maximum ef \201 cacy is often achieved at signi \201 cantly lower doses than in younger adults. Beware of dangerous sid e-effects such as postural hypotension, arrhythmias, and sedation. The elderly are particul arly sensitive to EPSEs and anti-cholinergic side-effects. Beware of drug interactions due to common problem of polypharmacy in the elderly. Atypical neuroleptics are generally bette r tolerated than conventionals. SSRIs, SNRIs, and NARIs are generally safer than TCAs; whil e MAOIs and lithium may be useful in resistant depression. Monitor lithium therapy closely as levels can \202 uctuate easily and long-term effects on thyroid and renal function are not infrequent. Always consider suicide risk as old age is a risk factor for suicide. 1 Baldwin R and Burns A (1998) Pharmacological treatments. In Butler R and Pitt B (eds), Se minars in old age psychiatry, pp. 247 \200\22365. London: Gaskell. 2 Gareri P, Falconi U, D e Fazio P, et al. (2000) Conventional and new antidepressant drugs in the elderly. Progr Ne urobiol 61: 353 \200\22396. 14_Semple_Chap14.indd 529 12/7/2012 3:43:49 PM CHAPTER 14 Old age psychiatry 530 Services for the elderly1,2 Services for the elderly are organized differently according to government policies and availability of resources. In principle though, the ideal service should plan to: \200 \200 \200 \200 \200 Maintain the elderly person at home for as long as possible. Respond quickly to medical and social problems as they arise. Ensure co-ordination of the work of those providing continu ing care. Support relatives and others who care for the elderly at home. Promote liaison be tween medical and social and voluntary services. Primary care services At the primary care level GPs, health visitors, community nurses, and health workers will deal with most of the prob- lems of elderly people. Acute and long-term hospital services Elderly patients often require admission for acute assessment and treatment, respite care, or long-term care. Ser vices may be situated within general medical wards for the elderly or within specialized ol d age psychiatry units. The advantage of acute services being located in general hospitals rather than in psychiatric hospitals is that a range of associated specialist services (suc h as old age medicine, neurology, and radiology) is often more readily available. Day and o utpatient care Ideally a service should have outpatient facilities for the assessment, trea tment, and follow-up of mobile elderly patients with mental health problems. Sometimes thes e clinics offer a spe- cialist service such as the \200\230memory clinic \200\231. Day-car e services may take the form of a general or psychiatric day hospital, and local authoritie s often provide day centers and social clubs for functional and social support. Community p sychiatric nurses (CPNs) CPNs provide a vital link between primary care and specialist serv ices. They often perform assess- ments on patients after receiving a referral from a GP. Th ey also monitor treatment in collaboration with GPs and the psychiatric services. In addi- tion, they take part in the organization of home support for the demented elderly. Informal carers These are the unpaid relatives, neighbors, or friends who care for the elderly pers on at home. Demographic changes and the move to community care have increased the burden on carers. Informal carers are twice as likely to be women. Carers often suffer considerable stress, especially where the patient is suffering from advanced dementia. Relieving carer b urden is a challenge for any service. Active involvement of medical and social personnel, a s well as provision of education and respite, are important aspects of carer support. Domic iliary services These include; home helps; meals at home; laun- dry and shopping services; emergency call systems. In some countries such as the UK, local authorities provide these s ervices; however, in many oth- ers these services are either privately engaged, obtained fr om voluntary organizations, or are unavailable. 14_Semple_Chap14.indd 530 12/7/2012 3:43:49 PM SERVICES FOR THE ELDERLY 531 Residential and nursing care In most countries the local authorities take responsibility fo r providing old people \200\231s homes and other sheltered accommodation. These range in st andard from large crowded institutions to small independent units and, ideally, they need t o balance individual privacy with involvement in outside activities. In many communities pr ivate homes are available, but \201 nancial constraints put these out of the reach of the majority of older people. In planning residential care for the elderly, authorities need t o provide for a wider range of accommodation: a small supported unit with 2 or 3 people may be ideal for the still independ- ent and mobile individual; while larger homes with nursin g support are required for those who are more dependent, with a number of physical and/or p sychiatric needs. 1 Wertheimer J (1997) Psychiatry of the elderly: a consensus statement. Int J Geriat Psychi at 12: 432 \200\2235. 2 Gelder M, Gath D, Mayou R, et al. (1996) Oxford textbook of psychia try, 3rd edn. Oxford: Oxford University Press. 14_Semple_Chap14.indd 531 12/7/2012 3:43:49 PM CHAPTER 14 Old age psychiatry 532 The end of life, living wills, and withdrawal of active treatment The end of life Managing a patient \200\231s \201 nal weeks or days and ensuring that their death is a \200\230go od death \200\231 is a challenge that has only recently been addressed in our health servic es and training programs.1 Many health professionals have never received any guidance regar ding their involve- ment in this common and extremely important phase of people \200\231s l ives. Contemporary palliative services stress the following components in pro- viding a \200\230good death \200\231: \200 \200 \200 \200 \200 \200 \200 A multidisciplinary approach Ability to \200\230diagnose dying \200\231 Communication with patient and family Provision of adequate physical support (e.g. analgesia, hydration) Mini mize unnecessary interventions Establish a non-resuscitation plan Psychological, social, cu ltural, and spiritual support Living wills A living will is an advance directive (usually written and witnessed), also re ferred to as an anticipaitatory care plan, made by an individual regarding their preference s for future treatment during a termi- nal illness. Usually the person speci \201 es the d egree of irreversible deteri- oration after which they want no further life-sustaining trea tment. They may also give clear instructions refusing certain medical interventions. If a h ealth professional is asked to assist someone in drawing up a living will, the following is sues should be considered: \200 the patient should be fully informed about the illness and treatment options; the patient s hould be mentally competent; the patient should be re \202 ecting his/her own views, free from in \202 uence. \200 The health carer is required to abide by the living will, although basic care (i.e. analges ia, catheter, \202 uids) should be provided in all cases. (The BMA has a code of practice entitled Advance Statements about Medical Treatment). The Mental Capacity Act 2005 (coveri ng England and Wales) allows for \200\230advance decisions \200\231 (b p. 876) in case of future incapacity. If a patient lacks capacity, and information about a written or verbal advance refusal of t reatment is recorded in their notes or is otherwise brought to your attention, you must bea r in mind that valid and applicable advance refusals must be respected. A valid advance ref usal that is clearly applicable to the patient \200\231s present circumstances will be lega lly binding in England and Wales (unless it relates to life-prolonging treatment, in which case further legal criteria must be met). Valid and applicable advance refus- als are poten tially binding in Scotland and Northern Ireland, although this has not yet been tested in t he courts. 14_Semple_Chap14.indd 532 12/7/2012 3:43:49 PM END OF LIFE, LIVING WILLS, AND WITHDRAWAL OF TREATMENT 533 Withdrawal of treatment2,3 The active or passive involvement of a carer in hastening an ind ividual \200\231s death is highly controversial and mor- ally complex. There are differing degrees of involvement that should be distinguished: \200 Withdrawal of active interventions such as medications, blood transfusion, etc. This is an accepted aspect of palliative care and draws little debate. Withdrawal of life-sustaining t reatment such \202 uids, food, etc. This is equivalent to \200\230allowing a patient to die \200\231. Since the current emphasis is on preserving human dignity rather than preserv ing life, this is morally acceptable for many and should not be considered euthanasia. Acti ve intervention which hastens or precipitates the patient \200\231s death \200\224 euthanas ia. This is distinguishable from homicide in that the patient has either consented to the a ssisted death or is unable to (e.g. comatose) and the intervention is regarded as a \200 \230mercy killing \200\231. That time of year thou mayst in me behold When yellow leaves, or none, or few, do hang Upon those boughs which shake against the cold, Bare ruin \200\231d choirs, where late the swee t birds sang. In me thou see \200\231st the twilight of such day As after sunset fadeth in the west; Which by and by black night doth take away, Death \200\231s second self, that sea ls up all in rest. In me thou see \200\231st the glowing of such \201 re, That on the ash es of his youth doth lie, As the death-bed whereon it must expire Consum \200\231d with tha t which it was nourish \200\231d by. This thou perceiv \200\231st, which makes thy love mor e strong, To love that well which thou must leave ere long. Shakespeare: Sonnet 72 1 Ellershaw J and Ward C (2003) Care of the dying patient: the last hours or days of life. Br Med J 326: 30 \200\2234. 2 Hermsen MA and ten Have HA (2002) Euthanasia in palliative ca re journals. J Pain Sympt Manag 23: 517 \200\22325. 3 Sharma BR (2003) To legalize physicia n-assisted suicide or not? \200\224a dilemma. J Clin Foren Med 10: 185 \200\22390. 14_Semple_Chap14.indd 533 12/7/2012 3:43:49 PM This page intentionally left blank 535 Chapter 15 Substance misuse The psychiatry of substance misuse 536 Substance use and misuse 538 Substance misuse disord ers 540 The dependence syndrome 542 Stages of change and harm reduction 544 Alcohol misuse 546 Alcohol as a drug 548 Screening for alcohol problems 550 Assessment of the patient with alcohol problems 552 Giving drinking advice 554 Planning treatment in alcohol misuse 556 A lcohol withdrawal syndromes 558 Management of alcohol withdrawal 560 Maintenance interventi ons in alcohol misuse 1: psychological methods 562 Maintenance interventions in alcohol misuse 2: pharmacological methods 564 Alcohol misuse disorders 1 566 Alcohol misuse disorders 2 568 Psychiatric comorbidity 570 W ernicke \200\223Korsakoff syndrome 572 Medical complications of alcohol misuse 574 Illegal drugs 576 Street slang associated with drug misuse 578 Opiates/opioids 580 Depressants 582 Stimulants 584 Hallucinogens 586 Other drugs 588 Assessment of the drug user 592 Planning t reatment in drug misuse 594 Substitute prescribing 1: principles 596 Substitute prescribing 2: opiates 598 Substitute prescribing 3: benzodiazepines 600 Monitoring of maintenance pre scribing 602 Psychotic illnesses and substance misuse 604 Legal issues related to drug and alcohol misuse 606 15_Semple_Chap15.indd 535 12/7/2012 3:47:55 PM CHAPTER 15 Substance misuse 536 The psychiatry of substance misuse The subspecialty of substance misuse is concerned with t he assessment and treatment of patients with problems arising from the misuse of harm- ful or addictive substances. These include: (1) alcohol, (2) illegal or \200\230street \200 \231 drugs, (3) prescription and over-the-counter medicines, and (4) volatile chemicals. Th e resultant problems include both mental and physical ill- nesses and family, housing, empl oyment, and legal dif \201 culties. Both psy- chological and pharmacological interventions are used in treatment, which may include detoxi \201 cation and substitute prescribing. The majority of medical interventions in patients with substance use problems are undertake n by GPs. In areas where there are no substance misuse specialists, more complex cases are seen by general psychiatrists, with management of the acute medical problems, including ove rdose and withdrawals, treated in the general hospital. All psychiatrists will have ample o pportunity to see and develop skills in treating patients with sub- stance misuse. Around the UK there is variable service provision for drug and alcohol misuse. Some service s will restrict themselves to the primary substance misuse, while others will address all m ental health needs. Specialists tend to work alongside voluntary and non-medical treatment agencies, many of which provide a good and vital service. Strong links between psychiatry/ substance use services and non-medical agencies should be fostered. Drug treatment services within the health care system make up only one part of the wider ra nge of centrally and locally funded and volunteer services for problem drug users. Within t he health service the majority of service provision is within primary care, who will have a variable degree of experience of (and enthusiasm for) such work. The availability of speci alist services will vary by area and setting (e.g. rural/urban) and may range from the spec ial interest of an individual psychiatrist or GP, to a specialist serv- ice with support st aff and dedicated facilities. Local pharmacists can also be a useful resource in supervisin g consumption of substitute drugs. Non-health care provision will also vary by setting, though may include: advice shops offer ing lea \202 ets and education about drugs and harm reduction strategies; self-help groups , some adhering to an Alcoholics Anonymous (AA)-style \200\230twelve-step approach \200 \231, usually involving peer sup- port from ex-users; and residential rehabilitation facili ties, offering detoxi- \201 cation and abstinence programs. The practitioner working in t he \201 eld of drug misuse should develop an awareness of these services and their referr al criteria and encourage a collaborative and co-ordinated approach to patient management. 15_Semple_Chap15.indd 536 12/7/2012 3:47:55 PM THE PSYCHIATRY OF SUBSTANCE MISUSE 537 The skills required for those working in the \201 eld of substance misuse are: \200 Knowledge of the psychiatric symptoms and syndromes associated with substance misuse This i ncludes the effects of substance misuse on the brain, in causing psychiatric symptoms, and the effects of substance misuse on pre-existing mental and physical illness. Knowledge and understanding of the in \202 uence of psychological and social factors on substance misuse and relapse. Experience of interviewing and counseling methods Skills in interviewing and motivating patients who may have very ambivalent feelings about changing their behavior. Ex perience of available pharmacological and psychological treatment methods An area undergoin g constant development, where there is a need to keep abreast of changes in evidence. Aware ness of the culture and pattern of drug use within a community Patterns of drug use change over time, and the types and strengths of drugs available in a community will also change d ynamically. Information from police and the voluntary sector can be helpful here. Willingne ss to be involved with other agencies \201 eld of substance misuse is done by agencies ou tside the health care system. Practitioners should attempt to understand the work of these agencies, and refer to them where appropriate. Understanding of the natural history of subs tance misuse/addiction Substance misuse disorders can be chronic, and at times lifelong, wi th a relapsing/remitting course (like many psychiatric conditions). Taking a long-term appr oach is therefore essential. Ability to consider health in its wider context Substance misu se gives rise to health risks beyond the effect of the drug (e.g. drink driving deaths, HIV infection). In addition, it is a community problem leading to lost productivity, crime, ro ad accidents, violence, and family break-up. Consideration of change beyond change in an in dividual patient Patterns of substance misuse in a society are susceptible to political man ipulation (e.g. licensing hours, decriminalization, legalization, availability of treatment services). One role of substance misuse specialists is to understand these factors and to present the case for political change. Valuable work in the A non-judgemental approach. Sometimes there is a perception that drug or alcohol users are \200\230dif \201 cult \200\231 patients to treat. Bear in mind GMC guide- lines direct th at it is \200\230unethical for a doctor to withhold treatment from any patient on the basi s of a moral judgment that the patient \200\231s activities or lifestyle may have contribut ed to the conditions for which treatment was being sought \200\231. Note: for the purposes of this chapter, we refer to alcohol misuse and drug misuse separate ly and refer to them collectively as substance mis- use. Alcohol is of course a drug and sh ould be thought of as such, but we believe this terminology to be clearer and more understa ndable to patients. 15_Semple_Chap15.indd 537 12/7/2012 3:47:56 PM CHAPTER 15 Substance misuse 538 Substance use and misuse \200\230Humankind cannot bear very much reality \200\231 T.S. Eli ot \200\230The urge to escape, the longing to transcend themselves, if only for a few minutes , is and always has been one of the principal appetites of the soul. \200\231 Aldous Huxley