The Shared Responsibility of Mental Health in the Elderly

At the dawn of the 20th century, psychiatry began to shift away from the rest of medicine, particularly from neurology. Fortunately, that trend was halted and dramatically reversed by the end of the century. My personal feeling is that apartheid policies rarely work, whether applied to political systems or health care systems. I believe that the separation of psychiatry from medicine was harmful to the psychiatrists, who continue to suffer from that legacy in the form of inadequate resources and lower pay as compared to many other specialists. Even more importantly, medical and surgical patients suffer from the lack of attention to their psychiatric and psychological needs.

The necessity of psychiatric expertise in caring for elderly patients is very easy to demonstrate. Medical illnesses are often complicated by depression, and a high level of skill is required to detect and manage depression in sick elderly patients. Geriatricians and geriatric psychiatrists both manage patients with dementia, and cooperation allows more efficient use of scarce resources. In fact, geriatric psychiatry has been in the forefront of demonstrating the degree to which collaboration between psychiatry and medicine can be valuable. Early on in my career, I visited the Department of Health Care of the Elderly at Nottingham University, England. This department combined both geriatric medicine and geriatric psychiatry and was headed by Tom Arie, one of the giants in the history of geriatric psychiatry. In this service, there was no way to say, "that patient is not our responsibility".

In my practice of geriatric medicine, not a day goes by that psychiatric issues do not surface. Not all the cases are complex enough to warrant consulting a psychiatrist, but many are. Unfortunately, psychiatrists with an interest in the problems of the elderly are not that common, despite their importance to geriatric care (the same could probably be said about geriatric medicine specialists). As a result, primary care physicians must develop some expertise in dealing with the psychiatric problems of their elderly patients, and that is the thrust of this month's issue of Geriatrics & Aging. There is an article on personality and mood adaptivity with aging by Dr. Scott Patten, and two articles focusing on sleep issues: Dr. Christina McCrae and Candece Glauser review insomnia in long-term care, and Dr. Daniel Foley discusses the issues of sleep disturbances and dementia.

Depression is a particular challenge to the primary care physician. Drs. Michael Irwin and Jennifer Pike provide a good review of depression screening instruments in primary care, while Dr. Marie-Josée Filteau reviews the important role of physical symptoms in the diagnosis of depression in the elderly. While we have many effective medications for depression, none are as effective and free of side effects as we would like, and so Dr. Kiran Rabheru's article on the new and emerging classes of antidepressant drugs serves as a valuable complement to this issue.

Furthermore, we have our usual collection of articles on topics of interest. Dr. David Gladstone continues his series on neurological examination with a discussion of the motor examination in the context of aging, dementia and cerebrovascular disease. We have articles on osteoarthritis by Dr. Shafiq Qaadri, urinary incontinence by Drs. Howard Fenster and Lynn Stothers, and valvular heart disease by Drs. Ernane Reis and Mercè Roqué.

Enjoy this issue.