bluuebunny/crossref_metadata_2025 huggingface dataset:
Multifaceted Change
Authors: Ferraro Kenneth F.
Published: December 2017

Aging involves multiple related systems; change in one system influences other systems. Nathan Shock referred to aging as a dynamic equilibrium and argued that studying the interrelationships of multiple systems is essential for gerontology. A growing number of researchers study relations across systems, but many focus on syndromes of declining health or function, without much regard for alternative scenarios such as nonlinear change and compensatory mechanisms. The axiom of multifaceted change contends that viewing aging as a syndrome of decline oversimplifies the changes involved. Instead, gerontology needs a biopsychosocial model to study aging as a multidirectional change process across multiple systems. Research on how social factors influence telomere length is used to illustrate this axiom.
Ageism
Authors: Ferraro Kenneth F.
Published: December 2017

Negative views of aging are pervasive and pernicious, and arise, in part, from a failure to recognize the heterogeneity of the older adult population. Many people, at various ages, view the aging process pejoratively, thereby exaggerating the declines associated with growing older, Ageism also may entail unfair treatment toward older people, often manifest as neglect and exclusion. The consequences of ageism are notable, including accelerated declines in biological, psychological, and social functioning as well as ignoring or minimizing the intellectual and creative potential of older adults. To counter negative views of growing older, examples of late life genius and creative endeavor are profiled.
The Gerontological Imagination at Work in Scientific Communities
Authors: Ferraro Kenneth F.
Published: December 2017

Specified in six axioms, the gerontological imagination enables scholars from a variety of fields to comprehend core concepts and ideas in the study of aging. This chapter highlights the interrelatedness of the axioms and outlines ways to apply this interdisciplinary paradigm in research on aging. A paradigm for the study of any subject matter is a sign of intellectual maturity, but the scientific community of those who study aging remains a loosely connected network, largely embedded in disciplines. A coherent paradigm for gerontology will aid research on aging in those disciplines and accelerate the evolution of gerontology as a field of study.
Respiratory Mechanics
Authors: Kreit John W.
Published: December 2017

Ventilation can occur only when the respiratory system expands above and then returns to its resting or equilibrium volume. This is just another way of saying that ventilation depends on our ability to breathe. Although breathing requires very little effort and even less thought, it’s nevertheless a fairly complex process. Respiratory Mechanics reviews the interaction between applied and opposing forces during spontaneous and mechanical ventilation. It discusses elastic recoil, viscous forces, compliance, resistance, and the equation of motion and the time constant of the respiratory system. It also describes how and why pleural, alveolar, lung transmural, intra-abdominal, and airway pressure change during spontaneous and mechanical ventilation, and the effect of applied positive end-expiratory pressure (PEEP).
Instrumentation and Terminology
Authors: Kreit John W.
Published: December 2017

Instrumentation and Terminology describes the general design of mechanical ventilators, reviews the functions of the ventilator–user interface, and defines and explains commonly used terms and acronyms associated with mechanical ventilators. Despite big differences in outward appearance, all mechanical ventilators have several basic features in common. All must be connected to high-pressure sources of oxygen and air. All ventilators have a user interface, which allows the clinician to easily choose from a wide variety of ventilator settings, and displays these settings, as well as important, real-time patient data. Tables 4.1 and 4.2 in this chapter list most of the terms that you’ll need to use and understand when caring for mechanically ventilated patients.
Respiratory Failure and the Indications for Mechanical Ventilation
Authors: Kreit John W.
Published: December 2017

Respiratory failure occurs when a disease process significantly interferes with the respiratory system’s vital functions and causes arterial hypoxemia, hypercapnia, or both. Typically, respiratory failure is divided into three categories based on the underlying pathophysiology: ventilation failure, oxygenation failure, and oxygenation-ventilation failure. With severe disturbances in gas exchange, mechanical ventilation is often needed to assist the respiratory system and restore the PaCO2, PaO2, or both, to normal. Respiratory Failure and the Indications for Mechanical Ventilation defines and describes the three types of respiratory failure and reviews the four indications for intubation and mechanical ventilation—acute or acute-on-chronic hypercapnia, refractory hypoxemia, inability to protect the lower airway, and upper airway obstruction.
Patient–Ventilator Interactions and Asynchrony
Authors: Kreit John W.
Published: December 2017

Patient–Ventilator Interactions and Asynchrony describes what happens when the patient and the ventilator do not work together in an effective, coordinated manner. Effective mechanical ventilation requires the synchronized function of two pumps: The mechanical ventilator is governed by the settings chosen by the clinician; the patient’s respiratory system is controlled by groups of neurons in the brain stem. Ideally, the ventilator simply augments and amplifies the activity of the respiratory system. Asynchrony between the ventilator and the patient reduces patient comfort, increases work of breathing, predisposes to respiratory muscle fatigue, and may even impair oxygenation and ventilation. The chapter describes the causes and consequences of patient–ventilator asynchrony during ventilator triggering and the inspiratory phase of the respiratory cycle and explains how to adjust ventilator settings to improve patient comfort and reduce the work of breathing.
Right Ventricular Failure
Authors: Kreit John W.
Published: December 2017

Right ventricular (RV) failure is common in the ICU. Chronic RV failure is most often due to long-standing left ventricular (LV) systolic or diastolic failure or other causes of chronic pulmonary hypertension. Acute RV failure can result from massive pulmonary embolism, ARDS, RV infarction, and acute LV failure. Finally, acute-on-chronic RV failure can be precipitated by any disorder that leads to an abrupt rise in pulmonary vascular resistance (PVR) and RV afterload. Right Ventricular Failure provides an in-depth review of the adverse hemodynamic effects of mechanical ventilation and PEEP in patients with right ventricular failure. The chapter explains the effect of positive pressure ventilation and PEEP on pulmonary vascular resistance and RV afterload and describes how to adjust the ventilator to minimize these hemodynamic effects.
Noninvasive Mechanical Ventilation
Authors: Kreit John W.
Published: December 2017

Although so-called invasive ventilation can be life-saving, it can also cause significant morbidity. It has long been recognized that positive pressure ventilation can also be delivered “non-invasively” to critically ill patients through several different types of “interfaces” (usually a tight-fitting face mask). Noninvasive Mechanical Ventilation explains when and how to use noninvasive ventilation to treat patients with respiratory failure. It provides a detailed explanation of how noninvasive (bi-level) ventilators differ from the standard ICU ventilators, describes the available modes and breath types as well as the indications and contraindications for noninvasive ventilation, and explains how to initiate, monitor, and adjust noninvasive ventilation.
Cognitive and Motivational Neuroscience of Psychotic Disorders
Authors: Young Jared W. , Anticevic Alan , Barch Deanna M.
Published: December 2017

Schizophrenia is a complex neuropsychiatric syndrome presenting with a constellation of symptoms. Clinicians have long recognized that abnormalities in cognitive function and motivated behavior are a key component of psychosis, and of schizophrenia in particular. Here we postulate that these deficits may reflect, at least in part, impairments in the ability to actively maintain and utilize internal representations of emotional experiences, previous rewards, and motivational goals in order to drive current and future behavior in a way that would normally allow individuals to obtain desired outcomes. We discuss the evidence for such impairment in schizophrenia, how it manifests in domains typically referred to as executive control, working memory, and episodic memory, how it may help us understand impairments in reward processing and motivation in schizophrenia, and the animal research consistent with these hypotheses.
The Neurobiology and Treatment of Bipolar Disorder
Authors: Burdick Katherine E. , Ospina Luz H. , Haggarty Stephen J. , Perlis Roy H.
Published: December 2017

Bipolar disorder (BPD) is a severe mood disorder that often has psychotic features. Its most severe forms are more common and significantly more likely to cause disability than originally thought. Studies of high-risk children have found them to be at increased risk for a variety of symptoms and neurobiological abnormalities. In contrast to schizophrenia, there is no formal prodromal syndrome that has been identified, and cognitive abnormalities do not precede the onset of the disorder. Abnormal sleep and circadian rhythms are prominent and have led to intriguing biological models. Neurobiological experiments have primarily focused on candidate pathways and include circadian abnormalities, epigenetic processes including histone modification, WNT/GSK3 signaling, other modulators of neuroplasticity, and mitochondrial dysfunction. Recent data suggest that BPD is a highly polygenic disease and that integration of prior modeling and data with the wide variety of new genetic risk loci will be productive in the future.
Novel Approaches for Treating Psychotic Disorders
Authors: Marques Tiago Reis , Kapur Shitij
Published: December 2017

Current antipsychotic medications have been the mainstay in the treatment of schizophrenia since chlorpromazine was introduced in 1952. However, all antipsychotics share the same mechanism of action, which involves a blockade of the dopamine D2-receptor. This chapter covers recent attempts to develop new treatments for psychotic disorders. These include new approaches to the delivery of existing antipsychotic medications and the most recent and promising mechanisms of action that are distinct from existing antipsychotics. Some of the new mechanisms of action include drugs targeting the glutamatergic system, the alpha7 nicotinic acetylcholine receptor, the phosphodiesterase 10A enzyme, or the muscarinic and serotoninergic system. Finally, we have reviewed a number of alternative nonpharmacological pathways, such as avatar therapy, repetitive transcranial magnetic stimulation, or cognitive remediation. The chapter ends by discussing some of the major challenges facing the development of new treatments for psychotic disorders.
Functional Neurocircuitry and Neuroimaging Studies of Anxiety Disorders
Authors: Goodkind Madeleine S. , Etkin Amit
Published: December 2017

Anxiety and fear serve adaptive functions and include wide-ranging subjective, physiological, behavioral, and cognitive responses. When these reactions are present chronically, and to a heightened degree that generalizes to signals beyond those that are objectively dangerous, one sees emergence of clinical anxiety disorders. Historically, anxiety disorders have been conceptualized as disruptions in fear processing, though more recent accounts also highlight changes in emotional reactivity beyond fear and deficits in emotion regulation. In this chapter, we review the neural circuitry relevant for fear processing and for emotional reactivity and regulation more broadly. We then review neuroimaging studies of social anxiety disorder, specific phobia, generalized anxiety disorder, panic disorder, and posttraumatic stress disorder. We highlight areas of overlap between disorders as well as disorder-specific perturbations.
Novel Approaches for Treating Anxiety Disorders
Authors: Sturman David A. , Kaufman Milissa L. , Bigony Cara E. , Ressler Kerry J.
Published: December 2017

While multiple effective pharmacotherapies and psychotherapies exist for anxiety disorders, to many they lack efficacy, tolerability, and/or accessibility. Only one-third of those with anxiety disorders seek mental health treatment and, of those who do, nonadherence and nonresponse (or incomplete response) remain substantial problems. There is thus a great need for novel treatments. In this chapter, we discuss approaches for the development of new anxiety treatments based on an improved understanding of the neurobiology underlying anxiety and fear-related disorders. We define novel treatments as those that hold potential promise but are not yet fully proven or available, or those that are recently available but not widely implemented.
Cellular and Molecular Mechanisms of Addiction
Authors: Reissner Kathryn J. , Kalivas Peter W.
Published: December 2017

Exposure to drugs of abuse can be a reinforcing experience that, in vulnerable individuals, can lead to continued use and the development of an addiction disorder. Evidence indicates that the escalation in use and compulsive motivation to obtain the drug is linked to long-lasting cellular changes within the brain reward neurocircuitry. In this chapter we describe the stages of transition in use from social use to habitual relapse, and within that context we describe the implicated neurocircuitry, and the enduring cellular and molecular changes that occur within that circuitry, that may mediate the preoccupation with drug seeking in addiction-vulnerable individuals.
Neuroimaging in Pediatric Psychiatric Disorders
Authors: Roberts Timothy P.L. , Bloy Luke
Published: December 2017

Noninvasive imaging and electrophysiological techniques have been developed to probe specific aspects of brain function and dysfunction, providing exquisite spatial maps of functional centers and temporal characteristics. The evolution of these techniques has advanced from single-modality methods identifying functional localization, specialization and segregation, through real-time measures of neuronal activity, toward multimodality integration of structural, functional, and spectro-temporal approaches. While these have an immediate impact in conditions where physical brain lesions are evident (e.g., brain tumor and stroke), making a commensurate contribution within neuropsychiatry is more complex. Nonetheless, by combining concepts of morphology, neurochemistry, neural signal propagation, and regional connectivity, there appears to be ample opportunity to contribute not only to the diagnosis of patients with mental illness but to the stratification and subtyping across behavioral phenotypes and, ultimately, to patient management. Here we present an overview of the most common noninvasive neuroimaging methodologies and their applications to pediatric neurodevelopmental disorders.
Neurobiology of Autism Spectrum Disorder and Intellectual Disability
Authors: Costales Jesse , De Rubeis Silvia , Foss-Feig Jennifer , Hof Patrick R. , Buxbaum Joseph D. , Kolezvon Alexander
Published: December 2017

Autism spectrum disorder (ASD) is defined by impairments in social communication, along with the presence of restricted and repetitive behaviors. Approximately half of affected children also suffer from intellectual disability (ID), which is defined by cognitive and adaptive functioning at least two standard deviations below the mean (e.g., standard scores <70). It is now well established that genetic factors are major contributors to both ASD and ID. The following chapter will outline emerging themes and integrate data from human and animal studies using genetic, imaging, and histopathological methods. Emerging findings from studies of the immune system and the microbiome will also be briefly reviewed.
Computational Psychiatry and the Bayesian Brain
Authors: Friston Karl J. , Dolan Raymond J.
Published: December 2017

This chapter considers recent advances in computational neuroscience that are especially relevant for psychiatry. We offer a review of computational psychiatry in terms of its ambitions, emerging domains of application, and promises for the future. Our focus is on theoretical formulations of brain function that accommodate subjective beliefs and behavior within formal (computational) frameworks—frameworks that can be grounded in neurophysiology down to the level of synaptic mechanisms. Understanding the nature and principles that underlie functional brain architectures is, we assume, essential for understanding and phenotyping psychopathology and its pathophysiological underpinnings. To illustrate computational approaches to psychiatric disorders, we focus on active (Bayesian) inference and predictive coding. Specifically, we try to explain how the basic principles of neuronal computation are being used to understand psychiatric phenomena, ranging from affiliative behavior and theory of mind in autism to abnormalities of smooth pursuit eye movements in schizophrenia.
Life course approach to understanding inequalities in health in later life
Authors: Bell Ruth , Marmot Michael
Published: December 2017

A long and healthy life is universally valued. The starkest inequalities in later life are how many years of life remain at an older age such as 65 years, and how many years of life that remain free from disabilities that impede physical, cognitive, and social functioning to the extent that they limit the sense of valuing one’s life. In this chapter we apply the frame of social determinants of health, using the life course approach to understand inequalities in health in later life. Healthy ageing is patterned by degrees of social advantage. Biological ageing, as revealed by physical and cognitive changes, is slower in people in better socioeconomic circumstances. These inequalities in health in later life need to be understood in terms of current social, economic, environmental conditions of living, as well as previous experiences and living conditions across the life course that affect the biological processes of ageing.
Comprehensive geriatric assessment: evidence
Authors: Pilotto Alberto , Panza Francesco
Published: December 2017

Comprehensive geriatric assessment (CGA) is a multidisciplinary diagnostic and treatment process that identifies the medical, psychosocial, and functional capabilities of older adults in order to develop a coordinated management plan. No standard criteria are available to readily identify subjects who are likely to benefit from CGA. Recent evidences suggested that the healthcare setting may modify the effectiveness of CGA programmes. Home CGA programmes and CGA performed in the hospital, especially in dedicated units, have been shown to be consistently beneficial for several health outcomes. In contrast, the data are conflicting for post-hospital discharge CGA programmes, outpatient CGA consultation, and CGA-based inpatient geriatric consultation services. The effectiveness of CGA programmes may be influenced also by particular settings or specific clinical conditions, with tailored CGA programmes for older frail patients evaluated for preoperative CGA, admitted or discharged from emergency departments and orthogeriatric units, or with cancer, organ failure, and cognitive impairment.
Falls
Authors: Becker Clemens , Woo Jean , Todd Chris
Published: December 2017

Falls are very common among older people, with 30–40% of people aged 65 or over falling each year. Incidence increases with age, is particularly high in residential care settings, and has a considerable burden in terms of morbidity, mortality, use of health services, and reductions in quality of life. In the first section of this chapter we define falls, then review the epidemiology of falls in the community, and acute hospital, residential, and long-term care. We review and identify the major risk factors for falls and the assessment and screening tools used to detect risk and resources of best practice recommendations for clinical practice. In the second section, we provide overviews of best practice in prevention and clinical management, first for older people living independently in the community, then for acute hospital care, and thirdly for residential and long-term care.
Injuries in sports activities in elderly people
Authors: Kostka Tomasz , Kostka Joanna
Published: December 2017

Regular physical activity in old age is widely recommended as an effective way to prevent chronic diseases and maintain well-being. Nevertheless, sports participation carries the risk of injury. In elderly people, the risk of injury is greater due to age-related pathophysiological changes and concomitant chronic conditions. Available data indicate an increasing number of injuries among older people, which is associated with there being more older people and an increasing number of these people are participating in sports and physical exercise. An appropriate identification of risk factors for injury and education of older people can reduce the incidence of injuries. Methods of preventing injuries include protective equipment such as helmets, warming up, and properly designed training programmes. Health benefits of participation in regular physical activity adjusted to health status and physical functioning outweigh hazards of sport-related injuries, even in advanced age.
Examining the nervous system of an older patient
Authors: Woodford Henry J. , George James
Published: December 2017

Ageing is associated with changes in the nervous system, especially the accumulation of neurodegenerative and white matter lesions within the brain. Abnormalities are commonly found when examining older people and some of these are associated with functional impairment and a higher risk of death. In order to reliably interpret examination findings it is important to assess cognition, hearing, vision, and speech first. Clarity of instruction is key. Interpretation of findings must take into account common age-related changes. For example, genuine increased tone should be distinguished from paratonia. Power testing should look for asymmetry within the individual, rather than compare to the strength of the examiner. Parkinsonism should be looked for and gait should be observed. Neurological assessment can incorporate a range of cortical abilities and tests of autonomic function, but the extent of these assessments is likely to be determined by the clinical situation and time available.
Cognitive impairment—risk factors and prevention
Authors: Mangialasche Francesca , Ngandu Tiia , Kivipelto Miia
Published: December 2017

Cognitive impairment is common in advanced age, with dementia representing the main cause of disability in older adults. Prevention is crucial to halt the pandemic increase of this disorder, and can be achieved by managing several risk factors, including vascular and metabolic disorders, and psychosocial and lifestyle-related factors. While evidence-based approaches still need to be defined, the multifactorial and heterogeneous nature of late-life cognitive impairment suggests that multicomponent interventions targeting several risk factors simultaneously are needed for optimal preventive effects. A life course approach should also be considered to identify strategies that can be efficacious for subjects of different ages and with different risk profiles. This chapter summarizes major findings on risk and protective factors for age-related cognitive impairment, dementia, and Alzheimer’s disease, and reviews key aspects of preventive strategies, focusing on primary and secondary prevention.
A practice with a very long history
Authors: Szmukler George
Published: December 2017

For over two centuries, the criteria for the detention and involuntary treatment of people with mental disorders in conventional mental health laws have remained fundamentally unchanged. They have been based on a combination of (1) a diagnosis of some form of ‘mental disorder’, generally loosely defined, if at all; and (2) the presence of risk of harm to the person or to others. The lack of change may be interpreted as evidence that such law works well. More likely, the reason for its persistence is the lack of a ‘voice’ of the largely socially excluded people who are subject to such laws. The broadly drawn nature of these criteria, it is suggested, contribute to the ‘shadow of coercion’ that continues to loom over the practice of psychiatry.
A new United Nations ‘disability’ convention
Authors: Szmukler George
Published: December 2017

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) presents in a tailored form the rights of such persons. Mental health disabilities are included. While the Convention is most welcome, it is hugely challenging when it comes to involuntary treatment. Important authorities have interpreted it as excluding all forms of ‘substitute decision-making’. The Convention demands ‘respect for the rights, will and preferences’ of persons with disabilities. This chapter examines the meaning of ‘will’ and of ‘preference’. A problem arises when a person’s currently expressed ‘preference’ (or desire or wish) diverges from the person’s ‘will’ (taken to mean a person’s relatively enduring and deeply held value commitments). Both cannot be respected at the same time. Which should have precedence? The method of ‘interpretation’ discussed in Chapter 7 allows such a determination to be made, and aligns the ‘fusion law’ proposal with the objectives of the Convention.
Treatment pressures and ‘coercion’
Authors: Szmukler George
Published: December 2017

In this chapter, compulsion is presented in a broader context of ‘treatment pressures’. A hierarchy of pressures is presented, each increment moving in a more coercive direction. It comprises persuasion; interpersonal leverage; inducements; threats; and compulsion. The last has been dealt with in previous chapters. The distinction between inducements and threats turns on whether rejecting a conditional proposal—if you do X, I will do Y; if you don’t, I will do Z—results in the subject being ‘worse off’ or not according to a ‘moral baseline’. Threats involve proposals making the person worse off and represent ‘coercion’; inducements, where rejection does not make the person worse off, do not. However, in the context of mental health care, inducements can be problematic. While threats, often covert, are very common in mental health care, they are considered unethical. Perhaps, if regulated, they could have a place. Justifications, across the board, can follow a ‘capacity–will and preferences’ approach.
Behavioral Neurological Aspects Involving the Elderly and the Law
Authors: Granacher Robert P.
Published: December 2017

Behavioral neurology has classically encompassed deficit disorders (those with negative symptoms), such as the aphasias, the amnesias, the agnosias, and the apraxias. The focus of this chapter is to explain those focal neurobehavioral syndromes of interest to forensic psychiatrists. These are syndromic disorders with significant behavioral neurological impact. The focal neurobehavioral syndromes covered here generally involve disconnections in gray matter regions, but most of these disorders also imply white matter pathology and include cerebral stroke, neoplasia, and demyelination plaques interrupting neural networks to produce deficit syndromes with negative symptoms. Most issues in the forensic psychiatry of the elderly involve capacity to willfully act (competency), capacity to understand (criminal issues, contractual issues, testamentary capacity), capacity to be aware and protect oneself (elder abuse, personal safety, ability to live alone), and capacity to behave according to societal norms (criminal responsibility, fitness for duty, sexual crimes, dangerousness). A portion of these behaviors are an output of executive function.
Patient Safety and Risk Reduction in Geriatric Psychiatry Patients
Authors: Holzer Jacob C. , Gluck Paul
Published: December 2017

Awareness of patient safety, error reduction, and risk management is increasingly important in clinical geriatric psychiatry and in medical-legal applications as the baby-boomer population ages and as psychiatric therapeutics gain in complexity. The concept of maximizing patient safety and minimizing risk is based in part on improvement in communication and team coordination adopted from airline and military operations. The elderly population presents unique challenges to safe management, including the risks of medical comorbidity, polypharmacy, cognitive impairment, and reduced sensory input and physical functioning. Understanding the reasons for increased risk in the geriatric population will help clinicians design strategies to lower these risks and reduce the potential for harm.
Elder Abuse
Authors: Kohn Robert , Warner Jessica , Verhoek-Oftedahl Wendy , Murphy Emily
Published: December 2017

There are five principal domains of elder abuse: physical abuse, psychological abuse, sexual abuse, neglect, and financial abuse. This chapter discusses the prevalence, prediction, and assessment of elder abuse as well as other factors related to abuse. The incidence of elder abuse is 24 times greater than the number of cases referred to social service, law enforcement, or other legal authorities. Caregiver factors, rather than risk factors associated with the abused elder, may be more important in predicting abuse. Lack of compliance with medical regimens, delay in seeking medical care, disparity in explanations given for injuries, unexplained injuries, and implausible or vague explanations may be warning signs. Elder financial victimization can be classified as door-to-door scams, professional swindles, and caregiver abuse. Elder abuse increases mortality, emergency room visits, hospitalizations, and skilled nursing home placement. The psychiatric assessment may raise red flags of suspected elder abuse and may necessitate reporting to adult protective services. Interventions should be tailored to the circumstances and the resources available.
Working with the Elderly Defendant through the Adjudicative Process
Authors: Wall Barry W.
Published: December 2017

As the U.S. population ages, there will be more cases of elder abuse, neglect, and financial exploitation and, consequently, an increase in elderly criminal defendants in the criminal justice system. Because elderly persons appear in criminal court most frequently as crime victims, understanding the problems and needs of the elderly defendant receives less attention. This chapter reviews the cognitive and psychological changes with normal aging, the heterogeneous nature of elderly defendants, and assumptions that law enforcement and court personnel may make when interacting with the elderly population. The chapter reviews the adjudicative process from the perspective of the elderly defendant, focusing on detention, mental competence to stand trial, physical competence to stand trial, discovery and trial. Controversies in adjudicating and sentencing elderly defendants are discussed, as well as the impact of the sharp rise in elderly offenders in prison. Accommodations for elderly defendants during the process of adjudication and the need for expert medical and mental health involvement are reviewed.
The Geriatric Witness
Authors: Ravven Simha , Zonana Howard
Published: December 2017

Witness testimony of the elderly is a topic of growing importance in U.S. courts. Because the number and proportion of older persons in the United States is growing, it is likely that more elderly people will be called on to provide witness testimony. This chapter examines the types of challenges specific to the geriatric witness in the courtroom. It reviews the elements of competency to serve as a witness in federal and state courts; challenges facing elderly witnesses, including neurocognitive disorders and sensory impairments; and the literature on perceptions of credibility and the geriatric witness and the ability of individuals with dementia to testify meaningfully. Case law pertaining to protection of elderly witnesses, specifically Crawford v. Washington and United States v. Campbell, are discussed as they relate to the geriatric witness. The 2011 New Jersey Supreme Court decision of State v. Henderson is examined as well. This decision addresses the science of memory as it relates to eyewitness testimony. Henderson led to revisions of admission of eyewitness identification evidence and juror instructions. The elderly expert witness is also discussed.
Geriatric Offenders
Authors: McGlasson Timothy J. , Champion Michael K. , Penn Joseph V.
Published: December 2017

Globally there is an increasing older patient population in jails, prisons, and other correctional settings. Effective and federally determined access to medical and mental health services for older offenders requires recognition of numerous challenges related to correctional custody, healthcare, and policymakers. Basic issues such as housing, appropriate supervision, ensuring safety, access to health care, communication and mobility issues, and living and recreational accommodations are examples of challenges encountered by correctional systems. This chapter presents an overview of the epidemiology, phenomenology, and clinical presentation of the older inmate. It addresses intake health screening, medical and mental health evaluations, chronic health issues within this vulnerable population, and challenges facing the geriatric offender, such as dementia. The chapter also discusses how healthcare services are provided to older offenders within correctional settings and how correctional systems have developed processes and services to ensure a continuum of care, from assessment to hospice, for the geriatric offender.
Suicidal Behavior in the Elderly and its Forensic Implications
Authors: Malin Maureen A. , Jimenez-Madiedo Carolina , Kohn Robert
Published: December 2017

The probability of death from a suicidal act increases exponentially with age. Risk factors for suicide in the elderly include mental illness, serious suicidal ideation, functional impairment, stressful life events, substance use disorder, physical illness, and type of social connectedness. Following depression, substance use disorder is the second most common psychiatric diagnosis associated with elder suicide. Risk factors associated with suicide in long-term care facilities are similar to those for the general population. This chapter presents the epidemiology of suicide among older adults and discusses the various risk factors for suicide and its occurrence in long-term care facilities. Also discussed are guidelines for prevention of suicide and clinician liability. Stratifying the risk severity and temporality in relation to risk factors may assist in ascertaining the actual risk and facilitate clinical decision-making. As elderly patients have the highest risk of suicide, clinicians need to be vigilant and implement good clinical practice standards to reduce liability.
Geriatric Forensic Report Writing
Authors: Soliman Sherif , Resnick Phillip J.
Published: December 2017

As the population ages, expertise in addressing forensic psychiatric issues that arise in the geriatric population is becoming increasingly important. These include the need for guardianship, contractual capacity, testamentary capacity (capacity to make a will), and undue influence. Legal decision-makers frequently rely on psychiatric expertise. The geriatric-forensic psychiatric report is a key part of communication between the medical and legal professions. Often the report is the doctor’s only opportunity to communicate his or her opinion, since the vast majority of cases do not go to trial. This chapter focuses on planning, writing, and editing forensic psychiatric reports regarding geriatric issues. Basic principles of writing for a legal audience are discussed and how these principles apply to forensic psychiatric reports involving the elderly. The chapter offers recommendations for each stage of the writing process and discusses common pitfalls in writing forensic reports.
The Role of the Law and Legal Profession and Relationship to the Psychiatric Consultant
Authors: Recupero Patricia R.
Published: December 2017

Understanding the roles of laws, regulations, and legal professionals is important to the successful practice of geriatric forensic psychiatry, as geriatric psychiatrists may be among the first clinicians to recognize an elderly person’s need for legal assistance. In working with attorneys, psychiatrists will find it helpful to gain a basic understanding of different aspects of elder law and the ethical obligations of attorneys. This chapter discusses professional ethical codes and rules that lawyers are held to and how these relate to working with the geriatric psychiatrist in assisting an elderly client. When working with an attorney or a court, the geriatric psychiatrist may serve as a consultant, expert witness, educator, or as the treating clinician for a patient involved in legal proceedings. Some degree of reciprocal education is often necessary: the physician can help the attorney learn about a client’s condition (such as its prognosis, treatment, and current or expected impact on cognition and functional status), and the attorney can help the physician to understand how different laws, regulations, or legal professionals may be helpful to the elderly patient or client.
Geriatric Psychiatry Research
Authors: Abubaker S. Khalid , Jones Tyler G. , Candilis Philip J.
Published: December 2017

Forensic research with older participants carries more ethical challenges than either geriatric or forensic research alone. Concerns with cognitive impairment, informed consent, and voluntariness combine to complicate investigations of criminal and civil competencies, aggression, and the needs of an aging correctional population. Despite the paucity of regulatory guidance, researchers have developed a number of tools for simplifying the complex requirements of forensic geriatric research. Formal assessments for capacity to consent, ongoing consent discussions and enhancements, use of surrogate decision-makers, attention to vulnerability and desperation, and research useful to the subjects themselves are all part of a best practice model that underscores the dignity and personhood of this vulnerable research population. This chapter addresses each of these elements of best practice in geriatric forensic research, as well as research ethics required in conducting geriatric psychiatry forensic research.
Geriatric Forensic Psychiatry Training in Forensic and Geriatric Psychiatry Fellowships
Authors: Read Stephen L. , Kaufman Aaron , Hackman Daniel T.
Published: December 2017

As people live longer and the aging population increases, the volume of court cases involving elderly persons has increased. For elderly persons in court proceedings, determinations of decision-making capacity predominate, owing to the high incidence of cognitive loss with aging. Another frequent issue is whether a decision is the result of influence from others. Specific matters at issue may include disputes about testamentary acts, need for conservatorship (guardianship), capacity to manage one’s affairs, as well as the full range of other civil and criminal actions. Elder abuse, including financial elder abuse and victimization by scams, continues to mushroom to epidemic proportions. Courts, therefore, increasingly require expert assistance for forensic matters involving the elderly. Existing training programs in geriatric psychiatry and forensic psychiatry, however, rarely provide adequate training in this crossover field. This chapter reviews the current status of such training programs, including fellowships, and discusses approaches to address this critical and growing need for professionals with both geriatric and forensic psychiatry expertise.
Image-Guided Robotic Radiosurgery for Trigeminal Neuralgia
Authors: Romanelli Pantaleo , Conti Alfredo , Bianchi Livia , Bergantin Achille , Martinotti Anna , Beltramo Giancarlo
Published: December 2017

BACKGROUND

Frameless, non-isocentric irradiation of an extended segment of the trigeminal nerve introduces new concepts in stereotactic radiosurgery for medically resistant trigeminal neuralgia (TN).

OBJECTIVE

To report the results of the largest single-center experience about image-guided robotic radiosurgery for TN.

METHODS

A cohort of 138 patients treated with CyberKnife® (Accuray Incorporated, Sunnyvale, California) radiosurgery with a minimum follow-up of 36 mo were recruited. Pain relief, medications, sensory disturbances, rate and time of pain recurrence were prospectively analyzed.

RESULTS

Median follow-up was 52.4 mo; median dose 75 Gy; median target length 5.7-mm; median target volume 40 mm³; median prescription dose 60 Gy (80% isodose line). Actuarial pain control rate (Barrow Neurological Institute [BNI] class I-IIIa) at 6, 12, 24, and 36 mo were 93.5%, 85.8%, 79.7%, and 76%, respectively. Overall, 33 patients (24%) required a second treatment.

Overall, 18.1% developed sensory disturbances after 16.4 ± 8.7 mo. One patient (0.7%) developed BNI grade IV dysfunction; 6 (4.3%) developed BNI grade III (somewhat bothersome) hypoesthesia after retreatment; BNI grade II (not bothersome) hypoesthesia was reported by 18 patients (11 after retreatment). Shorter nerve length (<6 mm vs 6 mm), smaller nerve volume (<30 mm3 vs >30 mm3), and lower prescription dose (<58 vs >58 Gy) were associated with treatment failure (P = .01, P = .02, P = .03, respectively). Re-irradiation independently predicted sensory disturbance (P < .001).

CONCLUSION

Targeting a 6-mm segment of the trigeminal nerve with a prescribed dose of 60 Gy appears safe and effective. Persistent pain control was achieved in most patients with acceptable risk of sensory complications, which were typically found after re-irradiation.
Reducing Physical Illness Stigma: Insights from the Mental Illness Arena
Authors: Corrigan Patrick W. , Bink Andrea B. , Schmidt Annie
Published: December 2017

This chapter presents a critical summary of stigma-change strategies employed in the mental health field as a means to inform the anti-stigma efforts of advocates in the broader health arena. This is done by drawing on the comprehensive research and conceptual work targeting the stigma of mental illness while also weaving in the emerging research on stigma-change related to physical illness. The chapter first provides a brief overview of the targets of stigma change—public stigma, self-stigma, and label avoidance—and specific agendas corresponding with the types of stigma that guide anti-stigma programs—service engagement, rights achievement, and self-worth. It next presents a discussion of the various approaches to stigma change organized by these targets and agendas. The chapter concludes with future directions and goals for advocates and researchers to effectively challenge the stigma of physical illnesses.
Sexual Minority Stigma and Health
Authors: Pachankis John E. , Lick David J.
Published: December 2017

Emerging evidence demonstrates that sexual minority individuals experience disproportionate physical health burdens compared to heterosexuals because of their exposure to stigma. Due in part to increased public recognition of this stigma, recent decades have witnessed the collection of high-quality data exploring its links with adverse health. This chapter reviews this accumulating evidence. It first describes historical trends that have enabled the scientific study of sexual minority physical health. Next, it reviews sexual orientation disparities in physical health and factors that have been proposed to account for these disparities, with a particular focus on stigma and minority stress as precursors of adverse health. It then outlines potential cognitive–affective, behavioral, and physiological processes linking minority stress with poor health. It also highlights bidirectional processes that might operate between stigma and health. The chapter concludes by suggesting several promising opportunities for future research in this nascent field of inquiry.
Discriminating Ecologies: A Life History Approach to Stigma and Health
Authors: Neuberg Steven L. , Kenrick Andreana C.
Published: December 2017

How does being discriminated against affect one’s health, and through what mechanisms? Most research has focused on two causal pathways, highlighting how discrimination increases psychological stress and exposure to neighborhood hazards. This chapter advances an alternative, complementary set of mechanisms through which stigma and discrimination may shape health. Grounded in evolutionary biology’s life history theory, the framework holds that discrimination alters aspects of the physical and social ecologies in which people live (e.g., sex ratio, unpredictable extrinsic causes of mortality). These discriminating ecologies pull for specific behaviors and physiological responses (e.g., risk-taking, sexual activity, offspring care, fat storage) that are active, strategic, and rational given the threats and opportunities afforded by these ecologies but that also have downstream implications for health. This framework generates a wide range of nuanced insights and unique hypotheses about the discrimination-health relationship, and suggests specific approaches to intervention while pointing to complex ethical issues.
Electoral Systems in Context
Authors: Ferree Karen E.
Published: December 2017

South Africa’s post-apartheid election outcomes demonstrate how contextual factors interact with electoral rules to shape party systems. South Africa’s national electoral system represents one of the most permissive in the world, combining parliamentary rules with an extreme form of proportional representation. These rules were selected to encourage broad representation of parties in the National Assembly. However, South Africa’s party system consistently defies expectations, with a low effective number of seat-winning parties at the national level and dominance by a single party, the African National Congress (ANC). Provincial and municipal outcomes also confound simple institutional expectations. In addition to describing electoral rules and party systems at all three levels of South Africa’s political system, this chapter argues that contextual factors like the salience of racial divisions and the ability of the ruling party to shape institutions and resource flows critically interact with electoral institutions to shape party system outcomes.
Dimensions of Variation in Electoral Systems
Authors: Gallagher Michael , Mitchell Paul
Published: December 2017

Electoral systems matter. They are a crucial link in the chain connecting the preferences of citizens to the policy choices made by governments. They are chosen by political actors and, once in existence, have political consequences for those actors. This chapter argues that electoral system choice is a highly consequential matter for democratic states and offers a comparative overview of the principal means by which electoral systems vary. What are the essential components of real-world electoral systems? The chapter emphasizes the importance of district magnitude, ballot structure (with three main types: categorical, dividual, and ordinal), “levels” of seat allocation, methods of selecting candidates within parties, and devices for limiting proportionality.