bluuebunny/crossref_metadata_2025 huggingface dataset:
Expanding the Possibilities: Populations, Settings, and Types of Work
Authors: Garland Ann F.
Published: May 2022

Many people have limited knowledge of the full range of career opportunities in the mental health field. This chapter expands on that knowledge by introducing a wide array of possibilities beyond familiar options such as private practice. The chapter describes a range of populations (e.g., children, adults, couples), work contexts (e.g., schools, clinics, media, business, technology, government), types of work (e.g., psychotherapy, assessment, consulting, research), and specialty areas (e.g., LGBTQ+, medical issues, foster care, bereavement, brain injury, substance abuse, military). Dozens of specific examples of real jobs which draw from each of these categories are listed for inspiration. To help readers clarify their own interests, a summary of the major benefits and challenges of working with each population group is provided. The goal of this chapter is to inspire the reader’s imagination about exciting career opportunities.
Ethical and Legal Issues in Mental Healthcare
Authors: Garland Ann F.
Published: May 2022

Mental health trainees are sometimes surprised by the weighty legal and ethical responsibilities they face. The purpose of this chapter is to introduce significant legal and ethical dilemmas so that trainees are not caught unaware later on. The issues addressed include maintaining professional boundaries, protecting confidentiality, managing mandatory reporting of child or elder abuse, and assessing for suicide or homicide risk. Brief case vignettes are used to illustrate some of the challenges in ethical decision-making. The consequences of ethical violations are briefly reviewed, and a suggested model to guide ethical decision-making is provided. The intersection of academic, research, and mental health ethical codes is discussed. Finally, readers are urged to pursue aspirational ethics beyond just adherence to laws and ethical codes. Aspirational ethics include advocacy for social and racial justice, as well as other social, environmental, human rights, health, or economic causes.
Diversity, Equity, and Inclusion in Mental Health
Authors: Garland Ann F.
Published: May 2022

The purpose of this chapter is to highlight how issues of diversity, equity, and inclusion are inextricably linked to mental health and to mental healthcare. The chapter encourages readers to engage in continuing personal reflection regarding how their life experiences influence perspectives on these issues; the author provides examples from her own life. Key concepts are defined with emphasis on describing the implications for mental health practice. These concepts include culturally competent care, cultural humility, and conscious and unconscious bias. Social determinants of mental health problems and mental healthcare as well as disparities in mental healthcare are reviewed. The goal of increased workforce diversity and representation is also discussed, and a number of resources to support increasing diversity in the mental health workforce are recommended, including scholarship opportunities for graduate students across disciplines.
Preparing for Success in Graduate School
Authors: Garland Ann F.
Published: May 2022

Graduate school represents a big investment of money, time, and intellectual energy. This chapter offers recommendations about how to maximize the return on that investment. First, the differences in undergraduate and graduate education are highlighted, and readers are urged to shift their mindset from a primary focus on grades to a more comprehensive focus on professional and personal development. Next, the chapter provides an overview of the course topics likely to be required in most graduate mental health programs, as well as specialty courses students may encounter in some disciplines. Recommendations for how to prepare for unfamiliar course topics are suggested. What to expect and look for in practicum training opportunities is also reviewed, with advice about how to choose practicum placements. The chapter concludes with recommendations about how to use graduate school as the launching pad for successful employment and professional networking.
The Future of Mental Healthcare
Authors: Garland Ann F.
Published: May 2022

To help prepare readers for a successful long-term career in mental health, this chapter highlights emerging trends and discoveries likely to shape the field in coming decades. Four major trends are reviewed: (1) technological innovations, (2) neuroscience applications, (3) integrated healthcare delivery, and (4) global mental health. Exciting innovations are described within each category along with preliminary research evidence of their impact. Particular emphasis is given to technological applications such as mobile apps, therapeutic video games, virtual reality, artificial intelligence, and precision medicine. The tension between intended benefits of innovations versus unintended consequences is also debated. In different ways, all these innovations have the potential to expand and improve mental healthcare, but innovations bring new ethical challenges as well. Readers are encouraged to imagine their own career capitalizing on any of these promising developments.
Custody and Intervention Recommendations in Family Law Cases
Authors: Hamel John , Baker Kelley
Published: May 2022

Children have been found to be adversely affected from not only having experienced physical abuse and neglect directly at the hands of their caregivers but also from having witnessed abuse between those caregivers, known as intimate partner violence (IPV). Because existing statutes limit child custody access to parents who have been shown to have engaged in such behavior, accusations are routinely brought forth by attorneys in family court cases on behalf of litigating parents. In this chapter, an overview is presented of the research evidence on IPV and its impact on the well-being of children. It is argued that accusations of IPV, while often valid, are too often false, exaggerated, or based on a misunderstanding of the extant scholarly research literature. Assessment procedures are suggested by which custody evaluators can make more informed decisions, so that children are protected from abuse and parental rights are not unnecessarily abridged.
The Same Coin
Authors: Harman Jennifer , Kruk Edward
Published: May 2022

The gender paradigm of intimate partner violence (IPV) research and theory has strongly influenced scholarly work on parental alienation. This paradigm has created a false “divide” between IPV and parental alienation scholars and professionals who work in these areas and has created unproductive and unnecessary conflict. This chapter highlights and draws parallels between research on IPV and parental alienating behaviors (PABs) to illustrate that they describe the same phenomenon. We also draw parallels in the research on how IPV and PABs affect the targets of these behaviors, their similarities in the patterns of abuse and motives of the perpetrator, and explore how children are affected. Finally, we detail how the gender paradigm has created controversies and the suppression of parental alienation and offers some solutions and suggestions on how this false divide can be bridged.
Couples and Family Interventions for Intimate Partner Violence
Authors: Bennett Victoria E. , Chu Janella , Pollard Deanna , Babcock Julia
Published: May 2022

Intimate partner violence (IPV) is a widespread public health problem that that has significant consequences for couples, their children, and their entire family unit. Traditional interventions take a one-size-fits-all approach and neglect the needs of couples that have children or wish to stay together. Although controversial, a small, but growing body of literature indicates that couples therapy is a safe and effective intervention for couples experiencing situational couple violence. Additionally, exposure to IPV has significant consequences for child witnesses and implications for children’s relationships later in adulthood. As such, there are a number of intervention and prevention programs for child witnesses and teen populations. These programs appear promising for reducing the harmful effects in childhood and decreasing the likelihood that adolescents will experience teen dating violence and IPV into adulthood.
Afterword: Recommendations and Resources
Authors: Hamel John , Russell Brenda , Dutton Don , Cox Jennifer
Published: May 2022

The chapters presented in this text offer insight and suggested reforms designed to ensure victim safety while balancing the rights of criminal defendants and the family unit. This afterword reviews recently suggested reform recommendations based on empirical literature and domestic violence organizations presently working to advance domestic violence policy and procedure. As this book has demonstrated, the gender paradigm can often lead to injustice in the criminal justice system. We review ideas for reform initiatives in arrest and prosecution, education, and intervention. States are encouraged to utilize evidence-based approaches and revise their current policies and standards to ensure equal protection for all victims while holding abusers accountable. Helpful resources are provided that can be used to develop more effective and inclusive domestic violence policy and procedures.
The Mite
Authors: Craig Errol
Published: May 2022

Scabies is an eight-legged mite which belongs to the phylogenetic class of arachnids, which also includes spiders and scorpions. More generally it is an arthropod, an invertebrate with an exoskeleton encompassing a large number of species including six-legged insects as well as crustaceans better known to humans as food in the forms of lobsters, crab, and shrimp, and the like. And most generically, it belongs to the animal kingdom. This chapter describes the physical characteristics and life cycle of scabies which varies according to the sex of the mite. The female scabies mite burrows into the skin where she lays her eggs, and constantly moves forward to seek nutrients while simultaneously evading the host immune system. The mating habits of scabies are discussed as well as behavior of the mite when present in warm and humid (tropical), climates.
Early Pioneers
Authors: Craig Errol
Published: May 2022

The medical establishment only very belatedly came to accept that scabies is directly caused by the itch mite, Sarcoptes scabiei. The father of French dermatology, Jean-Louis Alibert, in the early nineteenth century, encouraged his pupils to further explore the nature of scabies in Hôpital Saint-Louis, in Paris. In 1834 the Corsican medical student, Simon Francois Renucci repeatedly isolated scabies mites from patients with The Itch to an audience of the distinguished Parisian faculty. The esteemed Austrian dermatologist Ferdinand von Hebra further characterized scabies in his 1844 treatise, leaving no serious doubt that the itch mite was the true cause of scabies. This chapter includes a look at the more modern medical history of scabies and discusses the work of Alibert, Renucci, and von Hebra.
Conclusion
Authors: Craig Errol
Published: May 2022

The clinical presentation of scabies can be straightforward, but at times it can be challenging to diagnose. In clinical settings where a microscope is available, it behoves dermatologists to try to positively identify the itch mite. When this cannot be done, a presumptive diagnose can be made and treatment given. The author’s view is that definitive diagnosis is preferable. If a patient has scabies, attempts should be made to visualize and formally document the fact rather than assume it to be the case. To identify the mite it is essential to know and carefully examine the areas where it elects to reside. Good lighting and magnification are essential to detect burrows. Careful inspection of the penis in men and nipples in women should not be neglected. In very difficult cases, a trick that sometimes bears fruit is examination of the detritus under the fingernails. Topical treatment is highly effective when used properly, and in the vast majority of cases, where the mite burden is low, extraordinary and heroic decontamination measures are unnecessary. The chapter references Kenneth Mellanby’s experiments, which have been previously described, to remind readers that scabies is spread only by close contact, and that it should not invoke irrational fears. When properly identified, scabies is an eminently treatable disease.
John Hughlings Jackson
Authors: Greenblatt Samuel H.
Published: May 2022

John Hughlings Jackson (1835–1911) was a preeminent British neurologist in the nineteenth and early twentieth centuries. He began to establish that standing in the 1860s, when he incorporated the evolutionary association psychology of Herbert Spencer into his early analyses of aphasia. Jackson also benefitted from his early connection with the National Hospital, Queen Square, London. His nuanced theory of cerebral localization was derived from (1) his clinical observations of (what Charcot later called) Jacksonian epilepsy, in combination with (2) his innovation to think about neurophysiological events at the cellular level, as well as from (3) David Ferrier’s primate localization data. The result was our modern conception of the seizure focus, which was crucial to the beginnings of modern ‘brain surgery’, especially at the hands of Victor Horsley. Jackson’s influence on the neurophysiology of Charles Sherrington is widely acknowledged but poorly defined. In the larger Victorian culture, Jackson was a friend of George Henry Lewes, who was George Eliot’s companion. Lewes attributed ‘sensibility’ to everything in the nervous system, thus maintaining a monist position on the mind-body relation, whereas Jackson maintained a form of psycho-physical parallelism that was actually dualist (‘Concomitance’). Throughout his life Jackson had an interest in insanity, which he viewed from the point of view of Spencerian evolution and dissolution. The latter was an important component of Freud’s psychoanalysis, which Freud took from Jackson. Late in his life Jackson defined the ‘uncinate group of fits’, which was his version of temporal lobe epilepsy.
Prologue to Originality
Authors: Greenblatt Samuel H.
Published: May 2022

John Hughlings Jackson was born into a Dissenting family in Yorkshire, England, in 1835. During a medical apprenticeship, in 1852 he entered the York Medical School, where the faculty included Thomas Laycock. Jackson studied at St. Bartholomew’s Hospital, London, 1855–1856, and then he returned to York. In 1859 he moved permanently to London, where he lived with the family of fellow Yorkshireman Jonathan Hutchinson, until he married in 1865. In 1860 Jackson acquired his M.D. by examination at the University of St. Andrews, Scotland. Also in 1860 he was persuaded to specialize in neurology by Charles-Edouard Brown-Séquard, who helped Jackson obtain his first appointment at the National Hospital, Queen Square, in 1862. In 1863 Jackson was appointed Assistant Physician to the London Hospital.
Enlarging Prospects and Evolving Ideas
Authors: Greenblatt Samuel H.
Published: May 2022

In 1865 Jackson married his cousin, Elizabeth Dade Jackson, which was an indication of his stable position in the upper middle class. The marriage was childless but otherwise profoundly happy. In the period 1865–1867 his main interests were epilepsy and aphasia. In the mid-nineteenth century the nosology of epilepsy was chaotic and not consistently based on pathophysiology. Simultaneously, his efforts to understand aphasia brought him into intellectual contact with his native English tradition of associationism (association psychology), which was antithetical to the French faculty psychology. Associationism’s leaders at the time were Alexander Bain and Herbert Spencer, who together brought to it the results of early modern neuroscience. Bain emphasized the motor aspect of word recognition. Spencer had a conception of a ‘physiological unit’, which facilitated Jackson’s gradual acceptance of motor processes in the cerebral cortices.
Extending a Paradigm and Consolidating a Reputation, 1877–1879
Authors: Greenblatt Samuel H.
Published: May 2022

In the later 1870s Victorian society was becoming increasingly secularized, which loosened earlier theological restraints on thinking about mind in relation to brain. In addition to Spencer, Jackson had direct connections to leading public intellectuals through his friendship with George Henry Lewes and George Eliot. At the same time, his standing among his colleagues continued to rise. In 1876 David Ferrier dedicated The Functions of the Brain to Jackson. In 1877 Charcot gave the name ‘Jacksonian’ to the type of focal seizures that Jackson called ‘epileptiform’. And in 1878 Jackson and three colleagues founded Brain: A Journal of Neurology. Among the many subjects that Jackson considered in these few years were motor posturing (our term), neuro-ophthalmology, the cerebellum (a continuing conundrum), aphasia, associationism, brain levels, the dreamy state, parallelism, and the subjective–objective distinction. In 1879 he delivered the Harveian Lectures at the Harveian Society of London, ‘On the Diagnosis of Epilepsy’, which was primarily concerned with pathophysiology. Later in 1879 he published a series of articles on ‘Psychology and the Nervous System’, which was broadly concerned with psycho-physical parallelism.
What’s happening to me?
Authors: Marshall Cindy , Quiceno Mary
Published: May 2022

History-taking is the first step in working with any older individual. The basic history should include detailed questions about every area of neurocognitive function. There is often a lot of past medical and psychiatric history and multiple medications for older patients, which requires mining both paper and electronic records to corroborate the reported history. The social history will help humanize the patient and provide information to build rapport as well as begin to assess the influence of the current social network. The review of systems provides perspective on current physical complaints and limitations and helps to assess the patient’s current physical and sensory functioning. Caregiver history is critical to assessing the safety and integrity of the patient’s current living situation, including the role and competence of the caregivers involved in daily life.
Body, brain—and where the two meet
Authors: Nowaskie Dustin Z. , Chan Carol , Wang Sophia
Published: May 2022

A complete medical examination includes vital signs and a detailed physical examination. This include a full neurologic examination assessing cranial nerves, speech, motor and sensory abilities, balance and coordination, and posture and gait. Many components of this examination can also be observed while taking a clinical history from the patient and observing how they move and speak. Standard initial laboratory tests include a complete metabolic panel and blood count, with reflexive T4 level, fasting lipid panel, HbA1c, and vitamin B12 level. The decision to obtain more specific medical and neurologic exam assessments and laboratory studies should be guided by the differential diagnosis. It is common to include neuro-imaging at this point, especially for acute changes in presentation and when a neurocognitive disorder is suspected.
Mental status in the moment
Authors: Espinel Zelde , Crocco Elizabeth A.
Published: May 2022

Observing the patient’s appearance, attitude, and behavior throughout the mental status examination will reveal key diagnostic indicators. The way in which a patient organizes and expresses their thoughts, along with the content of the thoughts, can demonstrate key symptoms of mania, depression, anxiety, and psychosis. These findings in the mental status examination can then be corroborated with the patient’s reported mood and affective expression. With older patients in particular, a cognitive screen during the mental status examination is critical to identifying areas of impairment across key cognitive domains, including attention, orientation, memory, language, executive function, insight, and judgment.
A picture worth a thousand words
Authors: Yarns Brandon , Greene Aaron
Published: May 2022

Structural imaging is clinically useful for identifying or ruling out non-neurodegenerative causes of cognitive dysfunction, such as vascular pathology, abscesses, and mass lesions. Computed tomography (CT) and magnetic resonance imaging (MRI) are the two main forms of structural imaging. There are several MRI techniques and sequences that can be useful for clarifying potential causes of neurocognitive impairment when there is clinical suspicion. While there are specific patterns of atrophy that are representative of distinct variants of neurodegenerative disease, they are often not diagnostically definitive, are less prevalent than nonspecific findings, and may be difficult to identify without adequate comparative data. Molecular imaging via positron emission tomography (PET) scans can use specific radioactive agents, including fluorodeoxyglucose (FDG) for functional scans of cerebral metabolism and amyloid or tau-specific ligands for quantifiable amyloid plaque and neurofibrillary tangle burden seen in Alzheimer’s disease in order to corroborate or rule out suspected underlying neurodegenerative processes.
He became a different person practically overnight
Authors: Kern Matthew E. , Stovall Jessica , Padala Prasad R.
Published: May 2022

Vascular dementia is suspected in patients with a significant cardiovascular history, cognitive decline associated with cerebrovascular events, cardiovascular risk factors such as high blood pressure and diabetes, and neuroimaging findings of significant cerebrovascular injury. There are many variations of vascular dementia based on the location and degree of brain damage, with cortical and subcortical subtypes being one major distinction. Treatment should focus on reducing known risk factors in order to prevent or mitigate further cerebrovascular damage, and the use of both acetylcholinesterase inhibitors and memantine as used to treat Alzheimer’s disease. Depression and apathy are relatively more common in vascular dementia and should be routinely evaluated.
The man who mistook the trash for his dog
Authors: Merril David , Petrossian Melita
Published: May 2022

In dementia with Lewy bodies (DLB), cognitive symptoms typically develop before or concurrent with parkinsonism, while in Parkinson’s disease dementia, cognitive symptoms normally begin more than a year after the onset of movement symptoms. The core clinical features of DLB are dementia plus rapid eye movement (REM) sleep behavior disorder (RBD), parkinsonism, visual hallucinations, and/or transient fluctuations in awareness. Antipsychotics, especially typical antipsychotics, should be avoided given the increased risk of mortality when used in patients with dementia and the higher frequency of side effects in patients with DLB. Although there is no specific treatment for DLB itself, cognitive enhancing medications may provide some benefit. Attention should also be given to both behavioral and pharmacologic approaches to associated conditions such as RBD, agitation and impaired gait.
Suddenly carefree and careless
Authors: Vatsavayi Anil
Published: May 2022

Frontotemporal dementia (FTD) is the third most common form of dementia across all age groups, and the leading cause of early-onset dementia. The behavioral variant of FTD (bvFTD), the most common form of FTD is characterized by profound behavioral and neuropsychiatric changes (personality changes, disinhibition, loss of empathy, compulsive/perseverative behaviors, apathy, dietary changes) and mimics several psychiatric disorders. There are also language variants, including progressive aphasia and semantic dementia. A comprehensive clinical assessment incorporating a thorough history, neuropsychological testing, laboratory workup, neuroimaging, and genetic testing (if indicated) can help accurately diagnose FTD in patients presenting with psychiatric symptoms while minimizing misdiagnosis. There are no treatments or disease-modifying curative drugs for FTD that have approval from the U.S. Food and Drug Administration. Nonpharmacologic and pharmacologic interventions provide symptomatic relief by alleviating the severity of behavioral and psychiatric symptoms.
I can’t get those thoughts out of my head
Authors: Vardi Kalya
Published: May 2022

In late-life obsessive–compulsive disorder (OCD), many patients will not spontaneously report obsessions or compulsions due to fear and shame. The initial onset after age 50 is exceedingly rare and is usually associated with a neurologic illness or injury. The most effective treatment for OCD is a type of cognitive–behavioral therapy called exposure and response prevention (ERP). Selective serotonin reuptake inhibitors also play a key role in treating OCD in late life, especially when combined with ERP. However, these medications often take longer to work in older adults, and higher doses are needed to treat OCD compared to other anxiety and depressive disorders.
To switch or to augment: That is the question
Authors: Gebara Marie Anne , Karp Jordan F.
Published: May 2022

When treating depression in older adults, the clinician should ensure that the patient has received an adequate dose of medication for an adequate amount of time before considering a medication change. The patient’s co-occurring medical and psychiatric comorbidities should be considered. A treatment algorithm and a measurement-based approach should be followed, while attending to patient- and age-specific conditions that may interfere with treatment response. Psychotherapeutic approaches should always be included, especially one of several time-limited and structured therapies that have shown efficacy in late-life depression. When prescribing antidepressant medications, the best approach is “Start low, go slow, but go all the way.” Augmentation should be used for partial response and the medication should be switched for nonresponse. Clinicians should always engage caregivers and should implement a treatment team model.
Expecting the expected
Authors: Lehmann Susan W.
Published: May 2022

The primary principle of managing bipolar disorder in late life involves careful oversight of mood stabilizers and antidepressants. Clinicians must monitor clinical symptoms along with side effects of medications, especially when using lithium, as blood levels and specific metabolic parameters must be followed. Lithium-induced hypercalcemia and lithium-associated hyperparathyroidism may develop at any time with lithium treatment, but older adults with renal and vascular impairment may be more vulnerable. Lithium-induced hypercalcemia is diagnosed by sustained elevation of serum calcium levels above the reference range and is believed to occur as a direct effect of lithium altering the set-point of the calcium-sensing cells of the parathyroid glands. Endocrinology referral should be done and treatment may require the calcimimetic drug cinacalcet, but lithium treatment can usually continue for patients who have a good response to it for their bipolar symptoms.
Withering away
Authors: Fahed Mario , Zdanys Kristina
Published: May 2022

Failure to thrive (FTT) is a multifactorial geriatric syndrome characterized by weight loss, decreased appetite, poor nutrition, dehydration, depressive symptoms, inactivity, impaired immune function and low cholesterol. Three fundamental components whose interaction results in FTT include frailty, disability, and neuropsychiatric impairment. The relationship of FTT and depression may be bidirectional, and comorbid dementia is common. The work-up of FTT should consider factors such as medical illness, hypoactive delirium, neurocognitive disorder, and psychosocial stressors in addition to depression. Much of the medical work-up will look for factors that could be causing weight loss, including issues relating to dentition, chewing, swallowing, nutrition and underlying malignancy. Treatment of depression may improve FTT, and antidepressants such as mirtazapine as well as electroconvulsive therapy should be considered.
She thinks I’m someone else
Authors: Balachandran Silpa , Tampi Deena J. , Tampi Rajesh R.
Published: May 2022

Psychotic symptoms are a common part of the natural course of most major neurocognitive disorders and cause significant distress and disruption to both patients and caregivers. Although the neurocognitive disorder itself is a sufficient cause, a medical work-up should always be conducted to identify additional factors. Nonpharmacologic interventions, including caregiver education and support, should be first-line approaches for non-urgent psychotic symptoms, with pharmacologic interventions limited to severe, dangerous, or highly distressing symptoms. Second-generation antipsychotics are used to treat psychotic symptoms in Alzheimer’s dementia, vascular dementia, and behavioral variants of frontotemporal dementia. They should be used with caution in Lewy body dementia due to the risk of acute impairment in mental status.
Suspicious neighbors
Authors: Reinhardt Michael , Majoka Muniza A. , Michael Marco Christian
Published: May 2022

Delusional disorder in older adults is a diagnosis of exclusion, necessitating comprehensive evaluation before a diagnosis can be made. It is characterized by the presence of a fixed and circumscribed delusion but in contrast to schizophrenia, there are no other psychotic symptoms. It is often accompanied by cognitive deficits in working memory and attention, with increased risk for progressive cognitive decline. Patients with delusional disorder suffer from increased rates of major depression, placing them at increased risk for suicide. While data are limited, the best available evidence suggests that patients benefit from combined treatment strategies that include an atypical antipsychotic and cognitive–behavioral therapy.
No one can work with her
Authors: Agronin Marc E.
Published: May 2022

Agitation is common across all forms of dementia and is often associated with other behavioral and psychological symptoms of dementia (BPSD), including anxiety, depression, and psychosis. A helpful algorithm to manage agitation is DICE, which stands for Describe, Investigate, Create, and Evaluate. The best management strategy starts with a clear understanding of the context for the behaviors, including causes and responses, and uses medical and psychiatric exams to help identify these. Non-pharmacological approaches are considered the first line of treatment. Pharmacologic approaches must be carefully considered in terms of risks and benefits. It is important to re-evaluate the treatment response and adjust the plan accordingly.
Trustworthy or not?
Authors: Reimers Karen
Published: May 2022

Medicolegal questions abound in geriatric psychiatry, involving federal and state laws and rules, clinical assessment and treatment issues, ethical principles, and liability/risk management factors. Criteria for decision-making capacity include the ability to communicate a choice, understand the relevant information, appreciate the consequences of the situation, and reason about options and alternatives. A variety of functional issues can influence an older patient’s driving ability; clinicians may need to refer patients for specialized testing and counsel patients about “retirement” from driving. Elder financial exploitation is becoming widespread, and it involves the misuse, mismanagement, or exploitation of the older person’s property, belongings, or assets. Risk factors and “red flags” for undue influence include relationship, social/environmental, psychological, physical, and legal considerations.
Wired and ready
Authors: Kieran Kathryn , Vahia Ipsit V.
Published: May 2022

Various forms of existing and emerging technology are playing an increasing role in psychiatric treatment of older individuals. A patient-centered discussion of initiating digital care must begin with collecting an inventory of what devices or technology the patient currently owns and assessing their access and proficiency in using the internet and internet-based services. Help from aides, family, friends, and community resources often needs to be engaged. The COVID-19 pandemic has led to massive adoption of platforms used for telemedicine. Older adults should be encouraged to communicate using the device that is easiest for them to use. Once the appropriate hardware is available and functional, compatible apps and programs can be suggested. Studies to date indicate the apps are most effective when they are used to support, rather than replace, an actual therapist. Other relevant technologies include wearables and other systems to enable remote monitoring of patients or specific symptoms.
When even the birds die
Authors: Rega Paul P.
Published: May 2022

This chapter discusses a mass casualty HAZMAT event and what needs to be done in the on-scene response. The event occurs in the setting of a highway disaster involving coughing, vomiting trauma victims, dying animals, and a yellow-green smoke that is being emitted from one of the semis involved in the accident. Topics covered include the immediate actions that need to be taken to ensure the responders’ safety; the incident commander’s responsibilities; and how to assess the risk potential of the event. The segmentation of the disaster site into three sectors (hot zone, warm zone, and cold zone) is explained. Decontamination, triaging, and stabilizing are also discussed, as well as the levels of personal protective equipment necessary for rescuers.
The Bat-Phone rings: The tornado and the trailer park
Authors: Rega Paul P.
Published: May 2022

This chapter explores what to do when a natural disaster such as a tornado hits: a classical “simple disaster.” This includes a discussion on what the immediate next steps should be, with a few historical examples provided. The author discusses the importance of communications, and crisis leadership. Explored as well are the “first-wave phenomenon”; clearing the ED of current patients expeditiously and safely; conducting triage; prioritizing imaging, laboratory services, and blood products and services; and what to do in the aftermath of a disaster, including providing mental health services. The impact of language barriers between disaster victims and staff is also discussed.
The Bat-Phone rings again: A basketball game, a yellow-green cloud, and seizing victims
Authors: Rega Paul P.
Published: May 2022

The chapter discusses a HAZMAT situation that has generated victims from a poisonous gas released at a basketball game as well as additional trauma casualties resulting from the rush to exit the gymnasium. The author outlines the two principal objectives when dealing with a HAZMAT event: prevent contamination of and injury to the healthcare providers, and provide appropriate care to the victims. The decontamination process is discussed, including provisions that need to be made for pediatric patients and special populations. Information is provided on how to evaluate for blunt and penetrating trauma secondary to a stampede. Several historical examples are supplied.
A pruno party gone awry
Authors: Rega Paul P.
Published: May 2022

Botulism as a mass casualty incident has unique features from both patient management and logistical perspectives. The discussion that is presented here may even have application in other mass casualty events. This chapter discusses botulism poisoning at a state prison resulting from the ingestion of home-brewed alcohol. Ten inmates are affected. Botulism is not a disease entity that is well known by many in the healthcare profession, so just-in-time training for the ED staff is appropriate. Botulism can cause death acutely from two complications: (1) aspiration due to a dysfunctional swallowing mechanism and (2) respiratory failure due to paresis and paralysis of the intercostal muscles and diaphragm. The author explains what to do when the poisoned patients arrive at the ED and how triage should function in these circumstances, how to assess the criticality of each patient quickly, how to manage each patient's care acutely, and how to work with infection control, local public health, state public health and CDC regarding the expeditious release of botulism antitoxin.
They’re bombing the open-air market!
Authors: Rega Paul P.
Published: May 2022

This chapter discusses an attack on an open-air market in which a suicide bomber blew up a packed bus. Twenty are presumed dead and 50 or so have been wounded by bomb fragments, high-caliber bullets from a semiautomatic weapon, and machete hacks. The author examines immediate actions that need to be taken in an intentional mass casualty event like this to safeguard the ED team and patients. Anti-terrorism hospital preparations are detailed. The injuries caused by various blast overpressures are outlined. The response of Brigham and Women’s Hospital during the 2013 Boston Marathon bombings is analyzed, and other international case examples are provided.
Zap, sizzle, and fizz: Contamination, irradiation, and trauma
Authors: Rega Paul P.
Published: May 2022

This chapter explores one type of radiological emergency. The chapter covers how to activate the appropriate code from the hospital’s disaster plan and the actions that need to be taken by the radiation safety team in conjunction with and the emergency department personnel when a traumatized patient is also potentially radiologically contaminated and irradiated. Types of radiation are discussed including the difference between electromagnetic radiation and particulate radiation. The stages of acute radiation syndrome are outlined. Acute radiation syndrome refers to the sequence, degree, and types of manifestations that may occur when a human being is exposed to a given amount of ionizing radiation like gamma rays. The first priority for decontamination is areas of the body that may serve as conduits for the internalization of the surface contaminants (e.g., wounds, eyes, nose, and mouth). A systemic response to a radiological emergency requires communication, education, and drilling between ED and radiation safety teams.
Pandemic: Hospital preparedness and response for the future
Authors: Rega Paul P.
Published: May 2022

This chapter explores how to evaluate a hospital’s preparedness and response activities so that the facility and the staff are better prepared to deal with for the next pandemic. Surge capacity is defined as the maximum supply of resources that are available to address a given stage of the pandemic (conventional, contingency, and crisis). Potential actions associated with each of those levels are presented. The disaster committee should review its previous pandemic performance, noting what worked and what needs improvement in terms of equipment, personnel, training, communication, triage, infection control, and morale. A pandemic subcommittee within the disaster committee should be tasked with reviewing clinical, infection control, resources, personnel, structural, and ethical issues (such as resource allocation) for the next pandemic.
End of shift
Authors: Rega Paul P.
Published: May 2022

This chapter explores ways in which disaster preparedness and response information can be disseminated to the emergency department staff and everyone else in a hospital. It is recommended to start with the emergency department by evaluating the current syllabus and to reinforce it by adding topics based on the hazard vulnerability analyses that have been conducted. Detailed examples of tabletop exercises and gaming disaster scenarios are provided, along with drills, functional exercises, and full-scale exercises. The latter represent the “gold standard” of training, but all of these modalities contribute to the staff’s disaster preparedness and response. A variety of cases and scenarios are explored.
The epidemiology of heart failure
Authors: Guha Kaushik , McDonagh Theresa A.
Published: May 2022

Over the last 35 years we have gone from a famine to a feast in terms of the epidemiology of heart failure. The epidemiological data have evolved from those based on clinical descriptions of heart failure, through to those incorporating modern objective measurements of cardiac function. This chapter reviews the contemporary epidemiology of heart failure with regards to its incidence, prevalence, aetiology, hospitalization rates, prognosis, and economic burden both within Europe and the USA. The economics of heart failure are becoming particularly important with the ageing populations throughout the western societies, placing increasing strain on limited health care resources.
Metabolic disorders and heart failure
Authors: Plymen Carla M.
Published: May 2022

Inherited metabolic disorders are an important cause of heart failure, especially since many of them are amenable to treatment. It is therefore important that metabolic disorders are recognized and accurately diagnosed. The heart is dependent on normal metabolic function to provide a continuous source of energy at rest and even more so during exertion or stress. Many disorders of metabolism therefore affect cardiac function and may have devastating consequences. Cardiac failure in metabolic disorders is most commonly a consequence of cardiomyopathy. Hypertrophic cardiomyopathy is typical of the glycogen and lysosomal storage diseases as well as the disorders of mitochondrial energy production. Dilated cardiomyopathy is a feature of some of the organic acidurias, disorders of carnitine metabolism, and some mitochondrial disorders. Often the distinction is unclear, with a transition from hypertrophic to dilated cardiomyopathy as the disease progresses. Additional mechanisms leading to cardiac failure in metabolic disorders include valvular disease, arrhythmias and conduction disturbances, coronary artery disease, and pulmonary hypertension.
Infective and infiltrative causes of heart failure
Authors: Beggs Simon A. S. , Gardner Roy S. , Clark Andrew L.
Published: May 2022

Heart failure can result from any form of cardiac injury. Infective and infiltrative causes are rare, but important to identify, as many are potentially reversible. The acute syndrome of myocarditis often raises the possibility of an underlying infective or infiltrative cause, although reaching this diagnosis may itself be frequently challenging, potentially requiring advanced investigations such as cardiac magnetic resonance scanning or even endomyocardial biopsy. Other presentations of cardiomyopathy associated with infiltrative or infective causes, including chronic myocarditis or the gradual development of systolic dysfunction due to cardiac infiltration, may be more indolent, and a high index of suspicion is required. Identifying the underlying aetiology is crucial because specific therapies are often available, ranging from immunosuppression and chemotherapy to bone marrow or solid organ transplant.
Iatrogenic heart failure
Authors: Rosen Stuart D. , Khwanda Ahmad
Published: May 2022

This chapter investigates a number of areas in which the physician pursues a reasonable course of treatment, often for non-cardiological disease, and yet causes harm to the heart. There are reasons why the heart might be more prone to adverse effects of treatment than some other organs. The heart is often subject to mechanical stresses and pressure overload which evoke hypertrophic responses that, over time, prove maladaptive. There are also the reactions of the heart to metabolic stress, such as in diabetes. Iatrogenic acute heart failure typically occurs, even in the absence of pre-existing heart disease, in three scenarios: excessive intravenous fluid administration; use of cardio-depressant drugs; and chronic use of inotropic agents. The chapter then assesses the concept of cardiotoxicity, looking at treatments for cancer, psychosis, and infection, as well as rheumatological drugs.
The pathophysiology of heart failure
Authors: McDonagh Theresa A. , Dargie Henry J.
Published: May 2022

This chapter reviews the pathophysiology of heart failure by outlining what is known about its key players. These key players include haemodynamic abnormalities, ventricular remodelling, neurohormonal activation, and inflammatory responses. The pathophysiological processes at play in the heart failure syndrome combine to produce a progressive state of reduced myocardial performance, a dilated and/or adversely remodelled heart, and ultimately death from progressive pump failure or ventricular arrhythmia. Except in cases where the myocardial function returns to normal or near normal, neurohormonal blockade leads to some reverse remodelling which does lead to an improved outlook for patients. However, the natural history of heart failure for many patients is that treatment merely serves to delay further deterioration in left ventricular function, which will eventually resume in association with co-morbidities—particularly renal dysfunction—and ultimately lead to progressive multi-organ failure and death.
Myocardial energetics
Authors: Ormerod Julian O. M. , Frenneaux Michael P.
Published: May 2022

This chapter assesses myocardial energetics. The heart requires very large amounts of energy, cycling many times its own weight in ATP daily, and uses a variable combination of carbohydrates, lipids, lactate, and amino acids as fuel. A key feature of the healthy heart is ‘metabolic flexibility’, i.e. the ability to use different substrates according to circumstances. As the syndrome of heart failure progresses, a steady downregulation of all aspects of cardiac metabolism may be seen. In extreme disease states, a fundamental deficiency in ATP can be demonstrated, but more subtle metabolic abnormalities are detectable at an earlier stage. Additionally, there are multiple downstream disturbances in mitochondrial function, in the high-energy phosphate pool and in excitation–contraction coupling. Ultimately, the detection of abnormalities of myocardial metabolism and energetics has spurred an interest in therapeutic modulation of metabolism in heart failure. This is attractive, as potentially such modulation would improve myocardial efficiency without the need for increased fuel delivery. Such therapies could have an additive effect to current heart failure management which generally relies on correction of the maladaptive neurohumoral consequences of the heart failure syndrome.
Natriuretic peptides and novel biomarkers in heart failure
Authors: McDonagh Theresa A.
Published: May 2022

Over the last 30 years there has been a proliferation in the number of potential heart failure biomarkers. Despite all this work, however, the only truly established biomarkers, i.e. those that have made it into routine clinical use for heart failure, are the natriuretic peptide (NP) hormones. Many other peptides, proteins, hormones, immune and inflammatory markers, and microRNAs have increased circulating concentrations in patients with heart failure, but their additional clinical value has yet to be established. This chapter concentrates on the NPs and their current clinical usage, and then outlines the potential role of more novel biomarkers.
Diagnosing heart failure
Authors: Dargie Henry J. , McDonagh Theresa A.
Published: May 2022

It is often said that heart failure is not a diagnosis per se but a clinical syndrome consisting of a constellation of symptoms and signs, which are ultimately due to cardiac dysfunction. Nevertheless, it is important to diagnose accurately the presence of heart failure in order to facilitate the general and specific treatments that can modify its traditionally poor outlook. The diagnosis of heart failure involves three distinct yet related phases. First, there is the confirmation that the patient has heart failure; second, the nature of the underlying cardiac dysfunction needs to be determined; and third, the actual aetiology of the cardiac dysfunction should be identified. Following confirmation of the diagnosis of heart failure, some basic diagnostic tests must also be performed to determine the baseline status of key variables prior to initiation of therapy and to establish the presence of co-morbidities.