bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical features of ANCA-associated vasculitis
Authors: Gross Wolfgang L. , Holle Julia U.
Published: February 2014

The primary ANCA-associated vasculitides are granulomatosis with polyangiitis (Wegener's, GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss syndrome, CSS). They predominantly affect small (and medium-sized) vessels and share a variable association with ANCA (anti-neutrophil cytoplasm antibody) directed against neutrophil proteinase 3 (PR3, mainly in GPA) and myeloperoxidase (MPO, mainly in MPA and CSS). Crescentic necrotizing glomerulonephritis and alveolar haemorrhage due to pulmonary capillaritis represent classical (vasculitic) organ manifestations of the ANCA-associated vasculitides (AAV). MPA occurs as a 'pure' small (to medium-size) vessel vasculitis, whereas GPA and CSS are characterized by additional distinct clinical and pathological features. In GPA, granulomatous lesions of the upper and/or lower respiratory tract are a hallmark of the disease. Granulomatous lesions may be large in appearance and occur as space-consuming, infiltrating, and destructive inflammatory masses. GPA is believed to follow a stagewise course with an initial localized form, restricted granulomatous lesions of the upper and/or lower respiratory tract without clinical signs of vasculitis, and a consecutive generalization to systemic vasculitis which may be either non-organ-threatening (early systemic) or organ- and life- threatening (generalized GPA). Rarely, patients arrest in the localized stage and do not progress to systemic disease. In EGPA asthma, hypereosinophilia and eosinophilic organ infiltration (e.g. eosinophilic myocarditis) are typical features of the disease apart from vasculitis. Similarly to GPA, EGPA follows a stagewise course: asthma and eosinophilia may precede full-blown disease for several months or years. Recent cohort studies suggest different phenotypes in EGPA (predominantly vasculitic and MPO-ANCA-positive and predominantly with eosinophilic organ infiltration, usually ANCA-negative). This chapter focuses on the clinical features of the primary AAV and their outcome.
Osteoporosis
Authors: Yoshida Kanako , Hollick Rosemary J. , Reid David M.
Published: February 2014

Osteoporosis and consequent fragility fractures represent a significant burden of disease worldwide, and are associated with significant morbidity and mortality. With a growing elderly population this is expected to rise with substantial implications in terms of healthcare resources. Diagnosis of osteoporosis is conventionally based upon a reduction in bone mineral density (BMD) as measured using dual-energy X-ray absorptiometry (DXA) scanning. However BMD alone does not entirely predict risk of fragility fracture and a number of factors interact to determine an individuals’ risk of fracture, some of which are independent of BMD. Focus has therefore shifted to assessing an individuals’ lifetime risk of fracture and tailoring therapy accordingly.
Avascular necrosis
Authors: Rehart Stefan , Henniger Martina
Published: February 2014

Avascular necrosis (AVN) represents an important disease process of the cartilage-bone complex, which can occur at any age. According to aetiology one may discriminate between rare idiopathic avascular necroses and more common forms that occur as an effect of the underlying disease or rather the therapy, the secondary avascular necroses. Pathophysiologically it is assumed that a circulatory disorder leads to an ischaemic necrosis of bone, bone marrow, and adjunct cartilage. Sites of the human skeleton with predilection to AVN are the femoral head, humeral head, femoral condyle, proximal tibia, and ossicles of the foot and hand. Clinical signs are unspecific, but in the region of the load-bearing lower extremities pain occurs usually early. Plain radiographs, MRI, and sometimes also skeletal scintigraphy are used for diagnosis and staging. Usually 4-5 stages are distinguished; there are extra classification systems for individual entities. Spontaneous healing in terms of a return to normal without further damage can be found in small, circumscribed areas, but the bigger and the nearer the joint the more unlikely this is.
Depending on region, stage of disease, age of the patient, concomitant diseases and cause, several conservative and surgical therapies may be applied. Conservative treatments include exoneration and relief of the extremity, physiotherapy, and if necessary medical treatment. The need for surgical intervention becomes more likely as AVN increases in size and gets closer to the joint. Surgical therapies include core decompression, revascularizing techniques, vascular bone transplant, corrective/transposition osteotomy, arthrodesis/joint reinforcement, or joint replacement.
Shoulder
Authors: Östör Andrew J. K.
Published: February 2014

The shoulder joint has evolved to allow maximum mobility of the upper limb and hand in order to optimize function. As a consequence, stability of the joint has been sacrificed resulting in the potential for shoulder pathology. Although shoulder pain represents a ubiquitous human experience, a clear understanding of the epidemiology, assessment, diagnosis, and management of shoulder disorders remains elusive. Despite this, several defined conditions affect the shoulder including subacromial impingement syndrome, rotator cuff disease, instability and dislocation, inflammatory and degenerative arthritis, adhesive capsulitis, and calcific tendonitis. This chapter addresses these disorders as well as the anatomy of the shoulder. As imaging is critical to the accurate assessment of shoulder pain, examples are given to aid understanding of the pathology. It is imperative that the clinician has a comprehensive knowledge of this joint due to the prevalence of shoulder pain and the importance of accurate diagnosis in improving outcomes.
Elbow
Authors: Walker-Bone Karen
Published: February 2014

The elbow joint is a complex synovial joint allowing flexion, extension, and forearm rotation with movements facilitated by ligamentous insertions. Although less common than pain at some other regional sites, epidemiological surveys suggest that elbow pain affects around 12% of adults at any point in time and occurs at equal rates among men and women. The differential diagnosis of elbow pain must always consider the possibility of: a multisystem inflammatory arthropathy such as rheumatoid arthritis or gout; a chronic widespread pain condition such as fibromyalgia syndrome; referred pain; or a more unusual disease such as bone metastasis from a distant primary. However, the most common causes of elbow symptoms are soft tissue periarticular conditions such as lateral and medial epicondylitis and olecranon bursitis and ulnar neuropathy. Although widely diagnosed and widely treated, there remain few convincing data from high-quality randomized controlled trials as to the long-term safety and efficacy of most ’standard’ treatments for these soft tissue conditions.
Forearm, hand, and wrist
Authors: Walker-Bone Karen , Ellis Benjamin
Published: February 2014

The forearm, hand, and wrist is a functionally vital part of the musculoskeletal system and in consequence, is highly sophisticated and complex in its anatomical development. Frequently, the hand and wrist may be the site of onset of symptoms of a polyarthropathy such as rheumatoid arthritis or of osteoarthritis, so that the physician should always seek to screen for such conditions before making a local diagnosis. Tenosynovitis, de Quervain’s disease, trigger digit, Dupuytren’s, and carpal tunnel syndrome are local soft tissue pathologies which can usually be discriminated on clinical grounds with or without the use of simple diagnostic tests and are satisfying to treat for the most part. Non-specific forearm pain is more complex, with much controversy surrounding not only its aetiopathogenesis but also its existence. It can be difficult to diagnose and difficult to treat.
Pelvis, groin, and thigh
Authors: Speed Cathy
Published: February 2014

Problems of the hip, groin, and thigh are common, have a wide differential diagnosis and affect individuals of all ages and activity levels. Patients may present in a variety of clinical settings, and the rheumatologist must always consider that symptoms may relate to visceral and/or referred pain. Careful clinical assessment and appropriate investigations are vital to promote a good clinical outcome.
Knee
Authors: Wolman Roger
Published: February 2014

The knee is a large, synovial, weightbearing joint. It is therefore exposed to considerable mechanical stress as a result of walking and other weightbearing activities which can lead to injury. Biomechanical factors that influence lower limb alignment will have a considerable impact on the knee and will determine the risk of injury. The knee is composed of two different articulations, the tibiofemoral and the patellofemoral joints. The diagnosis of knee problems can be enhanced by understanding the anatomy of the knee and identifying the site of the pain. The anterior knee is the most common site of pain and is usually due to the patellofemoral joint problems. It is often caused by malalignment of the patella as it moves through the trochlear groove. Extra-articular pathology involves the tendons, bones, and bursa and is often the result of an overuse injury. Tendinopathies around the knee are particularly common and are influenced by biomechanical factors. Intra-articular pathology can result from disorders involving the synovium. This includes inflammatory arthritis as well as other less common synovial diseases. Intra-articular pathology can also involve the menisci, the articular cartilage, and the ligaments and these often occur as a result of a twisting injury. Injury to these structures, in particular the anterior cruciate ligament, increases the risk of developing osteoarthritis in later life. Imaging, especially MRI, has enhanced the ability to distinguish between these disorders.
Chronic musculoskeletal pain in children and adolescents
Authors: Clinch Jacqui
Published: February 2014

Paediatricians review a large number of children who have a wide variety of musculoskeletal pains. The most common chronic pain conditions reviewed in paediatric rheumatology settings include diffuse idiopathic musculoskeletal pain (also called juvenile fibromyalgia or chronic widespread pain), chronic pain related to childhood hypermobility, complex regional pain syndromes (CRPS), chronic back pain, and persistent joint pain following previous or controlled inflammation, e.g. juvenile idiopathic arthritis (JIA). The chronic experience of pain often has a large and wholly negative impact on physical and psychological well-being and also a serious negative impact on financial well-being. The annual financial burden of adolescent chronic pain on the United Kingdom economy is conservatively calculated at £3840 million. Children who suffer persistent musculoskeletal pain and associated symptoms have a significant chance of developing chronic widespread pain and continuing to have pain and pain-associated disability in adult life. This chapter reviews the epidemiology of musculoskeletal pain in childhood, current theories of the aetiology of pain, the impact of chronic pain, the clinical features of common pain presentations and their relevance to diagnosis and treatment planning, and rehabilitation interventions aimed at the management of chronic pain.
Neutrophilic dermatoses
Authors: Moinzadeh Pia , Krieg Thomas
Published: February 2014

Neutrophilic dermatoses (ND) comprise a group of non-infectious skin diseases characterized by a diffuse epidermal and/or dermal infiltrate consisting of polymorphonuclear neutrophilic inflammatory cells throughout the different skin layers.
Depending on the localization of this infiltrate, patients may present with a variety of skin lesions such as pustules/vesiculopustules (epidermal infiltrate), plaques or papules (dermal infiltration), nodules or ulcerations (deep dermal/subcutaneous infiltrate) and also with possible systemic symptoms, such as leucocytosis, arthralgias, myalgia, and malaise.
Depending on the localization of neutrophilic cells in the skin, the clinical picture of cutaneous lesions and further systemic symptoms the patients can be subdivided into different subgroups. These include Sweet’s syndrome (SS), pyoderma gangrenosum (PG), rheumatoid neutrophilic dermatitis, bowel-associated dermatosis-arthritis syndrome, subcorneal pustular dermatosis (Sneddon Wilkinson), acute generalized exanthematous pustulosis (AGEP), acrodermatitis continua of Hallopeau (ACH), palmoplantare pustuloses (PPP), pustular bacterid (PB), neutrophilic eccrine hidradenitis, and Behçet’s disease.
The pathogenesis is still not fully elucidated but it has been hypothesized that it is associated with immunological dysfunctions, with abnormal cytokine signalling, causing an uncontrolled recruitment of neutrophilic cells.
ND can be triggered by underlying systemic inflammatory diseases, malignancies, haematological disorders and/or medication use.
Diagnostic procedures include detailed physical examination, laboratory tests, and histopathological assessments.
The therapeutic management of ND includes systemic steroids in acute cases and immunosuppressive or immunomodulatory drugs in chronic forms. Underlying systemic conditions have to be diagnosed and treated.
Multicentric reticulohistiocytosis
Authors: Einsele Hermann , Maddison Peter J.
Published: February 2014

Multicentric reticulohistiocytosis (MRH) is a rare systemic disease characterized by the combination of typical papular and nodular skin lesions and a severe and destructive polyarthritis, although virtually any organ system of the body can be involved. MRH most commonly affects middle-aged white women; it is about three times more common in women with a mean age at onset in the fifth decade. MRH is a rare histiocytic proliferative disease of unknown aetiology, characterized by tissue infiltration by histiocytes and multinuclear giant cells. The stimulus for the histiocytic proliferation has not been fully elucidated, although there is an association with internal malignancies and abnormal immunological laboratory findings. The diagnosis is confirmed by skin or synovial biopsy. The disease often runs a waxing and waning course and sometimes stabilizes. Work-up for underlying malignancy cannot be overemphasized. The recommended treatment for MRH is oral methrotrexate plus prednisone tapered gradually over 3–4 months.
Biological aspects of human ageing
Authors: Gray Doug , Proctor Carole , Kirkwood Tom
Published: February 2014

At the molecular and cellular levels human ageing is characterized by the accumulation of unrepaired random damage, and an accompanying loss of function. A major source of damage is oxidative stress caused by the generation of reactive oxygen species as a by-product of respiration. DNA and proteins are both susceptible to damage but whereas DNA damage repair systems exist, faulty proteins are generally removed by protein degradation systems. During ageing these systems become less efficient and the subsequent accumulation of damaged protein promotes protein aggregation, a process which is especially problematic in the ageing brain. Other aspects of ageing include genetic and epigenetic changes, mitochondrial dysfunction, telomere shortening, and cellular senescence, all subject to stochasticity. The complexity of the biology of ageing has led to an increase in the use of systems biology approaches whereby the use of mathematical modelling and bioinformatic tools complement the more traditional experimental approaches.
Psychometric assessment in older people
Authors: Ritchie Karen
Published: February 2014

Psychometrics permits the quantification of cognition, affect and behaviour, thus permitting both the identification of pathology and degree of deviation from normality. These methods have been principally used in older populations to screen affective and cognitive disorders, as an adjunct to the differential diagnosis of different forms of cognitive dysfunction and also to describe and monitor the functional consequences of pathology. The application of psychometric tests in older populations raises several problems, notably the confounding effects of associated pathologies, changing definitions of disease threshold in parallel with advances in medical technology, and inadequate knowledge of normal information processing at higher ages. Computerized assessment, once considered inappropriate in older populations, is now commonly used to standardize administration procedures and tailor testing to individual competency. It has also permitted the more accurate measurement of information processing time, which is important in the diagnosis of many neuropsychiatric disorders.
Transforming concepts of ageing: three case studies from anthropology
Authors: Kaufman Sharon R. , Livingston Julie , Zhang Hong , Lock Margaret
Published: February 2014

Anthropological approaches to the study of old age are briefly outlined. Such research gives emphasis to the cultural, social, and political contexts of aging, and to the subjective experience of growing old and the role of the family in supporting its oldest members. In recent years the impact of aging populations world wide, together with the global spread of biomedical knowledge and technologies have become of central importance in anthropological research. Three case studies from Botswana, China, and the United States dramatically illustrate the enormous difference that economic development, political incentives, medical facilities, and technological interventions have on the experience of aging, and on families supporting their older members.
Epidemiology of old age psychiatry: an overview of concepts and main studies
Authors: Minett Thais , Stephan Blossom , Brayne Carol
Published: February 2014

Epidemiology is the foundation of public health and rational planning of services. In the field of old age psychiatry, the information provided by epidemiological research has been highly influential. As the world older population is growing proportionally faster than the other age segments, there is a continuous need for further epidemiological research in old age psychiatry. Neuropsychiatric conditions, such as depression and dementia, cognitive impairment, behavioural and functional decline, place a considerable onus on the health, social and economic systems. This chapter presents some of the world demographic data and basic epidemiological concepts, discusses some methodological issues in the epidemiology of mental disorders in old age, and presents a summary of many of the most important studies in this field.
Neuropathology
Authors: Attems Johannes , Jellinger Kurt A.
Published: February 2014

This chapter describes the main neuropathological features of the most common age associated neurodegenerative diseases including Alzheimer's disease, Parkinson's disease and dementia with Lewy bodies as well as other less frequent ones such as multiple system atrophy, Pick's disease, corticobasal degeneration, progressive supranuclear palsy, argyrophilic grain disease, neurofibrillary tangle dominant dementia, frontotemporal lobar degeneration with TDP-43 pathology and Huntington's disease. Likewise cerebral amyloid angiopathy, hippocampal sclerosis, vascular dementia and prion diseases are described. A main aim of this chapter is to assist the reader in interpreting neuropathological reports, hence criteria for the neuropathological classifications of the major diseases are provided. One section covers general considerations on neurodegeneration and basic pathophysiological mechanisms of tau, amyloid-β, α-synuclein, TDP-43 and prions are briefly described in the sections on the respective diseases. Finally, one section is dedicated to cerebral multimorbidity and we give a view on currently emerging neuropathological methods.
Clinical cognitive assessment
Authors: Kipps Christopher , Hodges John
Published: February 2014

Cognitive symptoms arise from the location of brain dysfunction and are not linked directly to any particular pathology. In the early stages of disease, symptoms may be non-specific, and while certain symptom clusters are commonly seen in particular disorders, atypical presentations are not infrequent. For example, in Alzheimer’s disease, patients may present with a focal language syndrome instead of the more commonly appreciated autobiographical memory disturbance despite identical pathology. In our approach to the cognitive assessment, we maintain a symptom oriented approach. This facilitates the localisation of pathology and subsequent clinical diagnosis, which may then be supplemented by associated neurological signs, imaging or other investigations.
Neuroimaging
Authors: Sexton Claire E. , Heise Verena , Ebmeier Klaus P.
Published: February 2014

Neuroimaging provides a way of examining the structure and function of the brain in life. This chapter gives an up-to-date summary of the methods employed in research and clinic, what is involved for the patient in taking part in imaging, and the clinical applications, both current and about to enter general old age psychiatry practice. Magnetic resonance imaging and imaging with ionising radiation, such as CT, SPECT and PET, are covered. In addition we give a short summary of the applications and potential of electro- and magneto-physiological techniques. We summarise the current and potential use of neuroimaging methods in diagnosis, prognosis, understanding illness mechanisms and the brain mechanisms that confer resilience against the brain diseases of old age.
Psychopharmacology in older people
Authors: Ritchie Craig W.
Published: February 2014

It is well recognised that older people are particularly sensitive to psychotropic medication. In general, pharmacological interventions in the elderly pose specific problems due to the patient exhibiting both altered pharmacokinetic drug profiles due to gerontological effects on absorption, distribution, metabolism and elimination of drug and pharmacodynamic effects related to aging and polypharmacy. Adherence to medication in later life also mediates sub-optimal pharmacological care. Finally, the effects of comorbidities which accumulate with advancing years should also influence prescribing practice in the elderly. The general principles underlying these changes and observations are discussed with specific examples listed to illustrate these points.
Brain stimulation therapies
Authors: O’Connor Daniel W. , Plakiotis Chris
Published: February 2014

Electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS) all entail the delivery of electrical impulses to the brain with the aim of relieving mental disorders. ECT is an effective treatment of depression, mania and catatonia and, to a lesser extent, of schizophrenia. Its side effects, principally cognitive impairment, are mitigated through the use of individually tailored, unilateral delivery. TMS is more convenient but of lesser effectiveness. DBS, while reversible and thus safer than lesional surgery, is a major undertaking that is reserved at present for profoundly disabling depression, obsessive-compulsive disorder and Tourette’s syndrome.
Cognitive behaviour therapy
Authors: Wilkinson Philip
Published: February 2014

Cognitive behaviour therapy (CBT) is a dominant psychological treatment in the management of a range of psychiatric disorders and is increasingly being refined to suit the needs older adults. This chapter summarises the theory and practice of CBT, with an emphasis on assessment, formulation, and adaptation of treatment with older patients. Management of depressive disorder, anxiety disorders and dementia caregiver distress are described in detail with relevant case examples. Problem-solving therapy and behavioural activation are described. Mindfulness-based cognitive therapy (MBCT) has potential benefits in the treatment of older adults. MBCT is described and applications with older people are reviewed. Newer applications are outlined, including treatment of psychological symptoms associated with physical illness, psychosis and memory impairment. The evidence base for CBT-based interventions with older adults is limited; the limitations and extent of the current evidence are reviewed.
Psychodynamic psychotherapy
Authors: Garner Jane
Published: February 2014

Psychodynamic therapy is based on a psychoanalytic approach drawing on concepts of human development, relationships and experience. Psychoanalysis is both a technique of investigation and a theory of treatment, and it can help us understand aspects of clinical practice, for example the sometimes apparently irrational responses of patients, families or staff. This chapter explores how psychoanalysis has been relatively slow to encompass older people’s issues, but how it now contributes important insights about maturity and later life. Older people are less likely to be offered psychotherapy even though there is good evidence that they benefit from treatment as much as younger adults. In undertaking therapy with older people, there are particular issues to bear in mind, for example the physical reality of the patient and the setting, as well as the transference and counter transference issues that may arise around this stage of life.
Family therapy
Authors: Pearce Jane
Published: February 2014

This chapter introduces Family Therapy (Systemic Therapy) as a psychotherapeutic approach which explores the patient’s problems in relational terms rather than treating them as if they reside in the patient alone. The focus is upon the dynamic, interactive connections between people and their wider social context and the history of evolving ideas and practices is summarised. The evidence of effectiveness of family therapy in adults is discussed and the implication drawn that there is evidence to support clinical application including older age populations. The chapter illustrates the range of ideas that have been found applicable and helpful in work with older people and illustrates some of these approaches with practice based scenarios from old age psychiatry.
Principles of service provision in old age psychiatry
Authors: Dening Tom
Published: February 2014

This chapter outlines the history, underlying principles and policy context for contemporary mental health services for older people. The usual components of such services, including community health teams, memory assessment services, day facilities, consultation-liaison services in general hospitals, and in-patient psychiatric care for older people are all discussed. Alongside these more familiar elements however, there have been other recent, sometimes destabilising, changes, including moves towards age-inclusive services and changes in working patterns for psychiatrists and other professionals. Working closely with primary care, greater integration with social services and providing support to care homes are all part of the current agenda. It is important to measure the quality of services and to ensure the populations who may be disadvantaged receive fair access to effective care and treatment. Obviously, the future increase in the numbers of very old people brings both challenges and opportunities for old age psychiatry services.
Primary care management of older people with mental health problems
Authors: Robinson Louise , Chew-Graham Carolyn
Published: February 2014

This chapter discusses the presentation and primary care management of the commonest mental health problems in older people; these include delirium, delusions, depression and anxiety, and dementia. Primary care is on the front line in dealing with older people who have mental health problems, supporting their families to care for them and managing people with complex co-morbidities in addition to mental health issues. Older people consult their GP almost twice as often as other age groups and up to 40% may have a mental health problem. Cases drawn from the authors’ real-life practice are presented firstly to represent clinical presentations and management within primary care and secondly to demonstrate how primary care links with secondary care and the wider services. The management of patients is discussed largely within reference to UK primary care systems and policy, but the international readership should find parallels within their own healthcare systems.
Liaison old age psychiatry
Authors: Holmes John
Published: February 2014

About one-third of general hospital beds are occupied by older people with dementia, delirium or depression. All these conditions bring poorer outcomes for individuals and organisations alike. In response to this, liaison psychiatry services for older people have evolved in order to provide timely mental health assessment, ongoing treatment and signposting to other mental health services. They also provide teaching and training for general hospital colleagues from a wide range of disciplines. There is wide variation in liaison service configurations and activity, from a part-time nurse to a large multidisciplinary team but the best evidence for effectiveness is for the latter. Liaison services can be difficult to set up, requiring agreement from all stakeholders, but once established they can bring improvements in quality as well as cost savings. This chapter explains the case of need for these services, considers different service models, examines service activities and support needs and helps the reader understand how local services can be evaluated.
Palliative care and end of life care
Authors: Sampson Elizabeth , Dening Karen Harrison
Published: February 2014

Our ageing population and changes in cause of death, mean that increasing number of people will die in old age. Older people have, in many countries, had poor access to good quality end of life care. Many will develop multiple co-morbidities associated with age; dementia, mental health problems and general frailty. Palliative care is an approach which aims to relieve suffering and take account of a person’s physical, psychosocial and spiritual needs as they near the end of life. Advanced dementia is now being perceived as a “terminal illness”. Interventions such as antibiotics and enteral tube feeding remain in use despite little evidence that they improve quality of life or other outcomes. A person-centred approach from a multidisciplinary team is vital in providing good quality end of life care in a range of settings The acknowledgement of anticipatory grief and provision of bereavement support are vital for some family carers.
The concept of dementia
Authors: Thomas Alan , Dening Tom
Published: February 2014

Recent developments have led to earlier assessment of people with cognitive impairment and earlier diagnosis of dementia. This has renewed discussion about the boundaries of dementia and its major causes and their relationship to ageing and also resulted in the publication of new sets of diagnostic criteria for dementia in general and the subtypes of dementia, e.g. Alzheimer’s disease. This chapter therefore consists of four contributions bringing different perspectives on the concept of dementia and its recognition and diagnosis.
Pharmacological treatment of dementia
Authors: Jones Roy W.
Published: February 2014

This chapter summarises the available clinical evidence for specific pharmacological treatments for dementia with a particular emphasis on practical considerations and realistic expectations of currently available anti-dementia drugs. It covers the treatment of both cognitive and non-cognitive symptoms. The search for specific treatments for dementia has inevitably concentrated on Alzheimer’s disease (AD), partly because it is the commonest cause of dementia and partly because scientific progress has provided more potential therapeutic targets for AD than other dementias. AD is treated with AChEIs (donepezil, galantamine or rivastigmine) and the goals of treatment should be explained at the commencement of treatment. For DLB use AChEI, especially for hallucinations and other behavioural disturbance and consider memantine or increasing dose if BPSD symptoms persist. For VaD look for sources of emboli (e.g. carotid disease) and consider anticoagulation for atrial fibrillation and low dose aspirin. Ensure other relevant conditions (e.g. hypertension and diabetes) are being managed appropriately.
Personal experience of lifelong illness
Authors: Green Sue
Published: February 2014

The author describes his experience of mental illness since the age of 13. He was admitted to the local psychiatric hospital, where his treatment included time in a padded cell, insulin coma therapy, and a leucotomy. He describes his long admission, and other aspects of his life – his marriage and employment, as well as the experience of stigma related to his illness. He reflects on what helps him to cope and how he has managed his life despite all the tribulations.
Severe and enduring mental illness
Authors: Hatfield Catherine , Dening Tom
Published: February 2014

Severe and enduring mental illness refers mainly to the long term experience of schizophrenia and psychosis but also to other chronic functional disorders. The prevalence of psychoses in older people is hard to measure but estimates are around 0.5% of the population. Historically many people with long term illness resided in psychiatric hospitals but now most are in the community, receiving variable amounts of support from mental health, primary care, and social services. The physical health of this population is often poor and they receive less treatment and support than other older people with comparable physical health needs. Problems with psychiatric comorbidity (e.g. depression and substance misuse), cognitive impairment and social exclusion are also common. Treatment includes the judicious use of medication, non pharmacological approaches, and social support – especially appropriate accommodation. Positive outcomes can be achieved by a recovery approach that attends to all aspects of the person’s health.
Older people with learning disabilities
Authors: Hanney Maria Luisa
Published: February 2014

Elderly people with Learning Disabilities are a heterogeneous clinically complex population with unique medical and social challenges. Little is known of the epidemiology of mental ill health in this group. Emerging evidence indicates that they suffer higher rates of mental illness than the general population and than their younger peer group. Point prevalence of mental ill health in elderly people with Learning Disabilities has been reported about 69% compared with 48% in the younger peer group. This higher rate of psychiatric diagnosis in the older group is mainly due to a higher rate of dementia of about 21 %. People with Down syndrome appear to have lower rates of mental ill health apart from depression and early onset dementia of Alzheimer’s type. People with Learning Disability due to other causes are also at higher risk of developing dementia at an earlier age than the general population
Sleep disorders
Authors: Mosimann Urs Peter , Boeve Bradley F.
Published: February 2014

This book chapter reviews the most common sleep disorders in older adults and their treatment. It begins with a brief review of sleep physiology and then gives an outline on how to take a comprehensive sleep history. Sleep is commonly defined as a periodic temporary loss of consciousness with restorative effects. There are physiological sleep changes related to ageing, but sleep disorders are not part of normal ageing and are often associated with mental or physical disorders, pain and neurodegenerative disease. The most common sleep disorders include insomnia, obstructive sleep apnoea, restless legs syndrome, REM sleep behaviour disorder, excessive daytime somnolence and circadian rhythms disorders. An in depth clinical history, including if possible bed-partner’s information, is the key to diagnosis. Patients need to be informed about the physiological sleep changes and the principles of sleep hygiene. They can benefit from pharmacological and non-pharmacological treatment strategies.
Ethics and old age psychiatry
Authors: Hughes Julian C.
Published: February 2014

This chapter starts by reviewing four of the main ethical theories – consequentialism, deontology, principlism, and virtue ethics – looking at their relevance to old age psychiatry. Next comes a practical framework, which can be used to deal with particular ethical dilemmas. The chapter goes on to consider the report on dementia produced by the Nuffield Council on Bioethics in 2009, with its emphasis on the importance of personhood and solidarity. In the final section arguments around assisted dying are discussed. Throughout the chapter the aim is to locate clinical practice in the broader field of ethical concerns, in which the person’s inter-relatedness with the broader social context is emphasized. Clinical decisions need to be seen as ethical decisions, which are either right or wrong, and which reflect the fundamental nature of ethical reasoning.
Crime, mental illness, and older people
Authors: Yorston Graeme
Published: February 2014

Though older people are less commonly the victims of crime than younger people, they fear the consequences of crime more, and are particularly vulnerable to certain types of crime. There have been difficulties in older people getting access to justice in the past, though this is now improving as the police and prosecuting authorities have become more sensitive to the needs of older people as witnesses. Older people commit far fewer offences than younger adults, but offending in late life can be a direct consequence of a range of mental disorders including depressive psychosis, organic personality change and dementia. Older mentally disordered offenders present different assessment, diagnostic and management challenges to their younger counterparts and specialist secure psychiatric services have evolved to meet their needs. The number of older people in prison has increased dramatically and depression is very common in this group, though it often goes unrecognised and untreated.
Driving and psychiatric illness in later life
Authors: O’Neill Desmond
Published: February 2014

Access to transportation, and in particular to driving, is possibly more important in later life for the maintenance of health and well-being than at earlier stages of life. Those involved with the care of older people with psychiatric illness need to routinely inquire about driving and transportation, and to develop routines of assessment and care which appropriately balance transportation needs and public safety. The increasing research evidence base favours a functional approach with emphasis on behaviour and judgement, collateral history, a broad view of cognitive function and a low-threshold for on-road testing for those with the early stages of dementia. In addition, initiating planning for transportation for when driving is no longer possible is recommended.
The law relating to mental capacity and mental health
Authors: Wheat Kay
Published: February 2014

This chapter will examine two key areas of law relating to medical treatment and care of those with mental disorder. The question of decision-making capacity is important for health care professionals, and other carers and agents dealing with older people. The law relating to this is covered by the Mental Capacity Act 2005 supplemented by previous case law where this is still relevant, and the key aspect of the law is the ability to treat people without capacity in their best interests. However, in the case of some patients, it may be necessary to use the Mental Health Act 1983. This legislation is focussed, not on the capacity of the patient, but upon the effect that a mental disorder can have upon the patient risking damage to their own well-being, or to the well-being of others. The relationship between the two areas is not always clear.
Problems before agreed psychiatric classifications were available
Authors: Cooper John E. , Sartorius Norman
Published: February 2014

The problems listed serve to illustrate some of the main problems that develop in the absence of an agreed “common language” that can form the basis of international communication. They range from the diagnoses of individual patients to large-scale national statistics. Sometimes these problems reflect differences in national diagnostic traditions and schools of thought, the study of which is potentially constructive, but sometimes they are due to political and ideological ways of thinking that cannot stand up to rational examination and scientifically-based new knowledge.
Large-scale collaborative studies on diagnosis
Authors: Cooper John E. , Sartorius Norman
Published: February 2014

The methods of interviewing and diagnosis just described in Chapter 2 made possible two large-scale collaborative projects on diagnosis. The first was the cross-national US/UK Diagnostic Project between London and New York, and the second, which overlapped in time, was the set of international educational and investigative programmes A,B,C, and D of the WHO. Using the PSE and the Diagno computer program of the MSS, plus the Glossary to ICD-8, The US/UK Diagnostic Project demonstrated that the much larger mental hospital admission rates for schizophrenia in New York were due to differences between the diagnostic concepts of the hospital psychiatrists rather than differences in the clinical states of the patients. Programme A of the WHO was a set of international seminars aimed at providing a basis for the forthcoming chapter V of ICD-9. Programme B was to test whether interviewing and rating methods, such as the PSE, could be translated and used in different cultures; this test took the form of setting up a network of Field Research Centres as a basis for the International Pilot Study of Schizophrenia(IPSS), carried out in Denmark, Columbia, Chekoslovakia, India, London, Moscow and Washington. Assuming that Programme B was successful, Programme C was planned to be an epidemiologically based international collaborative study on severe mental disorders; the Determinants of Outcome of severe Mental Disorders (DOSMED) study was the eventual result. Programme D was a long- term project aimed at the training and education of mental health workers in different countries in methods of epidemiological research
The first internationally understandable epidemiological studies
Authors: Cooper John E. , Sartorius Norman
Published: February 2014

For the International Pilot Study of Schizophrenia of the WHO (IPSS) eight Field Research Centres were set up, in(Denmark), Cali (Columbia), Agra (India), Ibadan (Nigeria), Taipei (Taiwan), Washington (USA) and London (UK). A ninth, Prague (Czechoslovakia) was added in 1967. In each centre a “convenience sample” of 120 patients likely to be suffering from schizophrenia were was assessed by means of the PSE and other schedules; diagnoses were made according to the Glossary to ICD-8. Patients with typical syndromes of schizophrenia were easily found in all centres, and followed up for 2 years. An unexpected finding emerged in the follow-up, in that there were higher proportions of patients in the favourable outcome categories in the centres in the under-developed countries (such as India and Nigeria) than in the developed countries (such as Denmark, London and the USA). This finding was one of the principal motivations for the subsequent epidemiologically-based Determinants of Outcome of Severe Mental Disorders (DOSMED) study. For this, a wider set of cultures was covered by the addition of FRCs in Chandigarh (India), Nagasaki (Japan), Honolulu (USA) and Dublin (Ireland). In the UK, Nottingham replaced London. Each FRC defined a catchment area of at least several hundred thousand persons aged 15- 54 years, from which all persons who developed a new (lifetime first) potentially schizophrenic illness were assessed and included in a two-year follow-up study. The tendency for a better outcome for patients in the developing centres was confirmed, but remained unexplained. Using a comparatively narrow definition of schizophrenia, its incidence was not significantly different between the centres, but using a wider definition some differences were found. These findings were confirmed again by the latest WHO report published as the International Study of Schizophrenia (ISOS). In this, the IPSS and the DOSMED data are put together with data from a number of other similar studies sponsored by the WHO, to give follow-up assessment on a total of more than 1000 patients in 14 countries, over follow-up periods of 15-20 years.
Some problems with research methods used in diagnostic surveys
Authors: Cooper John E. , Sartorius Norman
Published: February 2014

Since the presence of psychiatric disorders in the subjects of a survey is assessed by means of an interview, the training of the interviewer and the nature of the method of questioning will have a large effect upon what is recorded. A lay interviewer using the DIS or CIDI records the complaints of the subject whereas a psychiatrically trained interviewer using the PSE or SCAN records the symptoms. The extent to which these are equivalent for diagnostic purposes has been studied several times, and the conclusion is that they have considerable differences. In the absence of independent diagnostic tests, whether symptoms are preferable to complaints is a matter of opinion to be decided by the designers of each survey. In all survey schedules, the rating scales used for the questions are likely to be more useful if they are short rather than long and detailed. Designers of surveys also need to be aware of the differences between bottom-up and top-down schedules.
Translation and use of interviewing schedules for use in more than one language and culture
Authors: Cooper John E. , Sartorius Norman
Published: February 2014

The idea that the significance of behaviour and language can be assessed only within their own culture has been superceded by the view that with due precautions, realistic comparisons and equivalences can be reached. Attention needs to be paid to equivalence, which takes account of the setting in which behaviour occurs, and authenticity which refers to the ability of the interviewer to get direct and ‘genuine’ answers from the respondent. When translating, the translation needs to be checked for its semantic, conceptual, and technical equivalences. The extent to which these different types of equivalence can be achieved depends to some extent on the properties of the schedule being translated, and the structured semi-standardized types are the best for this. Translation needs to be done by bi-lingual psychiatrists, using the re-iterative back translation method in cooperation with local mono-lingual experts. Video- or tape-recordings can be used for some of these procedures, but face-to-face discussions are likely to be more productive. Some simple rules for the translation processes are given.