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Clinical Geriatric Psychopharmacology, Second Edition
Book Reviews DoNNA
B. GREENBERG. M.D.
BOOK REVIEW EOrrOR
Clinical Geriatric Psychopharmacology, Second Edition Edited by Carl Salzman, M.D. Williams & Wilkins, Baltimore, MD,
1992, 363 pages ISBN 0-683-07495-4, $59.00
Reviewed by John R. Siberski, M.D.
T
hat the elderly comprise the most rapidly increasing segment of U.S. society is a frequently cited fact in both professional literature and the mass media. The number of geriatric psychiatry fellowships attests to the need in this sector. Not all elderly patients, however, are going to receive psychotropics from a geriatric psychiatrist or even a psychiatrist. Family practitioners, internists, and others will continue to do the bulk of psychopharmacologic prescribing for the elderly in the foreseeable future. Thus, a need for a concise textbook on geriatric psychopharmacology existed. That this volume is "virtually a rewritten volume rather than merely an update of old information" is obvious. The authors are to be commended for the current references. Many chapters include references as late as 1991. The book's strengths are at the beginning and end with its middle more of a mixed bag. The chapter titled, "Drug Prescribing Patterns, Risks, and Compliance Guidelines," surveys pharmacologic, physiologic, and doctorpatient aspects of the use of psychotropics. Included is some practical advice on improving compliance and decreasing complications. Dr. Sunderland's short chapter, "Neurotransrnission in the Aging Central Nervous System," and the following one, "Psychotropic Drugs and the Aging Process: Pharmacokinetics and Pharmacodynamics," by D. R. Abernethy, could serve as either introductions for the novice 280
or a quick review for the experienced clinician. Both are well written, well referenced, and include extensive supplemental readings. The final two chapters "Memory Dysfunction and Dementia: Diagnostic Considerations" and "Neurobiology and Treatment of Dementia" are most informative. In the first, Reisberg describes the steady progression of Alzheimer's using scales and charts to note findings that are more or less contemporaneous as the disease worsens. Tariot's survey of experimental therapeutic strategies in Alzheimer's, including the soon-to-be-released tetrahydroaminoacridine (THA), is thorough and thought-provoking. It is the strongest chapter in the book. Chapter lIon the "Treatment of Insomnia in the Elderly" contains solid, basic information that would be helpful for anyone evaluating geriatric patients with sleep disorders. There is a welcome emphasis on getting a good history of the disorder, the possible role of interfering substances, and nonpharmacologic treatments. The appendixes are very useful. Beginning with the usual list of name and dosage ranges, there follow tables of adverse interactions for antipsychotics, heterocyclic antidepressants, atypical antidepressants, MAOIs, lithium, anxiolytics, and anticonvulsants. Multiple references and a scale of clinical significance for each interaction are noted. It's in the middle that this book loses strength. Most of the information on depression, anxiety, mania, and behavioral disturbance will supply little that is new for the experienced clinician. Part of the difficulty in these chapters is the reliance on unreferenced statements, such as the following from chapter five: "Recent reports suggest that low doses of c10zapine may be helpful in the treatment of psychotic symptoms that result from pharmacologic treatment of Parkinson 's disease." While I know this to be true from experience, there is neither reference nor PSYCHOSOMATICS
Book Reviews
supplemental reading on c10zapine in the chapter. Other similarly tantalizing but unreferenced statements are the most bothersome aspect of this book. The chapter "Treatment of Depression: Diagnostic Considerations" contains two incorrect statements. The first is: "Cerebral metastases of undiagnosed malignancies such as pancreatic carcinoma sometimes present with depression as the initial symptom." Metastatic cerebral involvement is not a feature of pancreatic cancer and certainly not a presenting symptom. I The second is: "They include antineoplastic drugs such as asparaginase and minor tranquilizers such as disopyramide and the benzodiazepines." Disopyramide is a type I antiarrhythmic. I question the use of the term "sundowning" in a geriatric textbook. Sundowning seems more a rationalization for behavior that the staff does not understand or wish to investigate than a diagnosis. "He's just sundowning" excuses a multitude of sins. A recent paper by Rindlisbacher and Hopkins notes that, "clinical writings disagree on virtually every aspect of the [sundowning] syndrome; and little research has been conducted to investigate this phenomenon."2 Too often, it is rediagnosed as delirium once it becomes more florid. Greater discussion of a number of topics would have made this book more useful for the geriatric psychiatrist. The use of methylphenidate in apathetic, withdrawn, and disinterested geriatric patients was described, and its successful use is illustrated in the clinical vignette of a 104-year-old woman. However, there was no mention of the use of dextroamphetamine. Amplification of other topics, e.g., lithium and thyroid augmentation of antidepressants as well as the previously noted use of clozapine in Parkinson's disease, would increase the value of this volume for the geriatric or consultation psychiatrist who will be confronted with such complex questions. Psychiatrists will find it a good textbook resource for quick access to therapeutic information and a very fine bibliogragraphic source for further reading. It is also is an accessible and practical volume for the neophyte or the primary VOLUME 34 • NUMBER 3 • MAY - JUNE 1993
care physician who will continue to do the bulk of geriatric psychopharmacologic prescribing for some time to come. Dr. Siberski is a Fellow in Consultation Psychiatry. Massachusetts General Hospital. Boston.
References I. Shakin EJ. Holland J: Depression and pancreatic cancer. Journal of Pain Symptom Management. 1988; 3: 194--198 2. Rindlisbacher R. Hopkins RW. An investigation of the sundowning syndrome. International Journal of Geriatric Psychiatry 1992; 7:15-23
Psychoimmunology Update: (Progress in Psychiatry #35) Edited by Jack M. Gonnan. M.D.• and Robert M. Kertzner, M.D. Washington, DC, American Psychiatric Press. Inc., 1991, 172 pages ISBN ~804845~,$26.95 (hardcover)
Reviewed by Donna B. Greenberg. M.D.
I
t has been a human conviction that mental coping and emotional suffering affect survival and that the mind affects the body's defenses against illness. Historically, the study of psychosomatic medicine explored links between the psyche and soma, and consultation psychiatrists, in particular, have been dedicated to strengthening emotional function as a patient suffers the assault of physical illness. Psychoimmunology, the study of connections between the immune system and the nervous system, represents the current pursuit of concrete physiological mechanisms connecting mind and white cells. Gorman hypothesizes that, once upon a time, "somewhere in distant phylogeny," the immune system was part of the brain. When neuropeptides and neurotransmitters could facilitate communication, the distinct immune system evolved. He distinguishes between the description of communication mechanisms and a Darwinian acknowledgment that not every mechanism must be clinically meaningful. In fact, it is likely that some connections between 281
B. GREENBERG. M.D.
BOOK REVIEW EOrrOR
Clinical Geriatric Psychopharmacology, Second Edition Edited by Carl Salzman, M.D. Williams & Wilkins, Baltimore, MD,
1992, 363 pages ISBN 0-683-07495-4, $59.00
Reviewed by John R. Siberski, M.D.
T
hat the elderly comprise the most rapidly increasing segment of U.S. society is a frequently cited fact in both professional literature and the mass media. The number of geriatric psychiatry fellowships attests to the need in this sector. Not all elderly patients, however, are going to receive psychotropics from a geriatric psychiatrist or even a psychiatrist. Family practitioners, internists, and others will continue to do the bulk of psychopharmacologic prescribing for the elderly in the foreseeable future. Thus, a need for a concise textbook on geriatric psychopharmacology existed. That this volume is "virtually a rewritten volume rather than merely an update of old information" is obvious. The authors are to be commended for the current references. Many chapters include references as late as 1991. The book's strengths are at the beginning and end with its middle more of a mixed bag. The chapter titled, "Drug Prescribing Patterns, Risks, and Compliance Guidelines," surveys pharmacologic, physiologic, and doctorpatient aspects of the use of psychotropics. Included is some practical advice on improving compliance and decreasing complications. Dr. Sunderland's short chapter, "Neurotransrnission in the Aging Central Nervous System," and the following one, "Psychotropic Drugs and the Aging Process: Pharmacokinetics and Pharmacodynamics," by D. R. Abernethy, could serve as either introductions for the novice 280
or a quick review for the experienced clinician. Both are well written, well referenced, and include extensive supplemental readings. The final two chapters "Memory Dysfunction and Dementia: Diagnostic Considerations" and "Neurobiology and Treatment of Dementia" are most informative. In the first, Reisberg describes the steady progression of Alzheimer's using scales and charts to note findings that are more or less contemporaneous as the disease worsens. Tariot's survey of experimental therapeutic strategies in Alzheimer's, including the soon-to-be-released tetrahydroaminoacridine (THA), is thorough and thought-provoking. It is the strongest chapter in the book. Chapter lIon the "Treatment of Insomnia in the Elderly" contains solid, basic information that would be helpful for anyone evaluating geriatric patients with sleep disorders. There is a welcome emphasis on getting a good history of the disorder, the possible role of interfering substances, and nonpharmacologic treatments. The appendixes are very useful. Beginning with the usual list of name and dosage ranges, there follow tables of adverse interactions for antipsychotics, heterocyclic antidepressants, atypical antidepressants, MAOIs, lithium, anxiolytics, and anticonvulsants. Multiple references and a scale of clinical significance for each interaction are noted. It's in the middle that this book loses strength. Most of the information on depression, anxiety, mania, and behavioral disturbance will supply little that is new for the experienced clinician. Part of the difficulty in these chapters is the reliance on unreferenced statements, such as the following from chapter five: "Recent reports suggest that low doses of c10zapine may be helpful in the treatment of psychotic symptoms that result from pharmacologic treatment of Parkinson 's disease." While I know this to be true from experience, there is neither reference nor PSYCHOSOMATICS
Book Reviews
supplemental reading on c10zapine in the chapter. Other similarly tantalizing but unreferenced statements are the most bothersome aspect of this book. The chapter "Treatment of Depression: Diagnostic Considerations" contains two incorrect statements. The first is: "Cerebral metastases of undiagnosed malignancies such as pancreatic carcinoma sometimes present with depression as the initial symptom." Metastatic cerebral involvement is not a feature of pancreatic cancer and certainly not a presenting symptom. I The second is: "They include antineoplastic drugs such as asparaginase and minor tranquilizers such as disopyramide and the benzodiazepines." Disopyramide is a type I antiarrhythmic. I question the use of the term "sundowning" in a geriatric textbook. Sundowning seems more a rationalization for behavior that the staff does not understand or wish to investigate than a diagnosis. "He's just sundowning" excuses a multitude of sins. A recent paper by Rindlisbacher and Hopkins notes that, "clinical writings disagree on virtually every aspect of the [sundowning] syndrome; and little research has been conducted to investigate this phenomenon."2 Too often, it is rediagnosed as delirium once it becomes more florid. Greater discussion of a number of topics would have made this book more useful for the geriatric psychiatrist. The use of methylphenidate in apathetic, withdrawn, and disinterested geriatric patients was described, and its successful use is illustrated in the clinical vignette of a 104-year-old woman. However, there was no mention of the use of dextroamphetamine. Amplification of other topics, e.g., lithium and thyroid augmentation of antidepressants as well as the previously noted use of clozapine in Parkinson's disease, would increase the value of this volume for the geriatric or consultation psychiatrist who will be confronted with such complex questions. Psychiatrists will find it a good textbook resource for quick access to therapeutic information and a very fine bibliogragraphic source for further reading. It is also is an accessible and practical volume for the neophyte or the primary VOLUME 34 • NUMBER 3 • MAY - JUNE 1993
care physician who will continue to do the bulk of geriatric psychopharmacologic prescribing for some time to come. Dr. Siberski is a Fellow in Consultation Psychiatry. Massachusetts General Hospital. Boston.
References I. Shakin EJ. Holland J: Depression and pancreatic cancer. Journal of Pain Symptom Management. 1988; 3: 194--198 2. Rindlisbacher R. Hopkins RW. An investigation of the sundowning syndrome. International Journal of Geriatric Psychiatry 1992; 7:15-23
Psychoimmunology Update: (Progress in Psychiatry #35) Edited by Jack M. Gonnan. M.D.• and Robert M. Kertzner, M.D. Washington, DC, American Psychiatric Press. Inc., 1991, 172 pages ISBN ~804845~,$26.95 (hardcover)
Reviewed by Donna B. Greenberg. M.D.
I
t has been a human conviction that mental coping and emotional suffering affect survival and that the mind affects the body's defenses against illness. Historically, the study of psychosomatic medicine explored links between the psyche and soma, and consultation psychiatrists, in particular, have been dedicated to strengthening emotional function as a patient suffers the assault of physical illness. Psychoimmunology, the study of connections between the immune system and the nervous system, represents the current pursuit of concrete physiological mechanisms connecting mind and white cells. Gorman hypothesizes that, once upon a time, "somewhere in distant phylogeny," the immune system was part of the brain. When neuropeptides and neurotransmitters could facilitate communication, the distinct immune system evolved. He distinguishes between the description of communication mechanisms and a Darwinian acknowledgment that not every mechanism must be clinically meaningful. In fact, it is likely that some connections between 281