Geriatric Medicine for Old Age Psychiatrists

The interface between psychogeriatrics and geriatric medicine is complex, particularly owing to overlapping presentations of physical and mental illness. Thus, rather than an exception, it had increasingly become a rule that primary care physicians—especially those with interest in managing the physical and mental illnesses of the elderly—have to be able to systematically analyze the symptoms of mental illness and arrange a comprehensive treatment plan. Hence, the obvious question, “Where to start this acquaintance?” The answer to this question asked by generations of physicians is Geriatric Medicine for Old Age Psychiatrists. The authors, in their introduction, paraphrase Einstein: “Everything will be made as simple as possible, but not one bit simpler.” The authors attempt to achieve this goal in their own witty and humorous style of writing over the 6 chapters that follow the introduction. I remember once attending a workshop on neuropsychiatry at which one of the eminent neurologists who spoke about neurologic examination said that he would teach us to do a neurologic examination in a minute's time—by finding out whether the patient could see, talk, and walk! This, he assured us, was not meant to be a satire on nonspecialists, but assessment of anything beyond such modalities of functioning would necessitate referral to a neurologist. An extension of this observation could be found in this book's chapter titled “History and Physical Examination,” in which the authors note that “many aspects of physical examination are not very reproducible and have low inter-rater reliability” (p. 9). The authors also offer 2 different ways of collecting basic medical history—the pragmatic-functional and the comprehensive-traditional approaches. My only issue with this chapter is that it has condensed the legal aspects of treating medical conditions in the mentally ill. Despite their best efforts, such summarizing does not do justice to very important issues such as consent and the Mental Capacity Act. Physician investigations often reveal 1 or 2 unexpected abnormal results. Then the charade begins with telephone conversations with specialists, which would make the physician believe that he or she has found out an extremely rare case—Eureka! The authors put a roadblock to such extravagances with their erudite chapter, “Interpretation of Abnormal Results.” Where they strike gold is in their ability to simplify the physiologic process and utilize this fundamental base to drive through the meaning of subtle to overt abnormalities. As a cynic, I would differ from the authors' style of listing the variabilities alphabetically, thus wedging a whole host of hematological indices between interpretations of calcium and other electrolyte abnormalities. The sheet anchor of this book is the chapter titled “Clinical Management.” The authors are very thorough in listing various symptoms and going through their differential diagnoses. They then address specific points from history, examination, and investigation to weed through the differential diagnoses. The management plan differentiates the possibilities from the impossibilities in a geriatric psychiatric ward, thus serving as a compass specifying when to seek out and make that crucial phone call to our medical colleagues. Where the authors falter in this chapter is again in their listing of symptoms in an alphabetical order. To someone trained in medicine and taught to think systematically, the lack of continuity of all respiratory or cardiovascular symptoms can be quite cumbersome. On the neurologic symptoms that almost always prove to be red herrings, however, the authors have provided extensive information in a structured and schematic manner. This will serve as a goldmine for primary care physicians, as they often have to make a clinical judgment on deciding between liaising with either a geriatric physician or a psychogeriatrician. This chapter is followed by “Case Vignettes” that demonstrate the logical and rational methods of assessing and managing clusters of symptoms very effectively. The chapter titled “Commonly Prescribed drugs” would be very useful in preventing untoward effects of polypharmacy. On a general note, the authors could have included diagrams, flowcharts, tabular columns, and imaging pictures, which would have broken the monotony of paragraphs of succinct explanation and rich information. On balance, though, this clever and concise effort by academics and clinicians in geriatric medicine and old age psychiatry would be invaluable to a primary care physician. In the authors' words, “confidence in what they are doing . . . cuts out unnecessary referrals or makes the information which backs up those referrals a little better.” In my opinion, this book, a very laudable effort on par with Lecture Notes on Geriatric Medicine1 or the Oxford Handbook of Geriatric Medicine,2 should be readily available to a primary care physician as it offers a rare insight into holistic approach in treating the elderly.