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In this chapter, we focus on the use of psychotherapeutic medications in the elderly, including the antidepressant, psychostimulant, antipsychotic, mood stabilizer, and anxiolytic medications that are used to treat the psychiatric disorders of late life, including major depression, anxiety, and the psychosis and behavioral disturbances that frequently accompany Alzheimer's disease (AD) and related disorders.

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Mood and behavioral disturbances are of particular concern in the elderly. Late-life depression, including major depressive disorder and dysthymia, affects 5% to 12% of older adults. These rates are consistent with those in younger adults; however, the elderly face a disease profile that is more chronic and treatment resistant with an element of cognitive impairment. Frequently, depression in elderly, community dwelling individuals remains unidentified and untreated. Depression occurring past age 60 is likely distinct from that which occurs in younger age groups. It has been associated with significant vascular disease as evidenced in the imaging literature, and with low testosterone levels in older dysthymic men. This idiosyncratic disease profile may account for treatment resistance. For example, structural abnormalities in frontal white matter have been linked to a poorer remittance of depressive symptomatology.

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Late-life depression leads to further deterioration in quality of life, as well as increasing risk for dementia and suicide. Depressed elders suffer greater rates of disability, mortality, and nursing home placement. Furthermore, when depression co-occurs with other medical or psychiatric illness, it negatively alters the disease process. For example, cardiac mortality is increased in depressed patients with unstable angina, postmyocardial infarction, or congestive heart failure, and comorbid anxiety impairs interpersonal function and leads to greater severity of physical symptoms. Consequently, the effects of depression result in greater strain on an already overburdened health care system.

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Anxiety disorders are also highly prevalent in older adults, between 2% and 19% in community dwelling elders, with the most common forms being generalized anxiety disorder (GAD) and phobias. Anxious symptomatology not meeting criteria for a clinical diagnosis is experienced by a further 20% of elderly individuals. Late-life anxiety can co-occur with physical illness, depression, or side effects of medication use. Risk factors for anxiety in elders include cognitive and physical impairments, economic difficulties, and social segregation.

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Older anxious individuals experience greater physical disability and cognitive impairment, as well as reduced ability to carry out activities of daily life. Quality of life is diminished and risk of mortality and coronary artery disease (particularly in men) is greater when anxiety is present in later life. Anxious elders are prone to excessive use of medical services, with anxiety disorders comprising 38% of mental health claims as compared to 21% for affective disorders.

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Behavioral instability, including agitation, aggression, and psychosis, also appears frequently in late-life, especially when associated with dementia. Approximately 2% to 5% of elderly individuals 60 years of age or older suffer from dementing illnesses, while 15% to 40% of those older than 85 develop dementia. At some point in the course ...

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