Introduction: Dementia, Delirium, Depression, Drugs, and Driving

Geriatric psychiatry pays a great deal of attention to the 3 Ds: dementia, delirium, and depression. Of the 3 informative articles included in this special geriatric collection, 1 offers a perspective on the treatment of depression that does not focus on somatotherapy. The others remind us of 2 additional geriatric Ds of importance: drugs and driving. The authors of these articles deserve credit for increasing our awareness of these topics, which are worthy of our attention.

Olivera Bogunovic, MD, who discusses baby boomers and substance abuse, draws attention to the disparity between the clin­ical importance of substance abuse dis­orders and the limitations of our knowledge of these conditions in older adults. Misuse of prescribed hypnotics and analgesics, along with alcohol use disorders, is of long-standing concern in the elderly because older adults are more susceptible to deleterious pharmacological effects. Furthermore, prescription drugs and alcohol can interact harmfully with comorbid medical disorders or with concurrent medications that are more common among the elderly. The aging of boomers is increasing the diversity and complexity of geriatric substance abuse because this cohort has greater comfort and familiarity with nonprescription “recreational” drugs.

Erika L. Clark, MA, and Margaret G. O’Connor, PhD, point out the hazards associated with older drivers whose cognitive and/or physical impairments interfere with the safe operation of a motor vehicle. Although the gold standard for driver assessment remains the road test, clinicians can screen for driving problems by taking a history and by administering any of several brief and significantly predictive cognitive screening tests, such as the Trail Making Test, the Useful Field of View, or the Mini-Mental Status Test. Asking the patient about his or her own driving skill is less likely to provide valid information. The ethical dilemmas posed for clinicians by older drivers are significant. In some jurisdictions, we risk legal consequences for reporting; in others, the consequences of failing to report are more severe. Nationally, there is no consensus regarding the most prudent approach for clinicians to take in screening or reporting potentially unsafe older drivers. This article outlines the concerns and potential interventions clearly.

Finally, Patricia A. Arean, PhD, discusses the evidence base for efficacy of psychotherapy in older depressed adults in her article, “Psychotherapy for Late Life Depression.” Her discussion of this treatment modality, which often takes a back seat to antidepressants, should elicit great interest. Recognizing the limited data available for such widespread approaches as psychodynamic ther­apy, behavioral activation, mindfulness-based therapies, reminiscence therapy, and supportive therapy, she presents the evidence for the efficacy of cognitive-behavioral therapy, problem-solving therapy, and interpersonal therapy. Her comments on the value of these therapies in depressed older adults with comorbid medical illnesses, cognitive impairment, or other disabilities are enlightening. She provides a useful chart for matching patients with particular syndromes to therapies that have been shown to be especially beneficial.

The field of geriatric mental health, similar to that of child or adult mental health, is immense and rapidly increasing in breadth and complexity. These glimpses of topics that are both timely and a little less familiar should whet your appetite for additional discussions regarding the concerns and care of a population that continues to grow in number and the associated morbidity as more adults survive into very late life.