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Clinical Manual of
Geriatric Psychiatry
This page intentionally left blank
Clinical Manual of
Geriatric Psychiatry
James E. Spar, M.D.
Professor of Clinical Psychiatry
Department of Psychiatry & Biobehavioral Sciences
Geffen School of Medicine at UCLA
Los Angeles, California

Asenath La Rue, Ph.D.

Senior Scientist
Wisconsin Alzheimer’s Institute
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin

Washington, DC
London, England
Note: The authors have worked to ensure that all information in this book is accurate
at the time of publication and consistent with general psychiatric and medical standards,
and that information concerning drug dosages, schedules, and routes of administration
is accurate at the time of publication and consistent with standards set by the U.S.
Food and Drug Administration and the general medical community. As medical
research and practice continue to advance, however, therapeutic standards may change.
Moreover, specific situations may require a specific therapeutic response not included
in this book. For these reasons and because human and mechanical errors sometimes
occur, we recommend that readers follow the advice of physicians directly involved in
their care or the care of a member of their family.
Books published by American Psychiatric Publishing, Inc., represent the views and
opinions of the individual authors and do not necessarily represent the policies and
opinions of APPI or the American Psychiatric Association.
Copyright © 2006 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED
Manufactured in the United States of America on acid-free paper
10 09 08 07 06 5 4 3 2 1
First Edition
Typeset in Adobe’s Formata and AGaramond.
American Psychiatric Publishing, Inc.
1000 Wilson Boulevard
Arlington, VA 22209-3901
www.appi.org
Library of Congress Cataloging-in-Publication Data
Spar, James E.
Clinical manual of geriatric psychiatry / James E. Spar, Asenath La Rue.—1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 1-58562-195-1 (pbk. : alk. paper)
1. Geriatric psychiatry—Handbooks, manuals, etc. 2. Older people—Mental
health—Handbooks, manuals, etc. 3. Older people—Psychology—Handbooks,
manuals, etc.
[DNLM: 1. Aged. 2. Mental Disorders—diagnosis. 3. Mental Disorders—therapy.
4. Age Factors. 5. Aging—psychology. WT 150 S736c 2006] I. La Rue, Asenath,
1948– II. Title.

RC451.4.A5S63 2006
618.97'689—dc22
2006005228
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
 Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
An Aging World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Health and Functioning of Older Adults . . . . . . . . . . . . . . 3
Mental Disorders in Later Life . . . . . . . . . . . . . . . . . . . . . . 6
Barriers to Geriatric Mental Health Care. . . . . . . . . . . . . . 8
Diversity in Patterns of Health and Aging. . . . . . . . . . . .12
Working Effectively With Older Adults. . . . . . . . . . . . . . .15
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

2 Normal Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Conceptual Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Cognitive Abilities in Later Life: A Processing
Resource Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Personality and Emotional Changes . . . . . . . . . . . . . . . .38
Social Context of Aging . . . . . . . . . . . . . . . . . . . . . . . . . .43
Biological Aging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
Aging and the Clinical Process. . . . . . . . . . . . . . . . . . . . .50
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

3 Mood Disorders—Diagnosis . . . . . . . . . . . . . . . . 67
“Normal” Grief (Bereavement) . . . . . . . . . . . . . . . . . . . .68
Complicated Grief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
Depression Due to a General Medical Condition . . . . .70
Substance-Induced Mood Disorder . . . . . . . . . . . . . . . .76
Major Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80
Dysthymic Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91
Minor Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92
Depressive Personality Disorder . . . . . . . . . . . . . . . . . . .95
Laboratory Evaluation of Depression . . . . . . . . . . . . . . .95
Psychological Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96
Symptom Rating Scales and Depression Screening . . .97
Assessing Suicidality in the Elderly . . . . . . . . . . . . . . . .105
Theories of Depression . . . . . . . . . . . . . . . . . . . . . . . . .107
 Hypomania and Mania . . . . . . . . . . . . . . . . . . . . . . . . . .110
Mixed Mood Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . .117
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117

4 Mood Disorders—Treatment . . . . . . . . . . . . . . . 127

Psychotherapy for Geriatric Depression . . . . . . . . . . . .127
New Directions in Psychotherapy Research . . . . . . . . .130
Combined Psychotherapy and Pharmacotherapy . . . .132
Psychopharmacotherapy for Geriatric Depression . . .132
Psychopharmacotherapy for Psychotic Depression. . .156
Psychopharmacotherapy for Bipolar Depression. . . . .157
Electroconvulsive Therapy . . . . . . . . . . . . . . . . . . . . . . .157
Experimental Therapies . . . . . . . . . . . . . . . . . . . . . . . . .159
Complementary and Alternative Approaches . . . . . . .161
Hypomania and Mania . . . . . . . . . . . . . . . . . . . . . . . . . .162
Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166

5 Dementia and
Alzheimer’s Disease. . . . . . . . . . . . . . . . . . . . . . 173
Identifying the Dementia Syndrome. . . . . . . . . . . . . . .173
Common Etiologies of Dementia . . . . . . . . . . . . . . . . .186
Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . .192
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .221
Resources for Dementia Caregivers . . . . . . . . . . . . . . .228

6 Other Dementias and Delirium . . . . . . . . . . . . 229

Frontotemporal Dementia . . . . . . . . . . . . . . . . . . . . . . .229
Dementia With Lewy Bodies . . . . . . . . . . . . . . . . . . . . .235
Vascular Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .241
Mixed Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248
Dementia Due to General Medical Conditions . . . . . .249
Substance-Induced Persisting Dementia . . . . . . . . . . .254
Reversible Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . .255
Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .256
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265
7 Anxiety Disorders and
Late-Onset Psychosis. . . . . . . . . . . . . . . . . . . . . 273
Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .273
Late-Onset Psychosis . . . . . . . . . . . . . . . . . . . . . . . . . . .293
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .306

8 Other Common Mental Disorders

of the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .313
Alcohol Abuse and Dependency . . . . . . . . . . . . . . . . . .320
Other Psychoactive Substance Abuse
and Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . .326
Sexual Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . .329
Psychiatric Illness Related to a General
Medical Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . .334
Chronic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .337
Influence of Aging on Disorders of Early Onset . . . . . .339
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .341

9 Competency and Related Forensic Issues. . . . 347

Decisional Competency . . . . . . . . . . . . . . . . . . . . . . . . .348
Undue Influence: The Question of Voluntariness . . . .358
Competency to Care for Oneself and
Manage One’s Finances . . . . . . . . . . . . . . . . . . . . . . . .360
Expert Consultation and Testimony
on Competency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .366
Competency to Drive . . . . . . . . . . . . . . . . . . . . . . . . . . .367
Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .371
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .373

Appendix: Clinical Assessment

Instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
Geriatric Depression Scale . . . . . . . . . . . . . . . . . . . . . . .380
Six-Item Orientation-Memory-Concentration Test. . . .382
Cognistat profile: Example . . . . . . . . . . . . . . . . . . . . . . .383
Instrumental Activities of Daily Living (IADL) Scale . . .384
Revised Memory and Behavior Problems
Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .386
Items Rated on the Neuropsychiatric Inventory. . . . . .388

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
 1
Introduction

An Aging World
For the first time in history, most people in societies such as our own can plan
on growing old. Life expectancy from birth has increased dramatically in the
United States, from about 47 years in 1900 to 77.3 years in 2002 (Federal In-
teragency Forum on Aging-Related Statistics 2004). Even those people who
are currently “old” can expect to live for many years. For men at age 65, aver-
age life expectancy is more than 16 years, and for women at age 65, it is almost
20 years; at age 85, men can expect to live 6 more years and women 7 years
(Federal Interagency Forum on Aging-Related Statistics 2004).
More than 20% of the current U.S. population are older than age 55, and
more than 12% are 65 or older (Federal Interagency Forum on Aging-Related
Statistics 2004). The elderly population is the only age segment of the popu-
lation that is expected to grow substantially in the next quarter century, so
that by the year 2030, one in three Americans will be age 55 or older, and one
in five will be at least age 65. Very old people (85 years and older) constitute
one of the fastest-growing subgroups of the elderly population (Figure 1–1).
In 1900, a little more than 100,000 people were age 85 years or older in the
United States, compared with an estimated 4.2 million in 2000 (National
Center for Health Statistics 2004). By 2050, there will be 19 million to 24
million people in this 85 and older age group, or nearly 5% of the total pop-
ulation. In 2003, more than 50,000 U.S. residents were 100 years or older, an
increase of 36% since 1990 (Administration on Aging 2004).

1
2 Clinical Manual of Geriatric Psychiatry

100

80

60
Population
(millions)

65 and older
40

85 and older
20

0
1900 1930 1960 1990 2020 2050

Projected

Figure 1–1. Populations of older adults in the United States (in millions).
Source. Adapted from Federal Interagency Forum on Aging-Related Statis-
tics 2004.

Worldwide, average life expectancy has increased to about 65 years (Cohen

2003), and by 2050, the number of people age 65 years and older is projected
at 2.5 billion worldwide (20% of the total population) (Olshansky et al. 1993).
Substantial increases in elderly populations are projected in the next quarter
century for North America, Europe, Asia, Latin America, and the Caribbean,
with smaller increases expected for areas such as sub-Saharan Africa, where both
fertility and mortality rates are high. China alone is expected to have 270 mil-
lion persons age 65 and older—nearly the total current population of the
United States—by the middle of this century. As one demographer recently
pointed out, the twentieth century may well be the last in which younger people
outnumbered older ones (Cohen 2003). By 2050, there will be more than three
adults age 60 years or older for every child age 4 years or younger.
 Introduction 3

Health and Functioning of Older Adults

Most people age 65 and older have at least one chronic medical illness, and
many have multiple conditions. The most common illnesses affecting elderly
people in the United States are arthritis, hypertension, and heart conditions
(Figure 1–2). Sensory impairments are also prevalent. Of 65- to 74-year-olds,
30% report problems seeing and 18% report problems hearing; these rates are
approximately twice as high for persons age 85 and older (Federal Interagency
Forum on Aging-Related Statistics 2004). Each of these conditions can limit
independent function and detract from quality of life. Being overweight or
obese has increased dramatically among older Americans in recent years. The
percentage of 65- to 74-year-olds who were overweight rose from 57% to
73% between 1976 and 2002, and the obesity rate increased from 18% to
36% (Federal Interagency Forum on Aging-Related Statistics 2004). By con-
trast, rates of cigarette smoking declined by 2002 to 10% among older men
and have remained steady in recent years at about 9% among older women.
Heart disease, cancer, and stroke account for two of every three deaths among
the elderly and also account for many doctor visits and days of hospitalization.
Death rates due to heart disease and stroke decreased by approximately one-third
from 1981 through 2001, whereas death rates due to diabetes and chronic lower
respiratory diseases increased by 43% and 62%, respectively (Federal Interagency
Forum on Aging-Related Statistics 2004). Alzheimer’s disease ranked sixth, after
heart disease, cancer, cerebrovascular diseases, respiratory diseases, and influenza
or pneumonia, among causes of death for Americans age 65 years and older in
2002 (National Center for Health Statistics 2004).
In 2002, people age 65 and older were hospitalized more than three times
as often as those ages 45–64, and they remained in the hospital about a day
longer on average than did middle-aged adults (Administration on Aging
2004). Older adults visited their physicians six to seven times per year on av-
erage, compared with three to four times for 45- to 64-year-olds.
In 1999, about 20% of older adults were chronically disabled as a result
of health problems; about 3% had limitations in only higher-order activities
of daily living (e.g., financial management, transportation, medication sched-
ules), 6% had impairment in one or two basic activities of daily living (e.g.,
eating, bathing, toileting), another 6% were impaired in three to six basic ac-
tivities, and slightly fewer than 5% were institutionalized (Federal Inter-
4 Clinical Manual of Geriatric Psychiatry

100

80
Americans age ≥65 (%)

Men Women
60

40

20

0
Heart Hyper- Stroke Emphy- Asthma Chronic Cancer Diabetes Arthritic
disease tension sema bronchitis symptoms

Figure 1–2. Percentage of people age 65 and older with selected chronic
conditions, 2001–2002.
Source. Adapted from Federal Interagency Forum on Aging-Related Statis-
tics 2004.
agency Forum on Aging-Related Statistics 2004). Of disabled older people
living in the community, 66% received informal care only, generally from rel-
atives; 26% received a combination of formal and informal services; and 9%
had formal care only (Federal Interagency Forum on Aging-Related Statistics
2004). The proportion receiving paid care has increased since the early 1980s,
reflecting improved financial resources of older persons as well as liberaliza-
tion in coverage rules under Medicare and Medicaid. Figure 1–3 shows age
trends in independent and assisted living within the United States.
Those with chronic needs that cannot be met at home generally receive care
in nursing homes. Although fewer than 5% of elderly Americans are in nursing
homes at a given time, the proportion of older persons requiring such care in-
creases quite sharply with age (see Figure 1–3). Among persons who reached
their 60th birthday in 1990, more than one-half of the women and one-third
of the men are expected to enter a nursing home at some point in the future.
However, older black Americans and elders from other minority groups use
 Introduction 5

1
100 5
1
5 Long-term-
2 3
19 care facility
Medicare enrollees (%)

80 7
Community housing
with services

60 93
98
92

Traditional
74
40 community

20

0
≥65 65–74 75–84 ≥85

Age (years)

Figure 1–3. Percentage of Medicare enrollees age 65 and older, by type of

residence, 2003.
Source. Adapted from Federal Interagency Forum on Aging-Related Statis-
tics 2004.
paid in-home services and nursing home care less frequently than do white
Americans (National Center for Health Statistics 2004). Between 1985 and
1999, the percentage of older adults residing in nursing homes in the United
States declined slightly, from 5.4% to 4.3%, but the total number of older nurs-
ing home residents increased from 1.3 million to 1.5 million because of growth
in the older population (Federal Interagency Forum on Aging-Related Statistics
2004). Three-fourths of current nursing home residents are women.
Health care costs for older Americans increased substantially from 1992
through 2001, after adjustment for inflation. During this time span, the pro-
portion of health care dollars spent on acute hospital care decreased, while the
proportion spent on prescription drugs increased. The average cost of provid-
ing health care for persons age 65 or older is currently three to five times
greater than health care costs for younger persons (Centers for Disease Con-
trol and Prevention 2004). Long-term-care costs, including nursing home
and home health expenditures, doubled between 1990 and 2001, a trend
6 Clinical Manual of Geriatric Psychiatry

shared by other developed nations. In 2001, the average annual cost for el-
derly residents of long-term-care facilities in the United States was $46,810,
compared with $8,466 for community residents of comparable age (Federal
Interagency Forum on Aging-Related Statistics 2004). Total Medicare spend-
ing increased from $33.9 billion in 1980 to $252.2 billion in 2002 and is pro-
jected to grow to twice that amount by 2012 (Centers for Disease Control
and Prevention 2004).
These trends present a significant challenge to the health care community.
The need to learn about aging and older people extends throughout the med-
ical and mental health professions. Creative approaches are required to stem
rising costs while maintaining quality assessment and intervention. Alliances
with families and other natural supports must be formed to ensure continuity
of care, and the strengths of older patients themselves must be marshaled to
cope with illness and to interact effectively within the health care system.

Mental Disorders in Later Life

Older people with mental disorders constitute a significant subgroup of the
elderly population. The multisite Epidemiologic Catchment Area (ECA)
Study conducted in the 1980s (Robins and Regier 1991) found that nearly
20% of Americans age 55 and older had diagnosable mental disorders, in-
cluding dementia (U.S. Public Health Service 1999). The ECA findings are
believed by many experts in the field to be underestimates because of meth-
odological limitations in the ECA assessment procedures. A 1999 consensus
conference on geriatric mental health estimated the prevalence of psychiatric
disorders in community-residing older adults at 25% or more (Jeste et al.
1999). Rates of mental disorder are much higher among elderly patients seen
in primary care or hospitalized for medical conditions, 30%–50% of whom
have psychiatric conditions (Borson and Unützer 2000; Rapp et al. 1988);
and in long-term-care settings, 68%–94% of residents have been found to
have mental disorders (Hybels and Blazer 2003). Table 1–1 compares rates for
several different types of mental disorders in the ECA community-based sur-
vey (1-month prevalence data) with a survey of hospitalized geriatric patients
conducted at about the same time. Overall, it is reasonable to estimate that
15%–25% of Americans who are currently age 65 or older have significant
mental health problems.
 Introduction 7

Older patients experience the same broad spectrum of mental disorders as

do younger adults. However, certain conditions are particularly notable in later
life because of either increased prevalence or high morbidity (see Table 1–1).
The elderly are at much greater risk for cognitive impairment than are
younger adults. In the community, at least 5% of people age 65 years or older
have prominent cognitive deficits, compared with fewer than 1% of people ages
18–64 (Regier et al. 1988). A larger proportion of older people have mild cog-
nitive problems, with estimates varying widely depending on the procedures
used to assess impairment (see Chapter 2, “Normal Aging”). The numbers in
Table 1–1 may underestimate the extent of problems related to cognitive defi-
cits, especially in the oldest age ranges. Recent data from the national Health
and Retirement Study showed that among Americans age 85 and older residing
in the community, one-third had moderate to severe memory impairment (Ad-
ministration on Aging 2004), and a widely cited epidemiological survey in the
East Boston area reported a prevalence of 47% for Alzheimer’s disease alone
among community residents age 85 and older (Evans et al. 1989).
Cognitive deficits in older patients have many different possible causes,
and in many cases, treatment of underlying problems can substantially allevi-
ate cognitive symptoms or slow the course of further decline (see Chapter 5,
“Dementia and Alzheimer’s Disease,” and Chapter 6, “Other Dementias and
Delirium”). Even for individuals with dementia of the Alzheimer’s type, gains
in functional ability can be obtained by treating coexisting medical or psychi-
atric illnesses. These small gains can make a great difference to family mem-
bers caring for these patients, as can support, psychotherapy, and respite
provided for caregivers.
Depression is an equally important condition in older adults. In the com-
munity, the percentage of older people meeting strict diagnostic criteria for
major depression is generally estimated at 5% or less (U.S. Public Health Ser-
vice 1999). However, traditional diagnostic criteria may not do justice to the
prevalence of depressive symptoms among older people. Serious depressive
symptoms were found in 8%–20% of elderly community residents and in up
to 37% of the elderly in primary care settings (U.S. Public Health Service
1999). In acute-care hospitals, as many as 25% of older patients have diag-
nosable mood disorders (e.g., Rapp et al. 1988), and nearly 50% of the ad-
missions of older adults to psychiatric hospitals are for depressive conditions.
The presence of comorbid depression or anxiety greatly increases health care
8 Clinical Manual of Geriatric Psychiatry

costs for patients in primary care (Simon et al. 1995), and over time, depres-
sion is associated with decrements in function and well-being that are similar
to, or greater than, those associated with chronic medical disease (Hays et al.
1995). Geriatric depression can be treated effectively with standard therapies
in 60%–80% of cases (U.S. Public Health Service 1999), but it is unlikely to
resolve spontaneously. Depression, anxiety, and alcohol and drug abuse in the
elderly today are only about one-quarter to one-third as common as among
middle-aged persons, and as the 55 million baby boomers grow old, their
mental health needs may prompt a crisis in geriatric care (Jeste et al. 1999).
Many older people without major mental disorders experience adjust-
ment reactions to personal stresses, bereavement, pain syndromes, and sleep
disturbance. Education and interventions directed at these problems may pre-
vent more serious psychiatric or medical problems from developing. The im-
portance of increasing prevention efforts for older adults as well as other age
groups was underscored in the U.S. surgeon general’s report on mental health
(U.S. Public Health Service 1999).
For psychiatrists, therefore, it is important not only to identify and treat
specific psychiatric disorders but also to provide education, support, and pre-
ventive interventions to strengthen older people and their families in manag-
ing common stresses of aging.

Barriers to Geriatric Mental Health Care

Improvements have been made since the early 1990s in the detection and
treatment of mental disorders in older adults in the United States. In an anal-
ysis of national Medicare fee-for-service data, for example, rates of diagnosed
depression in older adults increased from 2.8% in 1992 to 5.8% in 1998, and
two-thirds of those diagnosed received treatment of some type (Crystal et al.
2003). Similarly, since passage of the Omnibus Budget Reconciliation Act in
1987, efforts have been made, with varying degrees of success, to recognize and
treat mental disorders in patients in skilled nursing facilities. The number of
effective antidepressant medications has increased (Chapter 4, “Mood Disor-
ders—Treatment”), and medications to slow the course of common progres-
sive dementias have been introduced (Chapter 5, “Dementia and Alzheimer’s
Disease,” and Chapter 6, “Other Dementias and Delirium”). The usefulness
of psychotherapeutic interventions for common mental disorders of older
 Introduction 9

Table 1–1. Mental disorders among older adults

Distribution of psychiatric diagnoses (%)
Medical-surgical
Category of illness Community residentsa inpatientsb

Cognitive impairment 4.9 30.2

Affective disorders 2.5 18.5
Anxiety disorders 5.5 5.2
Alcohol abuse or 0.9 2.6
dependence
Schizophrenic disorders 0.1 0
Somatization 0.1 0
Personality disorder 0 8.3
Other psychiatric disorder 0 7.9
aAdapted
from Regier et al. 1988.
b
Adapted from Rapp et al. 1988.

adults has been more thoroughly confirmed (Chapters 4 through 8, “Mood

Disorders—Treatment,” “Dementia and Alzheimer’s Disease,” “Other De-
mentias and Delirium,” “Anxiety Disorders and Late-Onset Psychosis,” and
“Other Common Mental Disorders of the Elderly,” respectively), as have the
complex relationships between mental disorders and medical illness.
Despite these improvements, significant inequities remain in identifica-
tion and treatment of mental health conditions in older people and in acces-
sibility and use of geriatric mental health services (Areán and Unützer 2003;
Charney et al. 2003; Moak and Borson 2000). Adults older than 75, minor-
ity group members, and persons with Medicare only were less likely than
younger, white, and better-insured patients to have received treatment for
depression in recent years (Crystal et al. 2003), and even the most recent
studies continue to show that most cases of cognitive impairment without
obvious dementia go undetected and untreated in primary care (Chodosh et
al. 2004; Ganguli et al. 2004). Less common or less widely publicized con-
ditions are even more likely to remain unrecognized and inadequately
treated. In nursing homes, psychiatric services are generally restricted to a
consultative, as-requested mode instead of being a consistent and integrated
part of care management teams, and in the burgeoning numbers of assisted-
10 Clinical Manual of Geriatric Psychiatry

living and community-based programs for senior care, mental health services
are patchy and largely unregulated (Moak and Borson 2000).
Contemporary older Americans report less past use of mental health ser-
vices than do younger adults, and older Americans are less likely to express a
need for such services (Klap et al. 2003; Wetherell et al. 2004). Older adults
most often turn to primary care providers for help with mental health problems
(Kaplan et al. 1999), and typically, only one-half or fewer follow through with
referrals to specialty mental health providers. In a recent multisite randomized
trial, elderly primary care patients who screened positive for depression, anxiety,
or increased risk of alcohol use problems were offered collaborative mental
health services within primary care or enhanced referral assistance (e.g., sched-
uling, transportation, and payment assistance to outside mental health special-
ists) (Bartels et al. 2004). A significantly higher percentage of the patients
followed through on pursuing mental health treatment when it was available
within primary care (71% vs. 49%), and they completed more mental health
visits overall, than did those referred to mental health clinics or specialists, even
with enhanced assistance aimed at increasing the odds of compliance with the
referral. As the baby boom generation edges into the geriatric age range, the
“stiff upper lip” approach to managing emotional distress (Wetherell et al.
2004) may change, but the desire for proximal, integrated medical and mental
health services is likely to continue. Without more effective collaborative care,
underrecognition of mental health problems, especially among older patients
(Young et al. 2001), is likely to continue for several reasons:

• Multiple medical illnesses in elderly patients may divert physicians’ attention

away from psychiatric signs and symptoms, especially within the time-pres-
sured context of the standard brief office visit.
• Depression, anxiety, or memory problems may be viewed as normal for
older people with serious medical illness.
• Physicians with neither psychiatric nor geriatric training may have difficulty
distinguishing normal aging changes from signs of mental disorder or may
be reluctant to “open the can of worms” that treatment of emotional or cog-
nitive problems may entail.

A probability survey of primary care providers found that only 6% of gen-

eral internal medicine physicians and 22% of family practice physicians used
 Introduction 11

questionnaires or other structured procedures to screen for depression in their

older patients, relying instead on very brief informal interviews (Kaplan et al.
1999). Primary care physicians report that the subtlety of mild dementia
makes it difficult to recognize during brief interviews, but many physicians
remain reluctant to use formal cognitive screening tests (Boise et al. 1999);
many also believe that in the absence of effective treatment, there is little pur-
pose to diagnosing mild dementia, although this attitude may delay arrange-
ments for community support services and increase family strain (see Chapter
5, “Dementia and Alzheimer’s Disease”).
Among psychiatrists, attitudes about aging and age-related conditions
and limited training in geriatric psychiatry may further restrict the availability
and quality of mental health care for older patients. Many psychiatrists and
other mental health professionals find it difficult to work with elderly pa-
tients. Understandably, they may prefer to work with patients who have less
daunting problems with physical illness and personal loss, who remind them
less of their own mortality, and who are less likely to die in the course of treat-
ment. Nonetheless, recent research has not found mental health professionals
to be strongly or pervasively negative in their attitudes about older patients.
Instead, age bias seems to take more specific forms (Gatz and Pearson 1988).
American psychiatrists and other mental health professionals tend to refer
older patients less often for psychotherapy than comparably ill younger pa-
tients, and some of these professionals, in an attempt to avoid discrimination
against the elderly, may exaggerate the competencies and excuse the deficits
of elderly patients. “Fallacy for good reasons” is a phrase coined to refer to the
common situation in which a provider, as well as the patient and family mem-
bers, attributes the depression or anxiety experienced by the older patient to
medical illness, multiple losses, or financial difficulties that many older per-
sons face, especially the very old (Cole et al. 1997).
Inadequate insurance coverage for patients and limited reimbursement
for providers are ongoing barriers to geriatric mental health care. Because pre-
scription drugs have not been covered under Medicare until very recently, el-
ders who could not afford a coinsurance policy with drug benefits were
unable to afford psychiatric medications. The 50% copayment rule for psy-
chotherapy services under most insurance policies makes the decision to en-
gage in therapy costly to the patient, and allowable fees are often inadequate
(e.g., under Medicare, the psychotherapy fees allowed for an experienced psy-
12 Clinical Manual of Geriatric Psychiatry

chiatrist are half or less of the typical fee expected for this service). The elderly,
who generally have many health care needs, often have trouble coordinating
their own care, but there is usually no reimbursement for mental health pro-
viders to help with coordination.
The need for psychiatrists who are capable and willing to work with el-
derly patients, both in primary care and in specialty roles, is clear. Effective
models for collaborative medical and mental health services recently have
been developed for primary care (see Chapter 4, “Mood Disorders—Treat-
ment”), but this approach needs to be extended beyond clinical research, and
additional models need to be developed for geropsychiatric services within
community mental health settings and the full spectrum of long-term-care
services (Moak and Borson 2000). Older adults with medical comorbidity,
the oldest old, and those with significant chronic mental illness present par-
ticular challenges to existing service models (Borson et al. 2001).

Diversity in Patterns of Health and Aging

In 2003, persons of minority descent, including Hispanic whites, accounted
for 17.6% of the U.S. population age 65 and older, but by 2050, this percent-
age is projected to rise to 36%. Hispanic and Asian American groups as a
whole are the most rapidly growing minority populations, and these trends
are projected to continue (Figure 1–4).
Methodological difficulties encountered in the processes of sampling, de-
signing valid interview protocols, achieving subject cooperation, and control-
ling interviewer and subject bias have hampered attempts to generalize about
the health and other characteristics of black, Hispanic, American Indian, and
Asian populations in the United States. However, in key areas such as life ex-
pectancy, prevalence of chronic health conditions, residential patterns, and
education, significant differences have been documented across groups. In the
United States in 2001, average life expectancy from birth was 5.5 years longer
for white persons than for black Americans (Federal Interagency Forum on
Aging-Related Statistics 2004). At age 65, however, the life expectancy gap
narrowed to about 2 years, and by age 85, life expectancy was slightly longer
for older black persons compared with white persons. In 2000–2001, among
people age 65 and older, hypertension and diabetes were more common
among black than among non-Hispanic white persons; older Hispanics were
 Introduction 13

100

2003
80
2050–projected
Americans age ≥65 (%)

60

40

20

0
Non-Hispanic Black alone Asian alone All other races alone Hispanic
white alone or in combination of any race

Figure 1–4. Percentage of population age 65 and older, by race and His-
panic origin.
Source. Adapted from Federal Interagency Forum on Aging-Related Statis-
tics 2004.
comparable to non-Hispanic white Americans in rates of hypertension but
were more likely to have diabetes. By contrast, older white people were more
likely to have some form of cancer than were older Hispanic or black people
(National Center for Health Statistics 2004). Black and Hispanic elders are
less well educated than non-Hispanic white and Asian elders (see Figure 2–1
in Chapter 2, “Normal Aging”), and older black and non-Hispanic white per-
sons are more likely to find themselves living alone in old age than are their
Hispanic or Asian peers (see Figure 2–2 in Chapter 2).
Reports of prevalence of mental disorders for minority groups must be
viewed with caution because language and cultural differences can affect re-
sults on tests and interviews assessing depression, dementia, and other psychi-
atric disorders. However, data are emerging on the relative prevalence of
mental health–related problems in various groups and on availability and use
of mental health services. A recent supplement (U.S. Public Health Service
14 Clinical Manual of Geriatric Psychiatry

2005) to Mental Health: A Report of the Surgeon General (U.S. Public Health
Service 1999) concluded that the prevalence of mental disorders within the
most populous racial and ethnic minority groups in the United States (blacks,
Hispanics, and Asian Americans and Pacific Islanders) is similar to that of
white Americans. Among older adults, however, some important differences
in prevalence of mental health–related conditions have been documented for
racial/ethnic and gender subgroups. For example, the suicide rate is much
higher among non-Hispanic white men than in any other elderly subgroup
(National Center for Health Statistics 2004), and rates of alcohol abuse and
dependence are higher among elderly black men and women compared with
elderly white and Hispanic persons (U.S. Public Health Service 1999).
The surgeon general’s recent supplement underscored the pivotal role of
culture in maintaining mental health and the continuing, often striking, dis-
parities in availability of and access to mental health services among Ameri-
cans from minority backgrounds. Although not specific to older adults, the
recommendations for reducing barriers are as important for diverse geriatric
populations as they are for younger groups. The recommendations include
the following:

• Continuing research to establish the efficacy of evidence-based treatments

for racial and ethnic minorities and to better characterize how factors such
as acculturation and ethnic identity affect risk for, and protection from,
mental illness
• Improving access to treatment by improving geographic distribution of
services, increasing availability of services in preferred languages, and co-
ordinating care for the most vulnerable, high-need subgroups in which
racial and ethnic minorities are overrepresented (e.g., low-income or
homeless persons)
• Delivering effective, evidence-based treatments that are individualized ac-
cording to age, gender, race, ethnicity, and culture
• Working toward equitable racial and ethnic representation among mental
health providers, administrators, and policy makers

Women constitute the majority of older persons in the United States, out-
numbering men by a ratio of nearly 3 to 1 by age 85 and older. Important
gender differences have been reported for longevity, prevalence of specific
 Introduction 15

Table 1–2. Knowledge needed to work effectively with elderly

patients
Normal aging: biological, psychological, and social changes
Mental disorders predominantly observed in later life, including Alzheimer’s disease,
related dementias, late-onset psychoses
Effects of age on other psychiatric disorders, including mood and anxiety disorders
Adjusting psychiatric treatments for aging changes: dose and schedule of
psychoactive medications, drug-drug interactions, format and pace of
psychotherapy
Managing social and physical problems of later life: bereavement, role loss, pain,
sleep disturbance
Interactions of psychiatric and medical-surgical illnesses and their treatments

medical or mental conditions (e.g., heart disease, Alzheimer’s disease), and

rates of disability. At present, the price that women pay for longer lives ap-
pears to be a greater proportion of the late life span compromised by func-
tional disability, limited options for home care, and an increased likelihood of
spending their last years in a nursing home. Recent research, prompted by the
Women’s Health Initiative, is helping to elucidate whether preventive health
care, or more prompt and appropriate diagnosis and treatment of medical
conditions, can reduce the functional limitations now experienced dispropor-
tionately by women in later years.

Working Effectively With Older Adults

Psychiatric care of older patients requires a blending of specialized knowledge
with a broadly based, flexible approach to the patient (Table 1–2).
In addition to mastering the content areas covered in this Clinical Man-
ual, a psychiatrist treating older patients needs certain personal qualities and
professional approaches that are important for effective work in geriatric psy-
chiatry (Table 1–3). Although some older people can manage today’s complex
health care system, many more lack the energy, sophistication, cognitive abil-
ity, or funds to negotiate a specialty-oriented system successfully. As a result,
psychiatrists working with older people must be willing to play a generalist
role, combining routine medical management with psychiatric interventions
or helping with specific social or situational problems.
16 Clinical Manual of Geriatric Psychiatry

Table 1–3. Personal qualities and professional approaches

needed to work effectively with elderly patients
Willingness to provide broadly based, flexible management
Comfort in working closely with other health care professionals
Patience and skill in providing medical information and assisting in medical decision
making
Willingness to explore one’s own feelings about aging
Openness to discuss patients’ concerns about being treated by younger professionals
Acceptance of and comfort with limited treatment goals
Ability to maintain therapeutic optimism in the context of an ultimately poor
prognosis

The psychiatrist also must have patience and skill in explaining diagnoses
and treatments and in assisting older people in medical decision making. El-
derly patients often defer to physicians without truly comprehending benefits
and risks. This deference may increase efficiency of care in the short run, but
it may place the older person at risk for iatrogenic illness (e.g., delirium sec-
ondary to drug interactions). Finally, it is helpful to have a willingness to ex-
plore one’s own feelings about aging, as well as to be open to discussing older
patients’ reservations about the wisdom of youth. Elderly patients may be in-
clined to view younger therapists as similar to their children, and the thera-
pist, in response, may experience the reactivation of unresolved conflicts with
parents or grandparents or unresolved issues related to his or her own personal
aging (Meador and David 1994).

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18 Clinical Manual of Geriatric Psychiatry

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 Introduction 19

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 2
Normal Aging
Conceptual Issues
Who Is Old?
Biological and psychological aging changes usually occur gradually, over years or
decades, and as a result, there is no single age at which people in general can be
said to be old. The common practice of designating people older than 65 as “old”
began in Germany in the 1880s, when Otto von Bismarck selected 65 as the start-
ing age for certain social welfare benefits. In the United States, the age at which
full Social Security benefits can be received has now been raised to 67 years for
persons born in 1960 and later. Although this change is primarily a response to
fiscal concerns, the upward shift is also indicative of the increasing vitality and
productivity of the aging population. According to a recent national survey, 63
years is the average age at which Americans perceive individuals as becoming old,
but there was much variation in perceptions (Abramson and Silverstein 2004).
More than one-third of the sample named an age greater than 70 as the start of
old age, whereas another one-fourth cited ages less than 60 years.
Gerontologists often draw finer chronological demarcations within the
general group of aging persons. Comparisons may be made between the young-
old and the old-old (generally, those younger than and older than age 75, respec-
tively) or between these groups and the oldest old (generally 85 years and older).
Although these distinctions are also arbitrary, they can be useful in identifying
important differences in levels of functioning and can help to limit overgener-
alization about characteristics of older adults. It is also important to keep in

21
22 Clinical Manual of Geriatric Psychiatry

mind that individuals may age faster in some dimensions than others (e.g.,
being “old” physically but more youthful psychologically or socially).

Cross-Sectional and Longitudinal Views

The most common way to study the effects of aging is to compare a group of
older people with a separate group of younger adults. Because generational
differences in education, health practices, diet, and other important factors
are confounded with age differences when young and old subjects are com-
pared, cross-sectional investigations often provide an inflated estimate of the
magnitude of aging changes that will occur in individuals.
Longitudinal designs also have been used to study normal aging. These
investigations track the same individuals over years, or even decades. The least
healthy and able subjects are often the first to drop out from these samples,
so longitudinal investigations may provide an overly optimistic estimate of
the extent of decline with age.
The best picture of normative aging trends is obtained from studies in
which multiple cohorts are assessed longitudinally or by combining the re-
sults of separate cross-sectional and longitudinal studies. The Seattle Longi-
tudinal Study conducted by Werner Schaie (2005) and colleagues provides
one of the best examples of a multiple-cohort longitudinal aging study, out-
comes of which have helped to shape understanding of cognitive processes
that remain stable or reliably decline with age. At least 25 other longitudinal
investigations of behavioral aspects of aging are ongoing at this time, and a
burgeoning number of cross-sectional studies are being done.

Heterogeneity in Patterns of Aging

On many psychological and biological measures, variability is greater in old-
age samples than among younger adults. A longitudinal study of 426 elderly
community dwellers by Christensen and associates (1999) found increases in
interindividual variability with age in memory, spatial functioning, and speed
but not in crystallized intelligence. Being female, being more depressed, being
more ill, and having weaker muscle strength were associated with greater vari-
ability, whereas having a higher level of education was associated with reduced
variability. Pronounced variability decreases the sensitivity in upper age ranges
of many measures that are used to infer pathological changes and casts doubt
on the search for singular normative aging trends. Many different normal ag-
 Normal Aging 23

ing trajectories may exist, with varying trends for different genetic and socio-
cultural subgroups. Intraindividual variability (i.e., fluctuating performance
within and across assessments) is also increased in old age, especially for cog-
nitive and physical performance measures. Heightened variability within the
individual has been linked to an accelerated rate of cognitive decline over time
and may be a marker for neurobiological aging (MacDonald et al. 2003).

Cognitive Abilities in Later Life: A Processing

Resource Model
Cognitive changes with aging are well documented and affect a broad range
of functions (see the subsection “General Aging Trends” later in this section).
However, many of the differences in specific abilities can be traced to declines
in three fundamental cognitive-processing resources: the speed at which in-
formation can be processed, working memory, and sensory and perceptual
skill (Park 1999).

Processing Speed
Perhaps the most predictable of all cognitive changes is the reduced speed of
information processing and response. Slowed execution of component per-
ceptual and mental operations can affect attention, memory, and decision
making and can influence performance even on tasks that have no obvious
speed requirements (Salthouse 1996).

Working Memory
Working memory refers to short-term retention and manipulation of informa-
tion held in conscious memory, a type of “online” cognitive processing (Bad-
deley 1986). Examples include consciously recalling a telephone number long
enough to write it down, mentally calculating the sale price of an item that is
reduced by 15%, and mentally traversing a route that one intends to walk or
drive. Information fades from working memory within about 2 seconds, so to
keep details “alive” for a longer time requires active rehearsal or continuing re-
focusing of attention.
Aging is associated with a decline in working memory skills, especially
when active manipulation of information is required (e.g., repeating numbers
24 Clinical Manual of Geriatric Psychiatry

backward as opposed to forward). Reductions in working memory, in turn,

place limits on other complex cognitive skills, including reasoning and other
executive processes, and learning and recall of new information.

Sensory and Perceptual Changes

Most older adults experience decrements in visual and auditory acuity and
other perceptual changes. Some, but not all, of the age-related visual changes
can be corrected by glasses, and although hearing aids help with detection of
low-frequency tones, they often amplify background noise. In effect, many
older adults find it hard to hear or see well, especially with competing back-
ground noise and poor lighting conditions.
Recent studies suggest a strong correlative link between sensory and per-
ceptual changes and cognitive performance in old age. Younger adults tested
with degraded perception (e.g., by background noise or reduced visual con-
trast) perform much like older adults on measures of learning, memory, and
language (Schneider and Pichora-Fuller 2000). The extra time and effort re-
quired to process information necessitated by sensory and perceptual prob-
lems tax working memory, effectively overloading the system.
The combined effects of central nervous system slowing, reduced working
memory, and sensory and perceptual changes limit the processing resources that
older persons can bring to bear in particular situations. These changes increase
the likelihood of processing overload in circumstances that may have once pre-
sented little challenge. In advanced old age, even basic activities such as walking
or maintaining postural control become less automatic, with the result that
older persons must devote more conscious cognitive resources to these activities.

Neuropsychological Explanations of Cognitive Aging

Changes
Neuropathological and neuroimaging studies have documented widespread
changes in the human brain with aging (Raz 2000; Victoroff 2000). There are
generalized atrophic and white matter changes as well as region-specific vari-
ations in the extent of cell loss. Within the cortex, the prefrontal lobes are
disproportionately affected by aging changes, whereas temporoparietal asso-
ciation areas are less affected. Subcortical monoaminergic cell populations,
which connect to the frontal lobes by a complex network of projections, are
also subject to prominent decline in aging. Data are more conflicting regard-
 Normal Aging 25

ing changes in the hippocampus and entorhinal cortex, with some studies
noting minimal cell loss with normal aging in these regions and others show-
ing decremental changes. Areas in which there is relative sparing with age in-
clude the globus pallidus, the paleocerebellum, the sensory cortices, and the
pons (Raz 2000).
Some of the behavioral changes in aging, such as slowed information pro-
cessing and response, may be related to generalized changes such as decreased
brain volume and white matter density. Other changes appear to mirror the se-
lective pattern of differential change in prefrontal cortical structures and striatal
dopaminergic nuclei. Decreased working memory, problems with effortful
learning and recall, and changes in efficiency of executive functions are some of
the findings that suggest a mild degree of frontal or subcortical brain dysfunc-
tion in normal aging (Prull et al. 2000). The “frontal lobe hypothesis” is perhaps
the most popular neuropsychological model of normal aging at this time. How-
ever, hippocampal changes also may play a role in normal aging memory. Hip-
pocampal volume, as measured by magnetic resonance imaging, correlates with
memory performance in older adults, and those with smaller hippocampal vol-
umes are at greater risk for developing dementia. What remains to be resolved,
however, is whether reduced hippocampal volume is truly within the normal
aging spectrum or instead is a preclinical phase of dementia.
Functional neuroimaging studies have shown less regional specificity in
older adults’ patterns of brain activation to various cognitive tasks compared
with the regional specificity in young adults (Prull et al. 2000; Raz 2000). One
interpretation of this finding has been that older persons must recruit more
neural systems to perform even relatively simple mental operations. This inter-
pretation coincides in a general way with the behavioral model of reduced pro-
cessing resources and increased susceptibility to overload on complex tasks.

General Aging Trends

Table 2–1 summarizes general aging trends for intelligence and specific areas
of cognitive function. In this table, mild decline refers to changes that are generally
within a standard deviation of the mean for young adults, whereas moderate de-
cline refers to differences on the order of one to two standard deviations below the
average for young adults. As the table indicates, cognitive changes associated with
normal aging generally fall within the mild to moderate range, and there are some
areas in which performance remains stable or improves. The differential pattern
Table 2–1. Aging effects on cognitive performance

26 Clinical Manual of Geriatric Psychiatry

Ability Direction of aging change Comment

Intelligence
Vocabulary, fund of Stable or increasing May decline slightly in very old age; most pronounced on novel
knowledge tasks
Perceptual-motor skills Declining Decline begins by ages 50–60
Attention
Attention span Stable to mild decline
Complex attention Mild decline Problems with dividing attention, filtering out noise, shifting
attention
Language
Communication Stable In absence of sensory impairment
Syntax, word knowledge Stable Varies with education
Fluency, naming Mild decline Occasional word-finding lapses
Comprehension Stable to mild decline Some erosion in processing complex messages
Discourse Variable May be more imprecise, repetitive
Memory
Short-term (immediate) Stable to mild decline Forward digit span intact (7±2 items), but easily disrupted by
interference
Working Mild to moderate decline Reduced ability to manipulate information in short-term
memory
Secondary (recent) Moderate decline Encoding and retrieval deficits; storage intact
Table 2–1. Aging effects on cognitive performance (continued)
Ability Direction of aging change Comment

Memory (continued)
Implicit Stable to mild decline May recall incidental features more easily than consciously
processed information
Remote Variable Intact for major aspects of personal history
Prospective Variable Mild to moderate decline on laboratory tasks, but older adults
often outperform younger people on naturalistic prospective
memory tasks
Visuospatial
Design copying Variable Intact for simple but not complex figures
Topographic orientation Declining Most noticeable in unfamiliar terrain
Executive functions
Cognitive flexibility Mild to moderate decline Slower and less accurate in shifting from one thought or action
to another
Logical problem solving Declining Some redundancy and disorganization
Practical reasoning Mild to moderate decline Qualitatively intact, but reduced efficiency on complex or novel

Normal Aging
tasks
Speed Declining Slowing of thought and action is the most reliable aging change

27
28 Clinical Manual of Geriatric Psychiatry

of abilities shown in Table 2–1 is less apparent among the oldest-old (e.g., 85 or
older), for whom some studies report a generalized pattern of gradual decline. An-
other important qualification concerns secular trends in levels of performance. In-
tellectual performance scores have been increasing over the past few decades, and
the rate of increase is higher among older, as opposed to younger, adults. For ex-
ample, vocabulary scores on the commonly used Wechsler Adult Intelligence
Scale (Wechsler 1997) have increased nearly 5 IQ points per decade for 65- to 74-
year-olds, compared with 1.5 points for 18- to 24-year-olds (Uttl and Van Alstine
2003). Higher absolute levels of intellectual ability may benefit contemporary
older adults in learning new information and acquiring new skills (see the subsec-
tion “Effect of Cognitive Change on Everyday Function” later in this section).

Factors That Influence Cognitive Aging

Table 2–2 summarizes characteristics and experiences that influence the de-
gree of cognitive change individuals show as they age. The cumulative effect
of these factors, operating over months or years, may be responsible for in-
creasing variability in cognitive performance at older ages. Healthy and
stimulating lifestyles, in addition to early life advantages such as adequate ed-
ucation, are hypothesized to strengthen the “cognitive reserve” that individu-
als have available to cope with neurobiological changes resulting from aging
or illness (Scarmeas and Stern 2003). Increasing evidence, for example, indi-
cates that physical and mental exercise, a healthy diet, and strong social sup-
ports may serve as protective factors against the development of dementia
(e.g., Fratiglioni et al. 2004).

Learning and Memory

When older people complain about their cognitive abilities, they usually men-
tion problems with memory. Research substantiates these complaints, but as
shown in Table 2–1, some aspects of memory decline more with age than do
others (La Rue 1992; Prull et al. 2000). Short-term or immediate memory re-
mains stable or declines to a modest degree in later life. For example, the median
forward digit span for healthy persons in their 80s is six items, compared with
seven items for persons in their 30s (Wechsler 1997). On more demanding tests
of short-term memory, such as recalling information after an interfering mes-
sage, age differences favoring the young are likely to be observed, which coin-
cides with the declines in working memory discussed earlier.
Table 2–2. Cognition in normal aging: moderating variables
Genetic factors About 50% of cognitive variability in old age can be traced to genetic factors.
Health Optimally healthy elderly persons outperform those with medical illnesses on many cognitive tests.
Education Education accounts for up to 30% of cognitive variability in old age.
Mental activity Mentally stimulating activities correlate with higher cognitive performance and reduced
longitudinal decline.
Physical activity Aerobic fitness is associated with better cognitive performance in old age.
Expertise Aging experts may develop compensatory strategies to maintain a high level of performance despite
some erosion in underlying cognitive skills.
Personality and mood Depression correlates with self-perceived memory failure and with performance impairments if
symptoms are severe.
Social and cultural milieu Everyday memory lapses may be judged more critically when experienced by older people than
by young adults.
Cognitive training Cognitively unimpaired older persons benefit from practice and training in specific cognitive skills.
Cohort effects Recently born cohorts are outperforming those born near the turn of the century on many cognitive
skills.
Sex differences Cognitive aging trends are similar for the two sexes, but women may show decrements on spatial
tasks at an earlier age than men, and men may show decrements on verbal tasks at an earlier age

Normal Aging
than women.
Racial and ethnic differences Performance differences favoring elderly white persons have been reported on some cognitive tests,
but when education is equated across groups, these differences are reduced or eliminated.

29
30 Clinical Manual of Geriatric Psychiatry

Anecdotally, remote or long-term memory is well maintained in old age.

Research results are not so clear, partly because remote memory is difficult to
measure because initial or intervening exposure to the material cannot be pre-
cisely controlled (La Rue 1992; Prull et al. 2000). Overall, however, older
adults’ absolute levels of performance on remote-memory tests are often im-
pressively high; for example, one study found that people recognized names
or photographs of more than 70% of high school classmates after an interval
of almost 50 years.
Another type of memory that shows minimal or modest age change is im-
plicit or incidental recall. Incidental facts or features (e.g., the color of some-
one’s dress) can be recalled with about equal accuracy by young and old,
whereas the old are more prone to forget information that they had explicitly
hoped to retain (e.g., the person’s name).
Prospective memory (i.e., memory for actions intended in the future) shows
divergent age trends, depending on how and where it is measured (Henry et al.
2004). In laboratory settings, older adults typically do less well than younger
persons. However, on naturalistic tasks (e.g., remembering to call to make an
appointment), older adults often show superior follow-through, mainly because
of more reliable use of external aids such as reminder notes.
The largest age decrements are observed in recent, episodic memory (La
Rue 1992; Prull et al. 2000). Age differences favoring the young have been
found on many explicit tests of recent memory, such as remembering items
on shopping lists, learning to associate pairs of words, copying designs from
memory, and remembering content of stories and conversations. On the av-
erage, healthy older individuals make more mistakes than young adults on
memory items from mental status examinations, such as 5-minute delayed re-
call of three or four simple words. On demanding explicit memory tasks,
older persons recall less information initially compared with young adults,
but their performance improves with repetition, and they retain most of what
they learn after delays and distractions. This ability to retain information,
once it is acquired, is one of the best ways to distinguish normally aging mem-
ory from that of patients with amnestic conditions or Alzheimer’s disease (see
Chapter 5, “Dementia and Alzheimer’s Disease”).
Some of the problems that older people have with initial learning may be re-
lated to strategies used for processing new information (La Rue 1992). Many
older people take a more passive approach to learning and remembering than do
 Normal Aging 31

younger adults. For example, elderly people report less spontaneous use of mne-
monic strategies than do younger people and do not appear to capitalize as readily
on the organization inherent in words or actions as a basis for learning and recall.
The shallower memory traces that result are subsequently harder to retrieve, espe-
cially without the aid of reminders or cues. If older individuals are explicitly in-
structed to use mnemonics or organizational strategies, their learning and recall
often improve dramatically, at least in the short term.
Active encoding and retrieval may require greater expenditure of effort and
energy than most older people can afford. Declines in effortful processing may be
caused by altered neurotransmitter functions (especially catecholamines). Alterna-
tively, such processing changes may be seen as an adaptive response to the dimin-
ished demands of older adults’ everyday lifestyles. Also, it is important to note that
some healthy and active elderly people do as well on demanding recent memory
tasks as do more average young adults.
Older adults (and younger persons, too) often ask about ways to improve
their recall of everyday information. Mnemonic training can produce notable
gains in troublesome areas, such as recall of names, locations of objects, and lists
of things to be purchased or done, for old as well as young adults. Training is most
likely to be effective for young-old persons as opposed to the oldest-old and for
individuals with no decline on mental status examination (Verhaeghen et al.
1992). Training also works best in an individual or a small-group format and with
relatively short (e.g., half-hour) sessions as opposed to longer workshops or lec-
tures. Follow-up studies often show that people discontinue memory techniques
they have learned within a few weeks. In some cases, this may simply mean that
the training served its intended purpose (i.e., to prove that one can remember
more if need be), but it is also likely that the use of mnemonics may be too effort-
demanding in the long run. A greater drawback of mnemonic training ap-
proaches is that benefits often fail to generalize to everyday tasks not specifically
included in training (Ball et al. 2002). Education and counseling about memory
improvement is best approached from a broad perspective, in which improving
memory is seen as part of an overall wellness plan.
Of the many self-help books providing advice on how to maintain memory
function into old age, Keep Your Brain Young (McKhann and Albert 2002) is
among the best in terms of readability, breadth, and linkage to research. Learning
Throughout Life (National Retired Teachers Association et al. 2004) is another
good guide for the general reader. In The Memory Prescription, Small (2004) out-
32 Clinical Manual of Geriatric Psychiatry

lines a 2-week program of diet, exercise, stress reduction, and mental exercise de-
signed to boost brain function. The program is derived from an ongoing program
of research, but independent studies are needed to assess benefits of this approach.

Executive Function
The term executive function refers to cognitive abilities necessary for complex goal-
directed behavior and adaptation to change. Some of the skills included in this
category are reasoning, planning, anticipating outcomes of behavior, directing at-
tentional resources in a flexible manner, monitoring one’s own behavior, and self-
awareness. Performance of such skills requires the coordinated activity of multiple
regions of the brain and can be affected by injury to several different areas. How-
ever, the prefrontal cortex and frontal-subcortical brain circuits have been shown
to play a central role in executive functions. As noted earlier, normal aging has a
greater decremental effect on these brain regions than on many other areas, and
predictably, age differences are relatively large on executive function tasks (see
Table 5–5 in Chapter 5, “Dementia and Alzheimer’s Disease,” for examples of
neuropsychological tests of executive function). Performance on executive func-
tion tests correlates more closely than scores on many other cognitive tasks with
activities of daily living, and changes in executive function may play a role in de-
termining which older people come to clinical attention for mild cognitive
changes (Royall et al. 2005).
Although research generally shows that older adults do worse than young or
middle-aged persons on both laboratory-based and practical reasoning tasks
(Thompson and Dumke 2005), not all studies show this trend. For example, one
recent investigation found that cognitively healthy 65- to 74-year-olds provided
more relevant solutions to problem situations—such as trying to improve the
acrimonious tone of a meeting, dealing with excessive demands by one’s sons to
babysit their children, or having blood drawn by a physician who is having diffi-
culty with the procedure—than did a comparison group of 20- to 29-year-olds
(Artistico et al. 2003). In general, interpersonal problem solving is an area of
strength for older people (Thompson and Dumke 2005).

Effect of Cognitive Change on Everyday Function

Although normal aging is accompanied by a variety of cognitive changes,
most older adults are not impaired in everyday activities, even when relatively
complex cognitive processing is required.
 Normal Aging 33

Several factors help to maintain daily function in the face of mild cognitive
decline (Park 1999). The very gradual nature of age-related change allows time to
adjust to diminished speed and efficiency in cognitive function. The fact that gen-
eral knowledge is well preserved in later life allows older adults to access a broad
base of information that is useful in solving problems and addressing everyday
needs. With practice, many tasks become automatic and require little cognitive
processing or effort to perform, and maintaining a familiar environment and rou-
tine further reduces cognitive load. Also, many older adults make frequent and ef-
fective use of external cognitive aids such as writing reminder notes.
Some areas, such as driving and monitoring medications, pose particular
risks (Park 1999). Older adults are more likely to be involved in accidents while
driving than are younger persons, particularly in certain situations (e.g., left
turns in intersections). Cognitive research has identified a measure of peripheral
vision (so-called useful field of vision) that is more predictive of driving success
than are standard visual acuity measures, and this research also has found that
older adults can improve driving skill through a combination of perceptual
training and traditional drivers’ education classes (see Chapter 9, “Competency
and Related Forensic Issues,” for additional information on driving). Regarding
medications, it is important to note that some studies show better compliance
with medication regimens among older adults than among younger or middle-
aged persons, particularly if the older adults are taking only a single medication
for a long-standing condition (e.g., hypertension or arthritis). When they are
taking multiple medications that require dosing several times a day, the risk of
errors is increased, and it has been estimated that about 1% of acute hospital
admissions for older persons are precipitated by medical errors or medication
reactions.
In industrialized nations, an overabundance of new information and rapidly
changing technologies place a heavy demand on learning skills. Older adults
bring to this situation a wealth of accumulated knowledge and experience, which
can facilitate learning of new information in areas of prior knowledge. One re-
cent study found, for example, that older age proved to be an advantage in learn-
ing new information about cardiovascular disease, presumably because of older
adults’ greater baseline knowledge of health-related subjects (Beier and Acker-
man 2005). By contrast, younger adults were more adept at learning about a new
technology. Research on training methods has shown that older adults learn best
with self-paced training or other training environments that allow ample time to
34 Clinical Manual of Geriatric Psychiatry

assimilate the information presented (Callahan et al. 2003). These modes of ed-
ucating most effectively remediate, or compensate for, reduced speed of process-
ing and working memory or sensory limitations.

Clinical Implications of Cognitive Change

Cognitive declines that accompany normal aging complicate detection and
diagnosis of organic mental disorders. One common error is overdiagnosis of
dementia, particularly in persons with limited education. In one large multi-
cultural study, most old persons without dementia who had less than 5 years
of education were rated with standard mental status examinations as impaired
(Wilder et al. 1995).
Among healthy, well-educated old persons, brief cognitive screening may
fail to detect focal brain impairment or dementia in early stages. For example,
as many as one in three older patients with mild Alzheimer’s disease who are
otherwise healthy and have at least a high school education can be expected
to score in the normal range on very brief tests for cognitive screening.
Outcomes of cognitive mental status examinations in older people must
be interpreted cautiously, and the clinician should follow up with a more
thorough diagnostic assessment for those who score in the impaired range or
whose adequate performance on a screening examination is inconsistent with
lapses in everyday behavior. Paying attention to the pattern and types of errors
may also help to distinguish normal from abnormal cognitive changes. Chap-
ter 5 (“Dementia and Alzheimer’s Disease”) provides more specific guidelines
for screening for dementia through the use of cognitive mental status exami-
nations, and the following subsection discusses more specific diagnostic issues
concerning age-associated cognitive syndromes.
Age-related cognitive changes also have implications for the doctor-patient
relationship and for selection and monitoring of treatment. Extra care may be
required in explaining medical procedures to ensure informed decision mak-
ing. Asking the patient to repeat the main points and providing written sum-
maries or illustrations may help to make details of procedures clear, although
very complicated medication organizers or instructional charts may be coun-
terproductive.
In psychotherapy, the reduced pace of new learning and changes in rea-
soning processes may result in a slower rate of clinical improvement. Often,
this can be dealt with effectively by increasing the number of therapy sessions.
 Normal Aging 35

Abrupt changes in cognitive function always warrant medical attention.

Even more gradual declines, emerging over a year or two, may be an early
warning of occult illness (so-called terminal decline) and should be carefully
monitored. According to one recent study, subclinical cognitive decline in-
creases the risk of mortality in older men as much as a history of cancer does.

Diagnosing Age-Related Cognitive Change and Mild

Cognitive Impairment
In DSM-IV-TR (American Psychiatric Association 2000) nomenclature, the
category of age-related cognitive decline (780.9) may be coded to denote
functioning of an older person with mild cognitive changes that are within
normal limits for age and not attributable to a medical disorder.
No guidelines have been developed for identifying age-related cognitive
decline. However, diagnostic criteria have been proposed for a related, but
narrower, category of age-associated memory impairment (AAMI). Persons
with a diagnosis of AAMI must be 50 years or older, have subjective com-
plaints of memory loss affecting routine activities, and perform below the av-
erage level of young adults on a standardized memory test; exclusionary
criteria include any neurological, psychiatric, or medical disorders that could
reasonably be assumed to be producing the memory change. The prevalence
of AAMI based on objective assessment has been estimated to range from
40% for persons in their 50s to 85% for those 80 and older (Larrabee and
Crook 1994). Thus, five of every six very old, healthy persons can be expected
to perform somewhat lower than young or middle-aged adults do on memory
tests and possibly to have mild memory lapses in everyday activities. AAMI
has been shown to be stable over intervals of at least 4 years; thus, it is pre-
sumed to reflect normal aging, as opposed to beginning dementia or other
brain disorder.
Clinicians are also likely to see older adults whose cognitive skills are
somewhat worse than expected for their age but who are still coping well over-
all and do not appear to have dementia. Much research has been devoted to
this gray area of performance, generally referred to as mild cognitive impair-
ment. Diagnostic criteria for this condition are still evolving, and several def-
initions have been proposed (see Winblad et al. 2004).
The skill most commonly affected in mild cognitive impairment is learn-
ing and recall of new information, but in some cases, problems are noted in
36 Clinical Manual of Geriatric Psychiatry

other cognitive areas, such as language, visuospatial skills, or reasoning. The

term amnestic mild cognitive impairment is used when memory is impaired,
and the term nonamnestic mild cognitive impairment is used for other types of
mild cognitive deficits. Additional subcategorization has been proposed to
distinguish between cases in which a mild deficit is observed in a single do-
main (e.g., memory) or in multiple domains (e.g., memory and reasoning).
In all forms of mild cognitive impairment, there may be subtle difficulty with
higher-order activities of daily living such as financial management, but this
difficulty is often intermittent and can be dealt with by extra effort or com-
pensatory approaches such as note taking or double-checking one’s work.
Table 2–3 compares diagnostic criteria for amnestic mild cognitive impair-
ment with those for AAMI.
The very short tests included in mental status examinations are generally
not sensitive to mild cognitive impairment, and if this condition is suspected,
referral for neuropsychological testing is recommended. To improve screening
accuracy for amnestic mild cognitive impairment, a more challenging test of
learning and memory should be incorporated into the psychiatric examina-
tion (see Table 5–5 in Chapter 5, “Dementia and Alzheimer’s Disease,” for
examples of memory tests). DSM-IV-TR research criteria for mild neurocog-
nitive disorder (coded as cognitive disorder not otherwise specified, 294.9)
may be appropriate for some cases of mild cognitive impairment (i.e., when
there is mild cognitive dysfunction in two or more areas, and when deficits
do not meet criteria for dementia, delirium, or other major organic mental
disorders; American Psychiatric Association 2000).
The syndrome of mild cognitive impairment can have several different
underlying causes. In amnestic mild cognitive impairment, neurodegenera-
tion of an Alzheimer’s type is believed to be the most common etiology (Pe-
tersen and Morris 2005). However, depression or other psychiatric disorders,
metabolic or medical disorders, trauma, substance abuse or medication reac-
tions, and other conditions also may cause mild cognitive impairment of the
various types. In evaluating an individual who presents with mild cognitive
impairment, it may be helpful to review the full range of potential causes and
contributing factors that have been established for dementia (see Chapter 5,
“Dementia and Alzheimer’s Disease”).
As shown in Table 2–3, a substantial proportion of persons with amnestic
mild cognitive impairment eventually develop dementia, and a high pro-
Another Random Scribd Document
with Unrelated Content
 “Is he a scholar?”
“I do not know.”
“Is he logical?”
“I cannot tell. He claimed that he went to school only a few
months.”
“How long did you debate with him?”
“Six days.”
“What?” said Doctor Stone in astonishment, “You debated with
him six days, and could not tell whether or not he is educated?”
“Well,” continued the university president, in a meditative mood, “I
will say that he is—forceful.”
Doctor Stone looked blank for a moment, and then ventured with
a smile, “May be he whipped you?”
“I don’t know,” was the guarded answer, “but I am inclined to
believe that my people thought he did.” Observing that Stone was
intensely interested, Treat inquired:
“Are you thinking of debating with him?”
Stone answered in the affirmative.
“Can’t you get out of it in some honorable way?”
Stone replied that he was not wanting “out of it.”
“But you may want out of it,” was Treat’s not very assuring reply.
“Why, is he not fair in debate? Is he not a gentleman?”
“Yes,” answered Treat, “so much so that all your people who know
him love to be with him and hear him talk.” And the conversation
drifted into other channels. But Doctor Stone, being from Missouri,
waited to be shown. And the debate was held according to schedule.
About this time Doctor Stone was enjoying no small degree of
notoriety. He had debated with a Methodist minister in southern
Illinois, and so completely mastered him that he acknowledged his
defeat in sack cloth and ashes, and joined the Christian Church.
Stone was taking advantage of his newly-acquired popularity in
waging a relentless war against the “sects,” as he termed them,
when some of the Pedo-Baptists secured Newgent to meet him in
debate. And the challenge was brought to the great, self-important
Doctor Stone.
“Newgent!” said this supposed Goliath with a contemptuous sneer.
“He can’t debate. He’s an Irish peddler who used to sell table-cloths
in my father’s neighborhood.” The committee informed him that they
were willing to risk their case with the Irish peddler. However,
Stone’s visit to Doctor Treat to get information concerning the
Irishman would indicate that his contempt was more feigned than
real.
The debate was held in a small town in southern Illinois, where
the doctor had been making havoc of the “sects.” The table-cloth
story became current, and much speculation was indulged in
concerning the supposed vender of household commodities. His
coming to the village was awaited with intense interest. When the
train on which he was scheduled to arrive pulled in at the station, a
curious and enthusiastic crowd was waiting to get a view of the man
who dared to dispute the wisdom of Doctor Stone. As he stepped
from the car, a gentleman who knew him said, pointing him out,
“There’s the table-cloth peddler.”
A hearty salute was given by the crowd. Newgent, having been
apprised of the story, was equal to the occasion. As soon as the
hubbub ceased, he addressed the crowd, turning the table-cloth
story against his opponent in the following speech:
“Gentlemen, if you have come here to buy table-cloths, you will be
disappointed. I have changed my occupation. I have been informed
that there is some fine stone in southern Illinois, so I have come
down here to set up my shop and spend a few days dressing Stone.”
 The “Stone dressing” joke superseded the table-cloth story and
became a catch phrase throughout the debate.
It is likely that Stone often called to mind the friendly advice of
Doctor Treat, and regretted that he did not take it. He could cope
neither with the argument, the quick wit, nor the physical endurance
of his opponent. His voice failed completely, and the last two
addresses of Newgent were unanswered. The Stone-dressing
business proved eminently successful.
An amusing incident occurred in connection with a debate in
Kentucky with a Doctor Fairchilds, an eminent Baptist minister. A
story came to the ears of Doctor Fairchilds after he came on the
ground, to the effect that Newgent was a man of extraordinary
scholarship, that he was master of some thirteen languages, etc.
The doctor was visibly disconcerted by the story, and after hearing
Newgent’s first address, was fully persuaded that it was true,
especially the part relating to the thirteen languages. He was quite
nervous, and utterly broke down about the middle of the program,
leaving the supposed master of thirteen languages easily master of
the situation.
While on his official rounds as superintendent of the Tennessee
Mission Conference, he once chanced to invade a Lutheran
community, which set in motion a train of influences that terminated
in a debate with a representative of that body. This was about eight
miles from Greenville. He was visiting a United Brethren family that
had moved into the community, and in company with his host, called
at the district school, and made a talk to the pupils. Through the
influence of his host, the school house was secured for a preaching
service that evening. Other influences then began to be felt, and the
meeting was continued indefinitely, resulting in a sweeping revival,
the organization of a United Brethren church, and the building and
dedication of a church-house within two months from the close of
the revival.
This occasioned great concern among the Lutherans who lost
quite heavily as a result of the United Brethren invasion. To regain
their lost ground, they challenged Rev. Mr. Newgent to debate
certain doctrinal questions with a representative of their church.
Newgent was then in his element, in the debate, and answered that
he would be ready at any time to accommodate them.
The Lutheran champion was Dr. J. C. Miller, president of one of
their church schools. The much-mooted question as to what body
constituted the true church was the first taken up, Doctor Miller
posing as the representative of a church whose doctrines and usages
are identical with those taught and exemplified in the New
Testament.
This placed upon Miller the Herculean task of defending the
various tenets and practices peculiar to his church. Among other
specimens of Lutheran creed, Newgent read the following: “The
infant’s heart is corrupt, and it cannot be saved unless baptized by a
Lutheran minister with heavenly, gracious water.” When asked if his
church taught that, Doctor Miller admitted that it did.
Newgent showed this bit of dogma up in a bad light by the use of
an object lesson. Borrowing a baby from a mother in the audience,
he held it up before the crowd, stating that the “little rascal’s” heart
is corrupt and its only chance for salvation was by being baptized
according to the Lutheran formula. “Now,” he continued, “I want this
brother to demonstrate to this audience how a baby must be saved.
I want him to change this baby’s heart from a state of corruption to
a state of purity. I want to see how a baby is saved, for, according to
his theology, I have three babies in hell.”
The brother winced under this outburst of sarcasm. He refused to
baptize the child, which, had he done so under the circumstances,
would scarcely have made his doctrine appear less obnoxious. Other
peculiar Lutheran tenets appeared to the same disadvantage under
similar treatment, and the church’s hope of gaining its lost ground
completely vanished. The debate popularized the United Brethren
Church, giving it a strong hold in the community. Flag Branch, a
flourishing rural church, stands as a monument to Rev. Mr.
Newgent’s labors in that section.
 Another contest worthy of special note was with a Baptist minister
at Blue Springs, Tennessee, in 1882. The mode of baptism was a live
question throughout that region. The battle line was drawn by the
Baptists and Pedo-Baptists. They finally agreed to have the question
discussed in a public debate, each side to furnish its champion.
Three churches were represented on the immersion side, and seven
on the other. The immersionists secured as their representative,
Doctor Ingram, a prominent Baptist divine of Virginia. Newgent was
selected by the anti-immersionists. The debate was to cover six
propositions and to continue six days, one subject being slated for
each day.
The Baptists were very desirous of including infant baptism in the
list of subjects to be discussed. This was a question that Newgent
had never debated, and in which he had very little interest. But to
accommodate the Baptists, he consented to defend the practice of
infant baptism. His opponent proposed the question, stating it as
follows: “Resolved, That infants are fit subjects for baptism.”
Newgent consented to affirm it.
It was slated for the second day. In his opening remarks, Newgent
said: “Mr. President, this is a peculiar question; but my brother wrote
it and insisted that I affirm it. It is peculiar from the fact that I am
not to prove that the child needs baptism, or that there is any
command for infant baptism, or that there ever was an infant
baptized. I am simply asked to prove that a child is a fit subject for
baptism.”
At these remarks a storm of protest arose from the immersionists.
They expected him to defend the vast array of teaching that the
various Pedo-Baptist bodies had put forward on the subject.
“Keep cool,” he said to the immersionist part of the crowd as they
were clamoring for a hearing and creating no little confusion.
“Doctor Ingram and I signed these papers, and we agreed to be
governed by the board of moderators. This question simply deals
with the child’s fitness for baptism. I appeal to the moderators.” The
moderators sustained his position.
 He then asked his opponent whether or not the Baptist Church
would baptize a subject until he was converted and became as a
little child. His opponent stated that it would not. This gave him a
splendid foundation for his address, and, at the same time, removed
the last foundation stone from under his opponent, so far as infant
baptism was concerned. He made an earnest and eloquent address,
showing that the child is a type of the heavenly citizen, and as such
possesses special fitness for all the sacraments of God’s house.
While he was talking, his attention was called to Doctor Ingram.
The doctor, grip in hand, was making rapid strides toward the
railroad station. His moderator and some friends were accompanying
him, trying to persuade him to remain. But he could endure it no
longer.
The doctor’s retreat caused a great sensation, relished immensely
by the Pedo-Baptists, but a bitter dose to the immersionists. There
were yet four days of the program remaining. Newgent’s side
demanded, as they were paying him for his work, that he remain
and carry out his part of the program. This he did, but as the debate
had only one end to it during those four days, it spoiled the
excitement, though it served well the purpose of those who had
employed him.
Among his later debates was one held in 1898 at Mechanicsville,
Indiana. Dr. J. W. Haw, of the Christian Church, was his opponent on
this occasion. Doctor Haw had been holding revival meetings in that
part of Indiana, and being dogmatic in style and controversially
inclined, was unsparing in his denunciations of other denominations.
His aggressions and criticisms were disturbing the equilibrium of
some of the brethren whose churches were being used as a target
by this ecclesiastical Nimrod. They wrote to Newgent, then in
Tennessee, urging him to champion their side against Doctor Haw in
debate, offering him fifty dollars per day and expenses for his time.
He consented on condition that the propositions were fair and that
the reverend gentleman in question was a representative man in his
church.
 He was referred to a two-column article in a current number of
the Christian Standard relating to Doctor Haw. The article was
extravagant in the use of adjectives describing the doctor’s ability
and achievements, stating that he was the leading debater in the
Christian Church, having had more such battles than any other man
in it at that time. This was quite satisfactory to Newgent, as at that
period he did not care to waste any shot or shell on small game.
In this, as in all other such contests, Newgent abundantly
sustained his position and satisfied the expectations of his
supporters. His experience, self-control, complete mastery of the
subjects in hand, humor, and physical endurance made him an
antagonist that even the greatest debater in a debating church could
illy cope with. The general verdict of even Doctor Haw’s own
sympathizers was that it was decidedly a one-sided affair.
 Chapter Twelve.
Perrysville and Centerpoint—Industry Rewarded from
an Unsuspected Source—A “Slick” Wedding—
Fruitful Labors at Centerpoint—A One-Sided Union
Meeting—The Doctrine of the Resurrection Again
Demonstrated.

A year on the Perrysville charge in the Upper Wabash Conference,

followed by a year at Centerpoint, in his own conference, the Lower
Wabash, covering 1874 to 1876, closed Rev. Mr. Newgent’s work in
the pastorate for a season. It was from the latter charge that he
received his appointment from the Home, Frontier, and Foreign
Missionary Society as Superintendent of the Tennessee Mission
Conference. From thenceforth he was destined to serve the Church
in a larger capacity, though there is no work that he regards as more
exalted or more vital to the progress of the kingdom than that of the
pastor. And it is but just to say that there is no work in which he has
been happier or more in his element. The pastor, he regards, as the
pivotal man in the church militant, around whose personality must
revolve all the machinery of its organized life. Hence, in whatever
position he has been placed, he has ever been in fullest sympathy
with the men on the firing line, and has sought in every way to
encourage and magnify their work.
His going to Perrysville was in response to an urgent appeal from
his intimate friend, Dr. J. W. Nye, then a popular presiding elder in
the Upper Wabash Conference. His work here was fruitful and
congenial, and marked by some rich experiences, which he carries
with him as refreshing memories. One of these teaches a practical
moral lesson, namely, that honest industry has its reward in more
ways than one.
 It need not be explained here that industry is a part of his religion.
He believes with Paul that it does not injure, or lower the dignity of a
minister to labor with his hands. In this, as in other respects, he
made himself an example to the flock. Odd moments are always
occupied in diversions of a practical character. The outward
appearance of the parsonage never failed to testify to his thrift and
good taste. A garden served as an outlet to his surplus physical
energies as well as a means of supplementing the usually modest
income. Under his skillful hand it invariably became a thing of beauty
and an object of just pride.
Some five miles from Perrysville lived a horny-handed son of the
soil, a man who made industry not only the chief element in his
religion, but the sum total of it. He was an infidel in his belief—or
disbelief—and regarded the church as an imposition, and preachers
as an indolent, worthless lot. Passing through the village one day, he
noticed Rev. Mr. Newgent’s garden. It was by far the finest he had
seen. His surprise can only be imagined when, upon inquiry, he
learned that the owner of it was one of those lazy preachers.
A few days later he drove up to the parsonage with a barrel of
flour, which he unloaded and unceremoniously rolled upon the
porch. This time the surprise was on the preacher, as a reputation
for benevolence was a thing of which, up to that time, the infidel
could not boast. He explained that ordinarily he had no use for
preachers, but as he had found one that was not lazy, he “wanted to
help him.” The donation was an expression of his regard for the
minister who showed a willingness, according to the infidel’s
conception of the term, to earn his bread in the sweat of his face.
Another incident, picked up at random, occurred one cold day
during the winter of his stay at Perrysville. A couple whose
appearance did not indicate a superabundance of worldly prosperity,
came to the parsonage to be married. They had come from the
adjoining county, the boundary between the two counties being the
Wabash River, on the bank of which Perrysville was located. The
river was frozen over. The couple traveled afoot, having crossed the
river on the ice. The preacher explained that they would have to
recross the river before the ceremony could be performed, as the
law required that marriages be solemnized in the county in which
the license was issued. So he conducted the matrimonial candidates
to the river.
When the preacher was satisfied that they had proceeded beyond
the half-way point on the river, he ordered the couple to halt and
join hands. By this time their presence had attracted the attention of
the young people who were out on the ice in large numbers enjoying
the fine winter sport of skating. As the wedding was a public
function, no restrictions being placed on attendance, the ceremony
was performed in the presence of an enthusiastic multitude.
The service completed, the groom, who was unacquainted with
ministerial usages, inquired as to the amount of the fee. To save him
the responsibility and further embarrassment of determining the sum
to be paid for the service, the preacher suggested that a dollar
would be sufficient, fearing lest he might set the price too high for
his purse. Even at that it was painfully evident that the young man’s
financial rating was overestimated. After nervously fumbling through
his pockets he was able to produce but fifty cents. In his dilemma he
found it necessary to call upon his bride for financial assistance.
Happily she was equal to the emergency, and supplied the deficit
from her own purse.
 The Young Man’s Financial Rating Was Over-estimated.

“This is the fairest wedding I have ever seen,” said the preacher.
“It has always been my opinion that the lady ought to help pay the
preacher, and she receives as much benefit from the ceremony as
does the man. I hope you will always share each other’s burdens in
this way.” And wishing them happiness and prosperity, he sent them
on their way rejoicing.
The local paper gave a flowery account of the wedding that took
place on the ice, stating that it was the “slickest” wedding that had
ever occurred in that section. But the minister’s fee and the manner
of paying it was not allowed to become public, lest it should become
a troublesome precedent in matrimonial circles.
The following year, which was spent on the Centerpoint charge,
was a most fruitful one. Here, as in so many other places, he found
a splendid opportunity of demonstrating his favorite doctrine of the
resurrection—the resurrection of dead churches. The spiritual life of
the churches at Centerpoint was at ebb tide, and had been for an
indefinite time. Soon after his arrival the Methodist pastor, who was
also new in the town, called upon him to confer as to their plans for
revival work. As workers were scarce, it was thought best to plan
their meetings so that they would not conflict. Rev. Mr. Newgent,
Abraham-like, let his brother do the choosing, and the brother,
perhaps as anxious as Lot to get in on the ground floor, decided to
commence a revival at once. Newgent began a meeting at the same
time some few miles in the country. Newgent’s meeting immediately
developed into a revival of so great proportions that it became the
one overshadowing event of the whole country, drawing the
Methodist pastor’s congregation from him and rendering it
impracticable for him to continue. His situation was a rather lonely
one. In his extremity he sought another interview with his fellow
pastor, proposing to close his meeting at once if Newgent would join
him later in a union revival effort.
This Newgent consented to do on three conditions, as follows:
1. That the meetings be held in the United Brethren church.
2. That the United Brethren pastor do all the preaching.
3. That the United Brethren pastor do the managing.
Hard as the conditions seemed, the brother agreed to them. The
conditions, in fact, look egotistical and perhaps selfish on the
surface, but when the United Brethren pastor explained his reasons
for them they were seen to be neither. On the contrary they were
meant for the highest good of both churches, and were abundantly
vindicated by the outcome. He was intensely anxious that
Centerpoint have a genuine revival of religion. To promote such a
revival at any cost was his purpose. That this purpose might be
realized he would not permit modesty, formality, or any other
creature to stand in the way.
The United Brethren Church was the more commodious and had
the advantage in location. This was the reason for the first condition.
The reason for the second and third conditions was that Centerpoint
had been preached to death. A change of methods was imperative if
the people were to be reached. He wanted a meeting without
preaching, without too much human agency, but where God himself
might control to his own glory. Only by having the management left
to him could he apply the remedy needed according to his diagnosis
of the case.
His plan was now to be put to the test—a revival without
preaching, the laity to do the work as they felt divinely moved. The
meeting began on a Friday evening. But with no life there could be
no real activity. The chariot wheels dragged heavily at the first. On
Sunday morning he announced that at four o’clock p. m., a children’s
meeting would be held. Aside from selected helpers, only children
within a certain age limit would be admitted. Such meetings even at
that date were quite uncommon. The announcement, therefore,
aroused a great deal of curiosity. But that was one point in the
announcement. Something must be done to stir the people. There
must be a new avenue of approach to their cold hearts.
The children’s service produced the desired effect. At the
appointed hour the house was filled to overflowing. There were
three helpers, all ministers, present, who did their part according to
Newgent’s directions. Songs were sung, prayers offered by the
ministers as they were called upon, a brief talk by the leader, some
simple propositions, and the meeting closed in less than a half-hour
from the time it began. But that half-hour turned the tide in
Centerpoint. The children became the vanguard in a religious
movement that was to shake the town from center to circumference.
Many of them went home weeping to speak of the longing of their
tender hearts to fathers and mothers, who, in turn, were awakened
to a consciousness of their own need.
At the evening service which followed, seventy-five persons came
to the altar, most of whom professed conversion. The revival was no
longer a problem. It spread throughout the town and community like
fire in dry stubble. The church arose from the grave of lethargy and
formalism, cast off her grave clothes—and the doctrine of the
resurrection was again abundantly demonstrated.
 Chapter Thirteen.
Becomes a Missionary Superintendent—Second
Marriage—An Unexpected Welcome—Forms a
Quaker Friendship—The Spirit Moves in a Quaker
Meeting—A Quaker’s Prayer Answered—Builds a
College—Shows What to do for a Dead Church—
Another Tilt on the Doctrine of Baptism—
Conversion of a Dunkard Preacher—Turns a Great
Movement in the Right Direction.

In the fall of 1876, Rev. Mr. Newgent entered upon his duties as
Superintendent of the Tennessee Mission Conference, under
appointment of the Home, Frontier, and Foreign Missionary
Association. In the meantime he had married Miss Annie Crowther,
of Terre Haute, Indiana, who, under the divine blessing, abides as
the companion of his joys and sorrows amid the lengthening
shadows. She is a woman of rare and excellent qualities, which
especially fitted her for her position as the wife of an active and
ambitious minister. She is in fullest accord with her husband’s
ambitions and tastes, and has contributed her part toward the
success of his career. He freely accords to her this credit. With this
queenly woman ordering its affairs, the Newgent home has ever
been a haven of real rest, a retreat for God’s servants especially. It
extends a welcome and hospitality—a true home spirit—that at once
makes the wayworn pilgrim feel at ease in body and mind, and
charms the hearts of the young as well.
At the time of their removal to Tennessee, the United Brethren
Church was new in the South. Its attitude of open hostility to slavery
largely shut it out of regions south of Mason and Dixon’s line. The
Tennessee Conference then had less than four hundred members,
with only six houses of worship. So a great field spread out before
the new Superintendent, taking him back to conditions in many
respects similar to those in which he began his ministerial labors. It
was still a time of reconstruction in church affairs as well as in
matters political. But his was a work of construction rather than of
reconstruction.
Aside from the need of laborers and the vast opportunities
afforded for building up the church in this section, one reason he
had for accepting this appointment was the condition of his own and
his wife’s health. Both were threatened with failing health, and a
change of climate was advised, the high altitude of eastern
Tennessee being recommended as especially adapted to their
physical needs.
They arrived at Limestone, Tennessee, on a Friday evening in
September. Here was illustrated how his fame as a genial, good
humored personality had spread throughout the Church, so that the
people felt that they were acquainted with “Jack” Newgent (later
Uncle Jack) even though they had never met him personally. Arriving
at the city some time after dark, worn by the long journey, the
discomforts of which were aggravated by their poor health, they
little dreamed of finding in that particular realm an acquaintance or
anyone who had any concern for them.
Great indeed was Newgent’s surprise when, as he alighted from
the train, a gentleman, a total stranger, with a lantern on his arm,
stepped up and in a familiar manner accosted him, “Hello! Is this
Jack Newgent?”
He had been so familiarly known as “Jack,” that he had resolved to
be known by the more grave and dignified appellation of Andrew J.
Newgent when he came into his new kingdom. But his expectation
perished, as it would have done even had the circumstances been
otherwise. A man’s name, like his clothes, is a part of him, and if it
does not fit, his friends will persist in trimming it until it does. The
personality and the title cannot be unequally yoked together.
 “Well,” said the reverend gentleman from the Hoosier State, “I
suppose if I should land in the heart of Africa, some Hottentot would
come rushing out of the jungle and say, ‘Hello, Jack Newgent!’ Who
are you, anyway?” The stranger was Mr. W. C. Keezel, a prominent
layman in the conference, who had been advised of their coming by
Dr. D. K. Flickinger, Secretary of the Missionary Society, and was
there to take them to his hospitable home. It was a pleasant
surprise, and they felt at once that they were among friends whose
hearts God had touched with his spirit of kindness and tenderness.
Their anxieties were dispelled, and they felt as near heaven in
Tennessee as in Indiana.
Next day his host took him on a ten-mile ride by horseback over a
mountain road to a quarterly conference, where he met a number of
ministers, and began to get acquainted with his new co-workers. His
presence filled the little band of faithful toilers with new hope and
courage. He preached the following day (Sunday) at a neighboring
church to an immense crowd. Here he met Rev. Eli Marshall, a
minister of repute in the Quaker—or Friends—church, with whom he
was destined to form a close friendship, a friendship which revealed
later to both of these servants of God how mysteriously God moves
in answer to the earnest prayers of his faithful children.
Rev. Mr. Marshall was not only an able minister, but was also a
successful business man, being the owner of several plantations. He
took Newgent to his home, and later showed him a congenial
cottage on one of his plantations. “This is at thy disposal,” he said,
“if it suits thee.” Newgent replied that it was just such a place as he
was looking for, as it was but a short distance from town and the
railroad station, and inquired as to the rental value.
“Just move in,” said Marshall, “we will talk about that some other
time.”
But when Newgent insisted, he set a nominal price, which
indicated that he was not especially concerned about the financial
side of the transaction. He furthermore insisted on transporting
Newgent’s household goods from the station, but this privilege he
was compelled to share with Mr. Keezel. While they were moving his
goods from the train, his Quaker neighbors set to work and filled the
smoke-house with provisions, and supplied sufficient fuel to last him
through the winter. Such expressions of kindness and generosity
seldom had been seen.
The fourth week in October was the time for the Quakers’ yearly
meeting, to be held at Rev. Mr. Marshall’s home church. He had
issued an order to Newgent to have no engagement for that time, as
his presence and help were desired at the meeting. Under the
circumstances there was but one thing to do, and that was to
respect the order. These meetings were matters of no small
significance in that denomination. They usually lasted several days,
and were great seasons of fellowship. They were very largely
attended so that the program sometimes had to be carried out in
several sections. Newgent had never had the privilege of attending a
Quaker meeting, but his appreciation of the Quakers by this time
knew no bounds.
He first went to the meeting on Saturday morning and was
surprised to find more than a thousand people on the ground. His
friend, Rev. Mr. Marshall, met him immediately and said, “If the Spirit
moves thee to preach to-day, we want thee to preach in the church
this morning.” Some one was to preach in the school house nearby.
The Spirit moved, and Newgent preached.
In the afternoon he was “moved” to preach again. He was urged
to preach again at night. This time the Spirit was not consulted, but
his preaching had touched a responsive chord in the Quaker heart,
so it was taken for granted that the Spirit would be favorable. An
out-door service and a service in the school house besides that in
the church were required in order to accommodate the crowd.
Newgent declined to preach at this time, not wishing to usurp the
honors that belonged to the Quaker preachers. But the Quaker
“Spirit” refused to let him off. He was even urged to sing a special
song, which was a great departure from Quaker usage in those
days. While preaching with his usual power, it was evident to him
that great conviction prevailed in the congregation. As he had been
invited to depart from one of the Quaker usages, he now felt bold to
depart from another. Indeed he felt strongly moved by the Spirit to
give an invitation for seekers to come to the altar. The invitation
given, the altar was soon crowded with anxious penitents. He then
called upon the Quakers to come forward and to sing and pray with
the seekers. This a considerable number did, casting aside all
reserve, and the meeting became a typical United Brethren revival.
It was one time when the Spirit “moved” beyond question in a
Quaker meeting.
He was given right of way in the church on Sunday morning,
Sunday evening, and Monday evening. A new element was thus
diffused into Quakerdom. He held a meeting in that same
community a few weeks later, in which the Quakers took a leading
part, and which resulted in about a hundred conversions.
The best part of the whole procedure came to light when Newgent
called to pay his landlord the small pittance that was due on rent.
Rev. Mr. Marshall refused to accept even the nominal amount that
had been agreed upon.
“Let me explain,” he said, “I have never told anybody what I am
going to tell thee—not even my wife. Some three months ago I
moved my foreman out of that house, and began to pray for the
Lord to send us a good, live preacher from the North. I had got tired
of these slow-going Southern fellows. But I forgot to tell the Lord to
send a Quaker. So the Lord was free to send whomsoever he
pleased. And the first time I heard thee preach, I said, ‘There is the
answer to my prayer.’ Now, it would not do for me to charge rent of
the man the Lord sent in answer to my prayer, when he is living in
the property I vacated for him when I besought the Lord to send
him. That house is for thee as long as thee wants it.”
When this noble soul was called to heaven some years later, Rev.
Mr. Newgent was called from a distant State to preach his funeral.
Truly, he was a man of God.
 When the conference projected a college enterprise at Greenville,
Rev. Mr. Newgent took up his residence at that place so as to give
personal attention and encouragement to the institution. This college
was afterwards moved to White Pine, Newgent being the leading
spirit in the matter of relocation. He served as financial agent and
supervised the construction of the building. Through his personal
efforts the building was erected and paid for.
The evangelistic gift and executive faculty, both of which were
prominent in our subject, peculiarly fitted him for the duties of
Missionary Superintendent amid such conditions as the Tennessee
Conference presented. Much incipient work had to be done. The
routine work of his office required only a small portion of his time,
leaving him free to do the work of an evangelist, to encourage weak
churches and to survey new territory to conquer. This narrative has
already afforded many examples of his constructive work along
these lines. One more characteristic incident may not be out of
place.
Near Limestone, Tennessee, was a church which was so
unpromising that the quarterly conference seriously considered
abandoning it and disposing of the property. It was well located, but
there were strong churches on either side, and the little church,
overshadowed as it was by these older organizations, had never
been able to gain a proper standing.
“Let us give it another chance,” said Newgent, who was presiding
at the meeting. “I will hold a meeting there at the first opportunity,
and we will see if it can be saved.” He held the meeting accordingly
and received ninety-seven members into the church, and the little,
struggling church was lifted to such a position of prestige and
prominence that it overshadowed its rivals, becoming a strong
center of religious influence.
But it was not enough to merely get people converted and
brought into the church. They must be taught in the doctrines of the
church, so as not to get their doctrinal ideas from other sources.
 One of the strong churches of this community was of the Dunkard
order, and mainly through its influence a strong immersion sentiment
prevailed. At the close of the revival there were a large number of
applicants for baptism. According to prevailing custom, all expected
to be immersed. It was in order on such occasions for the baptismal
service to be prefaced by a sermon on baptism. Rev. Mr. Newgent
took advantage of the opportunity to make some remarks on the
mode of baptism, which was the one live subject in religious circles.
In his discourse he said:
“We often hear people say, ‘I want to be baptized as Jesus was.’ I
do not share this sentiment. For in one essential respect Jesus’
baptism was different from ours. It was for a different purpose. He
was baptized to fulfill the law; we, because we are sinners, either for
the forgiveness of sins or because they are forgiven.
“But we may be baptized in the same manner in which he was
baptized, and if you wish, I will tell you what that was. Paul said, ‘He
was made a priest like unto his brethren.’ Jesus said, ‘I am come,
not to destroy the law or the prophets, but to fulfill.’ He fulfilled
every jot and tittle of the law. The law required a priest to have the
water of consecration sprinkled upon his head when he was thirty
years of age. Hence, if Christ was made a priest like his brethren, it
is easy to see that his baptism was the same as that of the priests,
his brethren, and that the water was sprinkled upon his head at the
age of thirty; otherwise he would not have fulfilled every jot and
tittle of the law.”
A prominent Dunkard preacher present made a public statement
at the close of the discourse to the effect that, while he had always
believed and taught that Christ was baptized by immersion, he was
now fully convinced that he had been mistaken. When they came to
the baptismal service, all the applicants chose the mode of
sprinkling, though they had come prepared to be immersed.
Under his capable and aggressive leadership the conference
maintained a steady growth. At first its territory was confined to the
eastern part of the State. But in the early nineties he, with some
other ministers, advanced to the central and western parts of the
State on a sort of missionary-evangelistic campaign. They held a
number of meetings and were successful in winning quite a
sprinkling of converts. The work thus accomplished made possible
the organization of what was then known as the Tennessee River
Conference in 1896.
One of the most important events in connection with the
Tennessee Conference, and which was brought about mainly
through his influence, occurred in 1895. It is referred to as follows in
Berger’s History of the United Brethren Church, page 614:
“About two years ago a movement which had been for some time
in process of development, began to take definite form, resulting in
considerable additions both of ministers and laymen to the United
Brethren Church. The greater number of these came from the
Methodist Episcopal Church, some from the M. E. Church, South,
and a few from other denominations. Those coming from the
Methodist churches were attracted chiefly by the milder form of
episcopal government in the United Brethren Church. There was for
them no possible inducement in material or worldly considerations.
They could not look for larger salaries or easier fields of labor or
lighter sacrifices, nor was the prospect of official promotion better
than in the churches from which they came. Nor could they bring
with them any of the church-houses or other property which they
had aided in building. No thought or hope of this kind was
entertained; much less was any effort made to do so. Influenced by
principle alone, and in the face of present loss, they chose to cast in
their lot with us, and they have addressed themselves earnestly to
the work in their new relations. About twenty-five ministers in all,
with a considerable number of members, have thus connected
themselves with the United Brethren. Among the leading ministers of
the movement are: Dr. T. C. Carter, Rev. W. L. Richardson, J. D.
Droke, and others. They have been given a cordial welcome by the
United Brethren Church, not in any spirit of proselytism, for no
proselyting was done, nor from any desire to reap where others
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