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Mental and Behavioral Health Schizophrenia second-generation or atypical antipsychotic agents (Table 57). Newer antipsychotic agents may cause less sedation and fewer Schizophrenia is a heterogeneous psychiatric disorder com- anticholinergic side effects but carry an increased risk for prising both positive symptoms (hallucinations, disorganized weight gain and metabolic syndrome (particularly olanzapine thought, delusions) and negative symptoms (flattened affect, and quetiapine). Clozapine may be particularly effective for decreased activity). Worldwide prevalence is approximately refractory schizophrenia but is associated with significant 1%, with a slight male predominance. The pathogenesis of adverse effects, including agranulocytosis. Close monitoring schizophrenia remains unclear. for common adverse effects is extremely important with use of DSM-5 diagnostic criteria for schizophrenia require the any antipsychotic agent. presence at least two of the following: delusions, hallucina- tions, disorganized speech, disorganized or catatonic behavior, and negative symptoms. Diagnosis also requires at least one © Mortality is significantly increased in patients with schiz- area of functional impairment (occupation, social interactions, ophrenia because of concomitant cardiovascular disease, or self-care) and duration of at least 6 months, including behavioral disorders, and substance use; approximately 1 month of active symptoms. 5% of patients with schizophrenia commit suicide. Schizophrenia is associated with an increased risk for e Antipsychotic medications are effective at controlling diabetes, cardiovascular disease, and obesity; these coexisting positive symptoms of schizophrenia, but some negative conditions may be exacerbated by the metabolic complications symptoms usually persist; choice of therapy is based of antipsychotic therapy. Undertreatment of medical disease is primarily on patient comorbidities and adverse effect common in this population. Mortality is significantly increased profile. in patients with schizophrenia owing to coexisting conditions, behavioral disorders, and substance use. Approximately 5% of patients with schizophrenia commit suicide. Attention-Deficit/Hyperactivity Schizophrenia is usually co-managed with a psychiatrist. Antipsychotic medications are highly effective at controlling Disorder positive symptoms of schizophrenia, but some negative symp- Attention-deficit/hyperactivity disorder is characterized by per- toms usually persist. Because the effectiveness of different sistent inattention and/or hyperactivity-impulsivity that dis- antipsychotics is relatively similar, choice of therapy is based rupts functioning or development. Symptoms must interfere primarily on patient comorbidities and the adverse effect pro- with at least two different settings (e.g., home and work), and file. Typical or first-generation antipsychotic agents have a some must have been present since before 12 years of age. This higher risk for extrapyramidal symptoms (parkinsonism, disorder is most frequently recognized in childhood, but diagno- akathisia), tardive dyskinesia, and hyperprolactinemia than do sis may be delayed until adulthood. Most patients diagnosed

Schizophrenia second-generation or atypical antipsychotic agents (Table 57). Newer antipsychotic agents may cause less sedation and fewer Schizophrenia is a heterogeneous psychiatric disorder com- anticholinergic side effects but carry an increased risk for prising both positive symptoms (hallucinations, disorganized weight gain and metabolic syndrome (particularly olanzapine thought, delusions) and negative symptoms (flattened affect, and quetiapine). Clozapine may be particularly effective for decreased activity). Worldwide prevalence is approximately refractory schizophrenia but is associated with significant 1%, with a slight male predominance. The pathogenesis of adverse effects, including agranulocytosis. Close monitoring schizophrenia remains unclear. for common adverse effects is extremely important with use of DSM-5 diagnostic criteria for schizophrenia require the any antipsychotic agent. presence at least two of the following: delusions, hallucina- tions, disorganized speech, disorganized or catatonic behavior, and negative symptoms. Diagnosis also requires at least one © Mortality is significantly increased in patients with schiz- area of functional impairment (occupation, social interactions, ophrenia because of concomitant cardiovascular disease, or self-care) and duration of at least 6 months, including behavioral disorders, and substance use; approximately 1 month of active symptoms. 5% of patients with schizophrenia commit suicide. Schizophrenia is associated with an increased risk for e Antipsychotic medications are effective at controlling diabetes, cardiovascular disease, and obesity; these coexisting positive symptoms of schizophrenia, but some negative conditions may be exacerbated by the metabolic complications symptoms usually persist; choice of therapy is based of antipsychotic therapy. Undertreatment of medical disease is primarily on patient comorbidities and adverse effect common in this population. Mortality is significantly increased profile. in patients with schizophrenia owing to coexisting conditions, behavioral disorders, and substance use. Approximately 5% of patients with schizophrenia commit suicide. Attention-Deficit/Hyperactivity Schizophrenia is usually co-managed with a psychiatrist. Antipsychotic medications are highly effective at controlling Disorder positive symptoms of schizophrenia, but some negative symp- Attention-deficit/hyperactivity disorder is characterized by per- toms usually persist. Because the effectiveness of different sistent inattention and/or hyperactivity-impulsivity that dis- antipsychotics is relatively similar, choice of therapy is based rupts functioning or development. Symptoms must interfere primarily on patient comorbidities and the adverse effect pro- with at least two different settings (e.g., home and work), and file. Typical or first-generation antipsychotic agents have a some must have been present since before 12 years of age. This higher risk for extrapyramidal symptoms (parkinsonism, disorder is most frequently recognized in childhood, but diagno- akathisia), tardive dyskinesia, and hyperprolactinemia than do sis may be delayed until adulthood. Most patients diagnosed TABLE 57. Adverse Effects of Common Antipsychotic Medications

Schizophrenia second-generation or atypical antipsychotic agents (Table 57). Newer antipsychotic agents may cause less sedation and fewer Schizophrenia is a heterogeneous psychiatric disorder com- anticholinergic side effects but carry an increased risk for prising both positive symptoms (hallucinations, disorganized weight gain and metabolic syndrome (particularly olanzapine thought, delusions) and negative symptoms (flattened affect, and quetiapine). Clozapine may be particularly effective for decreased activity). Worldwide prevalence is approximately refractory schizophrenia but is associated with significant 1%, with a slight male predominance. The pathogenesis of adverse effects, including agranulocytosis. Close monitoring schizophrenia remains unclear. for common adverse effects is extremely important with use of DSM-5 diagnostic criteria for schizophrenia require the any antipsychotic agent. presence at least two of the following: delusions, hallucina- tions, disorganized speech, disorganized or catatonic behavior, and negative symptoms. Diagnosis also requires at least one © Mortality is significantly increased in patients with schiz- area of functional impairment (occupation, social interactions, ophrenia because of concomitant cardiovascular disease, or self-care) and duration of at least 6 months, including behavioral disorders, and substance use; approximately 1 month of active symptoms. 5% of patients with schizophrenia commit suicide. Schizophrenia is associated with an increased risk for e Antipsychotic medications are effective at controlling diabetes, cardiovascular disease, and obesity; these coexisting positive symptoms of schizophrenia, but some negative conditions may be exacerbated by the metabolic complications symptoms usually persist; choice of therapy is based of antipsychotic therapy. Undertreatment of medical disease is primarily on patient comorbidities and adverse effect common in this population. Mortality is significantly increased profile. in patients with schizophrenia owing to coexisting conditions, behavioral disorders, and substance use. Approximately 5% of patients with schizophrenia commit suicide. Attention-Deficit/Hyperactivity Schizophrenia is usually co-managed with a psychiatrist. Antipsychotic medications are highly effective at controlling Disorder positive symptoms of schizophrenia, but some negative symp- Attention-deficit/hyperactivity disorder is characterized by per- toms usually persist. Because the effectiveness of different sistent inattention and/or hyperactivity-impulsivity that dis- antipsychotics is relatively similar, choice of therapy is based rupts functioning or development. Symptoms must interfere primarily on patient comorbidities and the adverse effect pro- with at least two different settings (e.g., home and work), and file. Typical or first-generation antipsychotic agents have a some must have been present since before 12 years of age. This higher risk for extrapyramidal symptoms (parkinsonism, disorder is most frequently recognized in childhood, but diagno- akathisia), tardive dyskinesia, and hyperprolactinemia than do sis may be delayed until adulthood. Most patients diagnosed TABLE 57. Adverse Effects of Common Antipsychotic Medications | Medication EPS Elevated Anticholinergic Sedation Weight Gain Hyperlipidemia Prolactin Symptoms

Schizophrenia second-generation or atypical antipsychotic agents (Table 57). Newer antipsychotic agents may cause less sedation and fewer Schizophrenia is a heterogeneous psychiatric disorder com- anticholinergic side effects but carry an increased risk for prising both positive symptoms (hallucinations, disorganized weight gain and metabolic syndrome (particularly olanzapine thought, delusions) and negative symptoms (flattened affect, and quetiapine). Clozapine may be particularly effective for decreased activity). Worldwide prevalence is approximately refractory schizophrenia but is associated with significant 1%, with a slight male predominance. The pathogenesis of adverse effects, including agranulocytosis. Close monitoring schizophrenia remains unclear. for common adverse effects is extremely important with use of DSM-5 diagnostic criteria for schizophrenia require the any antipsychotic agent. presence at least two of the following: delusions, hallucina- tions, disorganized speech, disorganized or catatonic behavior, and negative symptoms. Diagnosis also requires at least one © Mortality is significantly increased in patients with schiz- area of functional impairment (occupation, social interactions, ophrenia because of concomitant cardiovascular disease, or self-care) and duration of at least 6 months, including behavioral disorders, and substance use; approximately 1 month of active symptoms. 5% of patients with schizophrenia commit suicide. Schizophrenia is associated with an increased risk for e Antipsychotic medications are effective at controlling diabetes, cardiovascular disease, and obesity; these coexisting positive symptoms of schizophrenia, but some negative conditions may be exacerbated by the metabolic complications symptoms usually persist; choice of therapy is based of antipsychotic therapy. Undertreatment of medical disease is primarily on patient comorbidities and adverse effect common in this population. Mortality is significantly increased profile. in patients with schizophrenia owing to coexisting conditions, behavioral disorders, and substance use. Approximately 5% of patients with schizophrenia commit suicide. Attention-Deficit/Hyperactivity Schizophrenia is usually co-managed with a psychiatrist. Antipsychotic medications are highly effective at controlling Disorder positive symptoms of schizophrenia, but some negative symp- Attention-deficit/hyperactivity disorder is characterized by per- toms usually persist. Because the effectiveness of different sistent inattention and/or hyperactivity-impulsivity that dis- antipsychotics is relatively similar, choice of therapy is based rupts functioning or development. Symptoms must interfere primarily on patient comorbidities and the adverse effect pro- with at least two different settings (e.g., home and work), and file. Typical or first-generation antipsychotic agents have a some must have been present since before 12 years of age. This higher risk for extrapyramidal symptoms (parkinsonism, disorder is most frequently recognized in childhood, but diagno- akathisia), tardive dyskinesia, and hyperprolactinemia than do sis may be delayed until adulthood. Most patients diagnosed TABLE 57. Adverse Effects of Common Antipsychotic Medications | Medication EPS Elevated Anticholinergic Sedation Weight Gain Hyperlipidemia Prolactin Symptoms First-Generation Antipsychotics

TABLE 57. Adverse Effects of Common Antipsychotic Medications | Medication EPS Elevated Anticholinergic Sedation Weight Gain Hyperlipidemia Prolactin Symptoms First-Generation Antipsychotics Fluphenazine th +H +/- + + + Haloperidol ++ + +/- +H + Thiothixene aa + + + +H = Chlorpromazine + + +H ++ +H we Thioridazine + + + + +H | Second-Generation Antipsychotics? {eleeaian +/- +/- ++ ++ ++ +++ | Risperidone +H ++ + + ++ + | Olanzapine + + + +H ++ +44 | Quetiapine +/— +/— +/— + “Er + | Aripiprazole + = = F + = | EPS = extrapyramidal symptoms. | *Weight, blood pressure, fasting plasma glucose, and lipid levels should be monitored periodically. | ‘Clozapine can also cause agranulocytosis and requires routine monitoring of blood counts. 88

Geriatric Medicine early in life continue to meet diagnostic criteria as adults. persons, with the objective of developing a plan for preserving Common manifestations in adults include inattention, disor- function and maximizing independence and quality of life. ganization, distractibility, emotional dysregulation, and restless- Common health issues in older adults include impaired mobil- ness. The diagnosis is clinical, and rating scales may be useful. ity and physical function, deficits in sensory function (particu- Anxiety, mood, and substance use disorders should be consid- larly vision and hearing), and cognitive decline. In addition, ered in the differential diagnosis but may exist concurrently. polypharmacy, psychosocial issues, and the cumulative effects Pharmacologic therapy is similar in adults and children, of chronic diseases may contribute to decreased functional with stimulants (methylphenidate, amphetamine) as first-line status and loss of independence. Identifying these issues therapy. Close monitoring for cardiovascular side effects (hyper- requires systematic and multidimensional evaluation, which tension, arrhythmia) is necessary. Given the potential for abuse, may be performed in the office, in the patient’s home, or upon these drugs should not be prescribed to patients with a history hospital admission or discharge. When completed in the home of substance use disorder; atomoxetine may be preferred in or a dedicated inpatient geriatric unit, comprehensive geriatric such patients. Bupropion and tricyclic antidepressants are also assessment may reduce mortality and the need for long-term beneficial in patients with contraindications to stimulants or institutional or nursing home placement. with concurrent depression. CBT is beneficial alone or in com- bination with pharmacotherapy for improving function. Functional Status Functional status assessment is evaluation of a patient’s ability ¢ Stimulants should not be prescribed to patients with to perform activities required for basic self-care (activities of

early in life continue to meet diagnostic criteria as adults. persons, with the objective of developing a plan for preserving Common manifestations in adults include inattention, disor- function and maximizing independence and quality of life. ganization, distractibility, emotional dysregulation, and restless- Common health issues in older adults include impaired mobil- ness. The diagnosis is clinical, and rating scales may be useful. ity and physical function, deficits in sensory function (particu- Anxiety, mood, and substance use disorders should be consid- larly vision and hearing), and cognitive decline. In addition, ered in the differential diagnosis but may exist concurrently. polypharmacy, psychosocial issues, and the cumulative effects Pharmacologic therapy is similar in adults and children, of chronic diseases may contribute to decreased functional with stimulants (methylphenidate, amphetamine) as first-line status and loss of independence. Identifying these issues therapy. Close monitoring for cardiovascular side effects (hyper- requires systematic and multidimensional evaluation, which tension, arrhythmia) is necessary. Given the potential for abuse, may be performed in the office, in the patient’s home, or upon these drugs should not be prescribed to patients with a history hospital admission or discharge. When completed in the home of substance use disorder; atomoxetine may be preferred in or a dedicated inpatient geriatric unit, comprehensive geriatric such patients. Bupropion and tricyclic antidepressants are also assessment may reduce mortality and the need for long-term beneficial in patients with contraindications to stimulants or institutional or nursing home placement. with concurrent depression. CBT is beneficial alone or in com- bination with pharmacotherapy for improving function. Functional Status Functional status assessment is evaluation of a patient’s ability ¢ Stimulants should not be prescribed to patients with to perform activities required for basic self-care (activities of attention-deficit/hyperactivity disorder and a history of daily living [ADLs]) or to live independently (instrumental

early in life continue to meet diagnostic criteria as adults. persons, with the objective of developing a plan for preserving Common manifestations in adults include inattention, disor- function and maximizing independence and quality of life. ganization, distractibility, emotional dysregulation, and restless- Common health issues in older adults include impaired mobil- ness. The diagnosis is clinical, and rating scales may be useful. ity and physical function, deficits in sensory function (particu- Anxiety, mood, and substance use disorders should be consid- larly vision and hearing), and cognitive decline. In addition, ered in the differential diagnosis but may exist concurrently. polypharmacy, psychosocial issues, and the cumulative effects Pharmacologic therapy is similar in adults and children, of chronic diseases may contribute to decreased functional with stimulants (methylphenidate, amphetamine) as first-line status and loss of independence. Identifying these issues therapy. Close monitoring for cardiovascular side effects (hyper- requires systematic and multidimensional evaluation, which tension, arrhythmia) is necessary. Given the potential for abuse, may be performed in the office, in the patient’s home, or upon these drugs should not be prescribed to patients with a history hospital admission or discharge. When completed in the home of substance use disorder; atomoxetine may be preferred in or a dedicated inpatient geriatric unit, comprehensive geriatric such patients. Bupropion and tricyclic antidepressants are also assessment may reduce mortality and the need for long-term beneficial in patients with contraindications to stimulants or institutional or nursing home placement. with concurrent depression. CBT is beneficial alone or in com- bination with pharmacotherapy for improving function. Functional Status Functional status assessment is evaluation of a patient’s ability ¢ Stimulants should not be prescribed to patients with to perform activities required for basic self-care (activities of attention-deficit/hyperactivity disorder and a history of daily living [ADLs]) or to live independently (instrumental substance use disorder; atomoxetine may be preferred activities of daily living [IADLs]). ADLs include bathing,

¢ Stimulants should not be prescribed to patients with to perform activities required for basic self-care (activities of attention-deficit/hyperactivity disorder and a history of daily living [ADLs]) or to live independently (instrumental substance use disorder; atomoxetine may be preferred activities of daily living [IADLs]). ADLs include bathing, in such patients. grooming, dressing, toileting, feeding, walking, and transfer- ring. IADLs comprise such tasks as managing finances, performing housework, shopping, self-administering medica-

in such patients. grooming, dressing, toileting, feeding, walking, and transfer- ring. IADLs comprise such tasks as managing finances, performing housework, shopping, self-administering medica- Autism Spectrum Disorder tions, using transportation, preparing meals, and communi- cating by telephone. Standardized screening instruments Autism spectrum disorder is a heterogeneous group of devel- for assessment of functional status are listed in Table 58. opmental disorders that feature repetitive behaviors and sig- Functional assessment may help determine the need for spe- nificant difficulties in communication and social interaction. cific services and the appropriate level of patient care. Pathogenesis remains uncertain but is most likely genetic. Symptoms must be present since childhood to make the diag- nosis, but symptoms may be masked until adulthood. Half of Vision patients have intellectual disability, and many have concurrent Older patients are at increased risk for many conditions that seizure and sleep disorders. Early intervention with behavioral cause vision loss, including cataracts, macular degeneration, and educational support improves long-term functioning. presbyopia, glaucoma, and disease-related retinopathy (e.g., Complementary therapies, such as specialized diets and diabetic retinopathy). Reduced visual acuity decreases func- music therapy, are also used but lack evidence of efficacy. tional status and quality of life while increasing risk for falls,

Autism Spectrum Disorder tions, using transportation, preparing meals, and communi- cating by telephone. Standardized screening instruments Autism spectrum disorder is a heterogeneous group of devel- for assessment of functional status are listed in Table 58. opmental disorders that feature repetitive behaviors and sig- Functional assessment may help determine the need for spe- nificant difficulties in communication and social interaction. cific services and the appropriate level of patient care. Pathogenesis remains uncertain but is most likely genetic. Symptoms must be present since childhood to make the diag- nosis, but symptoms may be masked until adulthood. Half of Vision patients have intellectual disability, and many have concurrent Older patients are at increased risk for many conditions that seizure and sleep disorders. Early intervention with behavioral cause vision loss, including cataracts, macular degeneration, and educational support improves long-term functioning. presbyopia, glaucoma, and disease-related retinopathy (e.g., Complementary therapies, such as specialized diets and diabetic retinopathy). Reduced visual acuity decreases func- music therapy, are also used but lack evidence of efficacy. tional status and quality of life while increasing risk for falls, Pharmacotherapy is reserved for targeted symptoms, such as depression, and cognitive impairment. Visual impairment may melatonin for sleep disturbance. Even with intervention, most affect eligibility for a driver’s license based on state-specific patients require lifelong assistance with functioning. requirements and may qualify the individual for disability Clinicians should understand each patient’s ideal com- benefits.

Pharmacotherapy is reserved for targeted symptoms, such as depression, and cognitive impairment. Visual impairment may melatonin for sleep disturbance. Even with intervention, most affect eligibility for a driver’s license based on state-specific patients require lifelong assistance with functioning. requirements and may qualify the individual for disability Clinicians should understand each patient’s ideal com- benefits. munication methods and allow extra time for explanation of Screening tests and examination techniques to assess procedures. Caregivers should be incorporated into health care vision in the primary care setting include standardized ques- visits, and consistency in the health care team can mitigate tionnaires, the Snellen eye chart, and direct ophthalmoscopic confusion and anxiety. Medical causes of acute behavioral examination; however, these tests may not detect such

munication methods and allow extra time for explanation of Screening tests and examination techniques to assess procedures. Caregivers should be incorporated into health care vision in the primary care setting include standardized ques- visits, and consistency in the health care team can mitigate tionnaires, the Snellen eye chart, and direct ophthalmoscopic confusion and anxiety. Medical causes of acute behavioral examination; however, these tests may not detect such changes should always be considered. disorders as glaucoma and macular degeneration. The U.S. Preventive Services Task Force (USPSTF) concluded that evi- dence is insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in asymptomatic Geriatric Medicine adults aged 65 years or older, whereas the American Academy of Ophthalmology recommends performing a comprehensive Comprehensive Geriatric eye examination in older adults every 1 to 2 years. Given the Assessment risks associated with decreased vision coupled with the preva- Comprehensive geriatric assessment is a multidisciplinary lence of common treatable eye conditions in older adults, it is diagnostic process to ascertain the physical, cognitive, psycho- reasonable to ask about changes in vision and refer the patient logical, environmental, and functional capabilities of older to an eye specialist when changes are present. 89