Prepared by Steven Rubin, MD

These clinical pearls apply to the developmental stage of life between middle and late adulthood (age 40 through incapacitation). The growing demand for geriatric health care will require innovative and practical management and interventions strategies.

1 Maintain integrity. A patient with dementia and toddlerlike behaviors can be managed with dignity. Physician integrity is not maintained by acting in a superior or submissive manner.

2 Rule of least restriction. Medication, physical, and environmental interventions should lead to as little restraint as feasible.

3 Therapeutic levels aren?t always. What may be regarded as subtherapeutic medicating for a young adult could be therapeutic or toxic to an elderly person.

4 Four is a lot, 6 is a lot more. Older adults are vulnerable to taking a lot of medications that are used by prescription and over the counter, as well as supplemental agents. Drug?drug interactions become very prominent by the half-dozen mark.

5 The 4 coins. Ask the patient to add the sum of 1 quarter, 1 dime, 1 nickel, and 1 penny. If the patient cannot do so correctly, chances are that the patient is unable to manage independently his/her medical or daily living needs.

6 Think medical. Consider acute mental stat?us changes in the elderly as symptoms of an underlying metabolic derangement. If no medical etiology exists, consider psychosocial problems or social stressors.

7 B & B. No, this does not stand for Bed & Breakfast. Bowel and bladder problems are leading causes of erratic mentation and behaviors in the elderly. Insufficient fluid intake and medication side effects (eg, diuretics, sedatives, anticholinergics) are common instigators.

8 Alcohol, a covert problem for any age-group. Elderly patients sometimes cannot, or will not, share information about alcohol use, which could be vital for correct diagnosis and treatment.

9 Ambivalence is not suicide. Indifference or the desire to not live needs to be differentiated from wanting to kill oneself and should be approached in a different way.

10 Feel the pulse. Don?t just check it or count it. Feel it, hear it with your touch, and listen for the vitality of the person behind the illness.

Dr Steven Rubin is a geriatric psychiatrist in Reno, Nevada. He can be reached through www.gerolecence.com.

To submit clinical pearls to this column, please contact the editor, D. Buffery, at dbuffery@ascendmedia.com, or call 732/656-1140, ext. 168.