The medical model in psychiatry assumes medical intervention is the treatment of choice for the constellations of diagnosed symptoms that comprise various mental disorders. These treatments may include pharmacotherapy, electroconvulsive treatment, brain stimulation, and psychosurgery. Therefore, psychopharmacology for older adults can be considered palliative rather than a cure for a brain disease causing psychopathology. Older adults experience many psychopathological problems, including anorexia tardive, anxiety disorders, delusional disorders, mood disorders, personality disorders, schizophrenia, and co-occurring disorders with substance abuse/dependence disorders. Therefore, it is critical for the social worker to understand the various manifestations of psychological problems in older adults from the perspective of an older adult, rather than extrapolating information commonly taught in social work programs that neglect to focus on older adults and restrict teaching to psycho-pathological problems in younger and middle-aged adults.

The baby boom cohort brings with it multiple types of substance abuse. Bisexual older adults have more co-occurring psychological problems than heterosexual older adults, older gay males, and older lesbians. An interesting finding is that immigration is contributory to older adult substance abuse. Older adults with alcohol-abuse problems do not seek help for their problems. Rather, they are often identified as having an alcohol-use problem when seeking care for other medical or psychological problems. Social workers assessing an older adult for alcohol abuse often confuse symptoms of possible alcohol abuse with dementia. Prescribing opioids and synthetic opioids to an older adult is complicated. An older adult can suffer from many forms of inner tension. Combining motivational interviewing with cognitive behavioral therapy is shown to be more effective for treating substance abuse that either therapeutic modality alone.

For older adults, the phenomenon of death is accepted and does not induce the fear experienced by younger adults. Older adults who do not engage in end-of-life planning may receive unwanted, unnecessary, costly, and painful medical interventions or withdrawal of desired treatment. Many older people feel that the goal of palliative care is to make the best possible dying experience for the older adult and his/her family. In addition to palliative care, an older adult will most likely find himself or herself in an intensive care unit as part of his or her terminal care. Euthanasia, or hastened death, is seen by some as an alternative to palliative care. A psychological aspect of death that an older adult is concerned with, in addition to place of death, is whether he or she will die in his or her sleep or die suddenly, making the death experience an individual phenomenon.

This chapter discusses the assessment and laboratory findings, imaging, diagnosis and management of ascites. A common complication of cirrhosis is ascites, or the accumulation of fluid in the abdominal cavity. Ascites that develops from cirrhosis is associated with portal hypertension. The patient with cirrhosis and ascites may complain of increased weight gain, lower extremity edema, and abdominal bloating or distension. Physical examination findings may reveal a distended or even tense abdomen, positive fluid wave, dullness to abdominal percussion, and peripheral edema. Routine laboratory testing, such as complete blood count, complete metabolic panel, and liver function testing, should be performed with new-onset ascites and at routine return visits. Patients with cirrhosis and ascites can develop electrolyte imbalances and renal failure. Ultrasound is helpful to determine whether ascites is present if there is any uncertainty upon physical examination. Patients should abstain from alcohol consumption and avoid using nonsteroidal anti-inflammatory drugs.

Inflammatory bowel disease (IBD) is a broad diagnosis that includes two major chronic diseases: ulcerative colitis (UC) and Crohn’s disease (CD). IBD is typically diagnosed in young adulthood. Smoking has been associated with a higher risk of developing CD. UC is an inflammatory disease of the mucosa of the colon and rectum. Typical symptoms include bowel movement urgency, tenesmus and bloody diarrhea. CD is a chronic inflammatory disorder of the alimentary tract. It is associated with high levels of proinflammatory cytokines. Referral to a gastroenterologist specializing in IBD may be needed. To confirm diagnosis, a flexible sigmoidoscopy is necessary in cases of UC and a colonoscopy is necessary in cases of CD. The goal for treatment of IBD is to suppress the immune system and help heal the bowel. Initial treatment for patients with mild to moderate UC includes 5-aminosalicyclic acid compounds.

Some drugs, like aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), have been blamed for peptic ulcer formation. The most common peptic ulcers are duodenal ulcers. Risk factors for the development of peptic ulcer disease are chronic NSAID use, older age, Helicobacter pylori infection, use of anticoagulant or anti-platelet medications, history of prior ulcers, use of corticosteroids, alcohol use, and smoking. One of the goals of treatment for the patient with peptic ulcer disease is eradication of H. pylori infection. Complications that develop if peptic ulcer is untreated include gastrointestinal bleeding, gastric cancer and gastric outlet obstruction, with bleeding the most common. Most patients with peptic ulcer disease are asymptomatic. When symptoms do arise, dyspepsia is a common complaint. Sucralfate, a formula of aluminum hydroxide and sulfated sucrose, is given to patients with peptic ulcer disease to protect the gastric and duodenal mucosa.

This chapter discusses the incidence and risk factors, assessment, laboratory and image testing, diagnosis and treatment of constipation. Constipation affects 15" of adults in Western countries and 33" of patients older than 60. History is important when trying to determine the cause of constipation. The patient should be asked for a detailed description of bowel movements, including how many per day or week, how often, and how long has constipation been a problem. A complete blood count and complete metabolic panel should be obtained. Several electrolyte imbalances can cause constipation. Constipation is often caused by inadequate fiber intake or hydration, inactivity, or can be medication-related. Providers should encourage patients with acute constipation to increase hydration and fiber intake to 20 to 35 grams per day. Nutritional modification may be enough to resolve constipation and can likely prevent further episodes. In some cases of chronic constipation, nonpharmacologic treatments are helpful.

This chapter discusses the incidence and risk factors, assessment and laboratory findings, diagnosis and management of celiac disease. Celiac disease is considered an autoimmune disorder with a genetic component. If left untreated, patients with celiac disease have an increased risk of developing gastrointestinal cancers and enteropathy-associated T-cell lymphoma. Some of the disease’s symptoms are asymptomatic, whereas some have severe malabsorption issues with skin manifestations. Celiac disease is frequently found in patients who have other autoimmune disorders. A serologic test called immunoglobulin A (IgA) anti-tissue transglutaminase (tTGA) is performed to detect possible celiac disease in patients over two years old. Characteristic histological changes of celiac disease are villous atrophy, crypt hyperplasia, intraepithelial lymphocytosis, and mucosal inflammation. The only curative treatment for celiac disease is strict adherence to a gluten-free diet (GFD). It is important to recognize other vitamin deficiencies in patients with celiac disease, including B 12, D, iron, and folate.

Diarrheal diseases are one of the top leading causes of death worldwide. Although in normal healthy people diarrhea is considered a self-limiting illness, certain individuals can be susceptible to severe dehydration that can cause serious complications. Providers should ask about the patient’s definition of diarrhea, as individuals may differ on its meaning. Correcting dehydration and preventing worsened hydration status is the top priority when treating the patient with diarrhea. Patients must be educated to eat high-carbohydrate foods like bananas, rice, baked potatoes, applesauce, and saltine crackers for a day or two prior to resuming a normal diet. Probiotics have been shown to recolonize the intestine with healthy bacterial flora, which may have been lost from episodes of diarrhea. Multiple episodes of diarrhea cause perineal irritation and tenderness, even pain. To slow down or reduce the frequency of diarrhea, loperamidine or atropine can be used.

Irritable bowel syndrome (IBS) is a common disorder. It is characterized as a functional disturbance of bowel motility with symptoms of lower abdominal pain and alternating episodes of diarrhea and constipation. Risk factors for the development of IBS include alcohol consumption and high levels of psychological stress. Diagnosis is made by history and physical examination. If bloody stools are reported, then a complete blood count is necessary to rule out anemia. Patients report mucus-like stools with IBS. The management of IBS depends mostly on symptom control, especially stress management. Dietary changes are necessary and include no alcohol or caffeine, avoidance of substances to which one is allergic, and an increase in dietary fiber intake. Adequate hydration is important. Some patients report relief from pain and abdominal distension with the use of probiotics. For any patient suffering from IBS, tricyclic antidepressants and antispasmodics can be tried to improve symptoms.