Geriatric Forensic Psychiatry: Principles and Practice

The task of determining an older person's ability to make decisions, drive, or live independently can be fraught with ethics and legal pressures. Geriatric forensic assessments require a methodical approach, yet many forensic evaluators lack basic skills in this area, leaving older adults vulnerable with regard to their basic rights in navigating the courts and judicial and correctional systems. Though AAPL's Practice Guideline for The Forensic Assessment discusses special considerations for children and adolescents and for persons with intellectual disability, there is no subsection for older adults, and dementia, for example, is only briefly discussed.¹

The scope of geriatric forensic psychiatry is expanding as the elderly population increases. Until recently, the field has suffered from a dearth of scholarly interest and resources. Prior to the publication of Geriatric Forensic Psychiatry: Principles and Practice, there was no seminal work to meet the needs of the average forensic or geriatric psychiatrist. The last major volume authored by a psychiatrist on the subject was published over three decades ago.² Psychology publications in the meantime have put forward advances in geriatric forensic assessment and capacity research, including the invaluable collaboration between the American Bar Association and the American Psychological Association³ and recently a first title dedicated to forensic geropsychology.⁴

Geriatric Forensic Psychiatry: Principles and Practice is a groundbreaking, multi-authored textbook representing a leap forward for the field of geriatric forensic psychiatry. It speaks to a multidisciplinary audience, covering a broad array of topics, including geriatric psychiatry, forensic psychiatry, medicine, neuroscience, and law. The textbook's editors are highly distinguished, with hundreds of publications among them in highly relevant areas. Ambitiously, they illuminate the connections between clinical concerns, laws, regulations, risk management, and improved safety.

The book's 42 chapters provide a broad overview of the field, with in-depth analysis of key areas of geriatric forensic psychiatry that are often glossed over in psychiatry textbooks. Chapters focus on the role age plays in the forensic context and the unique clinical and ethics challenges that arise in geriatric populations. The most important topics covered are those pertaining to mainstays of geriatric clinical practice: decision-making capacity, civil commitment of older persons, guardianship, counseling older drivers, evaluation of elder abuse and mistreatment, and end-of-life decision-making. The volume explores forensic and ethics principles underlying everyday clinical decisions including elements of civil law.

The textbook also incorporates indispensable content on challenges facing older adults in correctional settings and throughout the adjudicative process. The text also reviews topics related to elder-specific features of sociopathy, violence, aggression, and sex offenses.

Novel emerging topics in the book include structural and functional neuroimaging in geriatric forensic psychiatry, a rapidly evolving area, though currently with limited application to forensic questions. Case vignettes are used to illustrate longstanding and emerging cross-cultural challenges in geriatric forensic psychiatry, in the context of our modern world with its mass human migrations and population diversity.

The urgent need to improve geriatric forensic psychiatry training in both forensic and geriatric psychiatry fellowships is highlighted in a persuasive chapter on development of essential clinical and forensic skills. This work is vital given that geriatric psychiatrists often lack confidence in their skills to engage in forensic work, while forensic psychiatrists accustomed to working with younger evaluees may fail to address key aspects of aging that are potentially crucial to the main forensic question. A striking case example demonstrates that even fellowship-trained, experienced, board-certified forensic psychiatrists may neglect to perform a proper cognitive mental status examination in an older evaluee, or to explore obvious lapses in an evaluee's memory, disregarding symptoms of dementia or attributing poor recall and executive dysfunction to “normal aging.”

One drawback of the text is that it lacks cohesion between chapters. The importance of instituting best practices is also regrettably understated. Perhaps the most practical criticism of this work, however, is the paucity of specific guidance to help with everyday questions in geriatric psychiatry practice. The authors miss an important opportunity to offer clear guidance on real-world dilemmas or to provide pearls of wisdom for geriatric practice. Readers who seek straightforward answers to fundamental questions will be left wanting. Clinicians and forensic evaluators need further practical guidance on the specific professional guidelines, habits, and skills pertaining to their everyday work with older people.

Any weaknesses of this textbook, however, are far outweighed by its strengths. Authoritative and encyclopedic, Geriatric Forensic Psychiatry: Principles and Practice is vital for mental health professionals, geriatricians and internists, forensic specialists, attorneys and courts, regulators, and other professionals working with the older population. This extremely valuable text represents a long-anticipated leap forward for geriatric forensic psychiatry. Seeing the expertise and research momentum on display in this groundbreaking textbook, we can be hopeful it will not take another 30 years for psychiatrists to make the next major contribution on this essential topic.

• © 2019 American Academy of Psychiatry and the Law