Transcript Geriatric Psychiatry

In the name of God
Geriatric Psychiatry
Mohamad Nadi . MD
Psychiatrist
Geriatric population increasing
2000, estimated that 13% of
Americans were over 65 years of age
By 2050, estimates are that 22% will
be over the age of 65, and 5% over
age 85.
The population is aging rapidly ; it is
a global phenomenon
Geriatric population increasing
Why is it a subspecialty?
Mental disorders may have different
manifestations, pathogenesis, and
pathophysiology from younger adults
Coexisting chronic medical illness
More medicines
Cognitive impairments
Increased risk for social stressors,
including retirement and widowhood
What Is Normal Aging?
Some bodily functions decline with age,
but health problems are not inevitable.
“Normal” aging must be differentiated
from disease.
notion of chronological age (“how old
are you?”) be abandoned, and instead
that the stages of aging be considered.
Age cut-offs are artificial and arbitrary.
Prevalence of Mental Illnesses
Prevalence of psychiatric disorder
(excluding dementia), was
considerably lower in elderly
compared younger adults.
Nearly 20 percent of persons older
than age 65 years have diagnosable
psychopathological symptoms.
The Aging Brain
Structural Changes
Neurochemical Changes
Changes in Cognitive and Motor Abilities
Structural Changes Associated
with Brain Aging
Decline of brain weight
Neuron loss
Neuronal atrophy
Synaptic loss
Pruning of dendritic trees
White matter changes
Gliosis
Neurochemical Changes in Aging
marked changes in dopaminergic
neurons
decrease in the levels of markers of
the cholinergic system
Changes in Motor Abilities
Gait slowing
Reaction time slowing
Balance changes (vestibular,
sensory, motor, and brain)
Changes in Cognitive Abilities
 Mental speed
Executive function
Retrieval
Episodic memory vs procedural
memory
Free recall worse than recognition
Changes in Cognitive Abilities
Cognition includes learning, memory,
&. . .
Learning is the ability to gain new
skills and information. It may be
slower in elderly, especially verbal
learning.
Changes in Cognitive Abilities
 Memory : immediate, short- and
long- term memory.
Immediate and Short-term memory
remain intact, however, there ar
affected by concentration which may
be less in older adults.
Long-term memory is most affected
by aging. Retrieval is less efficient;
the elderly need more cues
Prospects for Healthy Brain Aging
 Control hypertension
Treat diabetes and vascular risk
factors
Mental activity
Cognitively demanding pastimes
Social networks
Prospects for Healthy Brain Aging
Regular physical activity
Diet : Similar components to a
heart-healthy diet
Relatively low fat and cholesterol
Anti-oxidant rich diet
Mental Disorders of old age
Most common : cognitive disorders ,
depressive disorders, substances use.
Risk factors include loss of social
roles, loss of autonomy, deaths,
declining health, increased isolation,
financial constraints, and decreased
cognitive functioning.
Mental Disorders of old age
Most common :
cognitive disorders
depressive disorders
substances use.
Cognitive Disorders
Include:
 Delirium
 Dementia
 Amnestic Disorders
 Psychiatric disorders due to a
Medical Condition
 Postconcussional Syndrome
Delirium
Altered state of consciousness
(reduced awareness of and ability to
respond to the environment)
Cognitive deficits in attention,
concentration, thinking, memory, and
goal-directed behavior are almost
always present
Usually acute and fluctuating
Features of delirium
May be accompanied by
hallucinations, illusions, emotional
lability, alterations in the sleep-wake
cycle, psychomotor slowing or
hyperactivity
Features of delirium
Types:
Hyperactive , hyperalert delirium:
almost always consultation
Hypoactive, hypoalert delirium: no
consultation
Prevalence of delirium
The prevalence of delirium at hospital
admission ranges from 10 to 35 percent
Furthermore
prevalence increases with multiple factors
such as age, medication use, and
comorbidities
Delirium Prevalence in Multiple Settings
prevalence of
Population
delirium
Prevalence Range (%)
General medical inpatients
10–30
Medical and surgical inpatients
5–15
Critical care unit patients
16
Cardiac surgery inpatients
16–34
Orthopedic surgery patients
33
Emergency department
7–10
Terminally ill cancer patients
23–28
Institutionalized elderly
44
The mortality of Delirium
The mortality outcome at 6 months
post discharge for delirious patients
not identified was three times higher
than the delirious patients who were
identified and treated.
25 percent of delirius postoperative
patient had a lethal outcome; control
population 13%
Burden of Delirium
Increased
Increased
Increased
Increased
Increased
mortality
nursing care
length of stay
risk of cognitive decline
risk of functional decline
Burden of Delirium
Delay in postoperative mobilization
Prevention of early rehabilitation
Increased need for home care
services
Increased distress to caregivers
Barrier to psychosocial closure in
terminally ill patient
Etiologies of Delirium in Elderly
Patients
Systemic illnesses
Infections: Pneumonia, urinary
tract infection, sepsis, influenza
Cardiovascular conditions:
Arrhythmia, congestive heart failure,
myocardial infarction, severe
hypertension
Etiologies of Delirium in Elderly
Patients
Medications
Anticholinergics
Benzodiazepines, other sedativehypnotics (e.g., barbiturates)
Antiarrhythmics, Digoxin
Certain antibiotics (e.g.,
fluoroquinolones, clarithromycin)
Interferons
Etiologies of Delirium in Elderly
Patients
Primary brain diseases
Stroke or transient ischemic attack
Trauma: Brain injury, subdural
hematoma
Infection/inflammation: Abscess,
meningitis, encephalitis,
Etiologies of Delirium in Elderly
Patients
Metabolic derangements:
Dehydration, hypoxia, hypoglycemia,
hyperammonemia, uremia,
hyponatremia, thiamine deficiency,
hyperthyroidism
Etiologies of Delirium in Elderly
Patients
Surgery or trauma
Hip fracture repair
Open heart surgery (e.g., coronary artery
bypass grafting)
Withdrawal states
Alcohol
Benzodiazepines, other sedative-hypnotics
Treatment of delirium
Look for underlying cause
Close supervision, especially by family
Reorient frequently
Try not to use restraints, as it can
worsen confusion.
Treatment of delirium
Medication
Avoid polypharmacy
Low dose neuroleptic is treatment of
choice, unless the delirium is due to
withdrawal.
If due to withdrawal, use a longacting benzodiazepine.
Dementing Disorders
Only arthritis more common in
geriatric population
5% have severe dementia, and 15%
mild dementia in those over 65
Over 80, 20% have severe dementia
Dementing Disorders
Most common causes: Alzheimer’s
disease, vascular dementia,
alcoholism, and a combination of
these 3
Risk factors are age, family history,
and female sex
Dementia
Changes
Cognition, memory, language
Personality, abstract thinking,
aphasias
However, level of awareness and
alertness usually intact in early
stages (differentiates dementia from
delirium)
Noncognitive symptoms
accompanying dementia
Depressive disorder
Pathological laughter and crying
Irritability and explosiveness
Delusions or hallucinations occur
during the course of dementias in
nearly 75%
Behavior problems in dementia
Agitation, restlessness, wandering,
violence, shouting
Social and sexual disinhibition,
impulsiveness
Sleep disturbances
Dementia and treatable
conditions
10-15% from:
 heart disease, renal disease, and
congestive heart failure
 endocrine disorder, vitamin
deficiency,
 medication misuse
 primary mental disorders
Alzheimer’s Disease
50-60% of patients with dementia
5% of those who reach 65 have
Alzheimer’s Disease
15-25% of those 85 or older
More common in women
Alzheimer’s Disease
General sequence is memory,
language, then visuospatial functions
On autopsy: neurofibrillary tangles
and neuritic plaques
Involves cholinergic system arising in
basal forebrain
Death occurs in about 7 yrs
Vascular Dementia
Second most common type
Can reduce known risk factors:
hypertension, diabetes, cigarette
smoking, and arrhythmias
Other types of dementia
Multiple sclerosis is characterized by
multifocal lesions in the white matter.
May show early mood lability
Vitamin B12 deficiency--neurologic
changes may occur before
megaloblastic changes
Hypothyroidism
Wilson’s disease
Treatment of behavior problems
Consider the likelihood of depression
and anxiety first
Neuroleptics should not be first
choice, and should be on a “prn”
basis ,unless the patient is psychotic
Medicines for behavioral
problems
Valproic acid, trazodone, and
buspirone may be of benefit
BZDs may aggravate confusion
Drug treatment for Alzheimer’s
Disease
Most current ones affect
acetylcholine
Tacrine
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Reminyl)
Early intervention may prevent or
slow decline
Depression
15% of all older adult community
residences and nursing home
patients
Accounts for 50% of older adult
admissions to a psychiatric facility
Age is not a risk factor, but
widowhood and chronic medical
illness are
Depression
May have more somatic complaints
such as decreased energy, sleep
problems, pain, weakness, GI
disturbances
Increases use of primary care
medical resources
Depression
For those with a medical condition,
depressive symptoms significantly
reduce survival
Increases risk of suicide
Depression in medical illness
Medicines or the medical illness may
cause depression
Rule out medical causes
Use psychological symptoms such as
hopelessness, worthlessness, guilt
Depression in older adults
May have delusions which are usually
persecutory or hypochondriacal in
nature
Need treatment with both an
antidepressant and an antipsychotic
ECT may be treatment of choice
Bereavement
Normal grief starts with shock,
proceeds to preoccupation, then to
resolution
May be prolonged in elderly, but
consider major depression if there is
marked psychomotor retardation,
lasts over 2 months, marked
impairment, or if suicidal ideation
Bipolar Disorder
Do organic workup if onset is over 65
Usually more irritable than euphoric,
and paranoid rather than grandiose
May have dysphoric mania, with
pressured speech, flight of ideas, and
hyperactivity, but thought content is
morbid and pessimistic
Schizophrenia
Usually before 45, but there is a late
onset type beginning after age 65
Paranoid type more common
Residual type occurs in 30% of those
affected: Emotional blunting, social
withdrawal, eccentric behavior, and
illogical thinking predominate
Delusional Disorder
Onset between 40 and 55
Persecutory or somatic delusions most
common
May be precipitated by stress, loss,
social isolation , visual impairment,
deafness, immigrant status
Anxiety Disorders
Very common in elderly
May occur first time after age 60, but
not usually
Most common are phobias, especially
agoraphobia
May be due to medical causes or
depression
Substances and Alcohol
Brain is more sensitive as ages
Due to changes in metabolism, a
given amount may produce a higher
blood level
May worsen normal changes in sleep
and sexual functioning
Sudden onset delirium in hospitalized
patients usually from withdrawal
Personality disorders
Borderline, narcissistic, and histrionic
personality disorders may become
less intense
Before diagnosing a personality
disorder, verify that it is not an
improperly treated Axis I disorder
Some personality traits may become
more pronounced
Sleep disorders
Advanced age is associated with
increased prevalence of sleep disorders
REM sleep behavior disorder occurs
among elderly men
Advanced sleep phase
Dementia associated with more
arousals, increased stage I sleep;
decreased stages 3/4