Geriatric Psychiatry - .GERIATRIC PSYCHIATRY Prof. Nahathai Wongpakaran, MD, FRCPsychT Geriatric

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Text of Geriatric Psychiatry - .GERIATRIC PSYCHIATRY Prof. Nahathai Wongpakaran, MD, FRCPsychT Geriatric

GERIATRIC PSYCHIATRY

Prof. Nahathai Wongpakaran, MD, FRCPsychT

Geriatric Psychiatry Unit Department of Psychiatry, Faculty of Medicine

Chiang Mai University Psy 515

Objectives

Learners will be able to list and describe common mental illnesses in the elderly, and

the management of these conditions.

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Outline

Introduction

Late-life depression

Late-life psychosis

Late-life anxiety disorders

Substance use disorders in the elderly

Alcohol

Sedative-hypnotics

Neurocognitive disorders

Behavioral and Psychological Symptoms of

Dementia (BPSD)

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11 June 2018 nahathai.wongpakaran@cmu.ac.th 4

Social transition

Income level

Daily routine

Retirement

Lifestyle

Financial

planning Family

relationship

Social

relationship

Perceived

role

Old age transition

Physical frailty

Health condition

Loss of indipendence

Bereave

ment

Placement

Functional assessment tasks Activities of daily living (ADL)

Bathing

Ability to transfer

Dressing

Going to toilet

Grooming

Ability to feed self

Instrumental activities of daily living (IADL)

Able to use telephone

Shopping

Food preparation

Laundry

Motor transportation

Responsibility for own medication

Ability to handle finances

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Prevalence of LLD among Thai elderly

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7

Studies Prevalence

(%)

Remarks

Siriwanarangsan P et al,

2005

17.5

M 13.8, F

20.9

N = 9,632

Liang G et al, 2009 21.0 N = 200

TGDS, TMSE

Wongpoom T et al, 2011 5.9 MDD, PHQ-9

Wongpakaran N et al, 2012 23 N = 81, MDD by

MINI, LTC

Risk factors

Older age

Female gender

Unmarried

Low education

Poverty

Family history of

depression

Poor social support

Living in rural areas

Loss and grief

Loneliness

Social isolation

Care-taking

responsibility

Dependency

Role loss: mentor

Life crisis

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Barua A, et al. Indian J Psychol Med. 2010.; Bchtemann D. et al. J Affect Disord., 2012.;

Zhang L, et al. Int J Geriatr Psychiatry. 2012.

Health problems at risk for LLD & comorbid

Cognitive impairment

Chronic physical illness

Ischemic heart disease

Poor function: ADL

A history of depression

Substance use: alcohol,

nicotine

Sensory deprivation

Pain

Degenerative arthritis

Hypertension

Urinary incontinence

Diabetes

Parkinsons disease

Hypothyroidism

Neurologic disease

Stroke

Cancer

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Barua A, et al. Indian J Psychol Med. 2010.

Co-occurring psychiatry diagnoses

Anxiety disorders of 10-20% (Lenze EJ et al 2000, Beekman AT et al 1998)

Personality disorders of 10-30%

Alcohol use disorders (Devanand DP et al 2002)

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LOD: Association with cognitive disorders

Late-life depression increases risk for

developing Alzheimers disease

(Alexopoulos G. 1993.; van Reekum, R. 1999.;

van Reekum R. 2005)

Depressive symptoms are associated with

an increased risk for developing mild

cognitive impairment (MCI)

(van Reekum R. 2006)

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Mechanisms that link depression to MCI

1.

2.

3.

4.

Adapted from Geda et al. Mild Cognitive Impairment. Textbook of Alzheimers Disease and Other dementias 2009.

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Depression

Increased

corticosteroides Brain

damage MCI

Susceptibility

gene variant

or other risk

factors

Preclinical

MCI

Interaction

Depression

MCI

Depression

MCI

Depression MCI

Susceptibility

gene variant

or other risk

factors

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Neurobiological theories

Less genetic influence

Less likely to have a family history of psychiatric illness

Subtle structural brain damage

Decrease neurogenesis

Decrease in brain volume

Prefrontal lobes, caudate, hippocampus

White matter lesions and other abnormalities on imaging

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Neurotransmitter: 5-HT, NE, DA, Ach

Declining health, inappropriate

medications, malnutrition

Coexist with chronic disease and disability

Regulation of homeostasis, organ system

reserve, immunologic responsiveness, and

body composition

Cardiovascular pathology: Hypothesis of

vascular depression

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Psychodynamic theories

Loss

Premorbid personality

Socially inhibited

Helplessness

Narcissistic injury

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Cognitive and behavioral theories

Learned helplessness

Losses & schema

Negative automatic thought

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Social factors

Loss of important social support and system due to death of spouse or siblings

Death of adult child (Prince et al 1997)

Retirement

Relocation (NIH 1992)

Negative life events

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MDD

Dys

DD

No

2

P

values

Interest

81 (10.23) 8 (1.01) 6 (0.76) 141 (17.80) 70.97 < 0.001

Sadness

86 (10.86) 10 (1.26) 7 (0.88) 91 (11.49) 142.81 < 0.001

Sleep

112 (14.14) 25 (3.16) 7 (0.88) 365 (46.09) 20.85 < 0.001

Appetite

67 (8.46) 5(0.63) 4 (0.51) 92 (11.62) 77.25 < 0.001

Energy

87 (10.99) 13 (1.64) 5 (0.63) 151 (19.07) 74.44 < 0.001

Cognition

78 (9.85) 26 (3.28) 9 (1.14) 402 (50.76) 5.73 0.126

Somatic

33 (4.16) 5 (0.63) 0.00 60 (7.58) 21.86 < 0.001

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Chief complaints of elderly patients with depressive disorders

(n=792) Wongpakaran N, et al. DAS Prelim. 2015.

Did you know? Depression without sadness

Loss of interest and motivation

Functional impairment is confused with

lower functional expectation

More frequent with delusions

Still meet DSM-5 criteria

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Assessment

History

Examination

Cognitive screening

Labs

CBC, U/A, Meds plasma,

Ca, Mg, PO4, e,

FBS, BUN/Cr,

LFT, TFT

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15 (TGDS-15)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

_ _/15

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Wongpakaran N, et al. J Clin Med Res, 2013.

. . 2559.

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Depression management strategies in

primary care

Detection

Promoting treatment engagement and

adherence

Stepped care

Collaborative care

Park M. et al. Psychiatr Clin North Am. 2011

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Aims of treatment

To reduce symptoms, remission

To prevent suicide, relapse, recurrence

To help with coping with patients disability

To decrease risk for developing cognitive disorders

To improve general health status

To improve cognitive and functional status

To improve quality of life

To reduce family or caregivers burden

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8-12 wks

6-12

1, 2, 3,

(Alexopoulos GS et al 2000), (Frank E. 1994)

Choices of medication First-line agents

SSRIs (Esc, Ser, Par, Fluv, Fluo)

SNRIs (Venlafaxine/pristiq, duloxetine, +/- Milnacipran,

reboxetine (NaRI))

Second-line agents

Mirtazapine (NaSSA)

Bupropion (NDRI)

Third-line agents

TCAs (Nortriptyline)

MAOI

Psychostimulant

Tianeptine (SSRE)

Others: Quetiapine, Aripiprazole, Olanzapine, agomelatine Ravindran L, et al., 2005.; Shanmugham B. et al 2

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