In the name of God

Geriatric Psychiatry

DR. ISMAIL SADEKLECTURER OF PSYCHIATRY

FACULTY OF MEDICINE ALAZHER UNIVERSITY

CAIRO - EGYPT

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Points of Geriatric Psychiatry Definition

Epidemiology Prevalence of mental disorder Barriers to mental health service utilization

Normal aging Metabolic changes Treatment

Pharmacotherapy, Psychotherapy Treatment models

Psychiatry disorders or problems commonly seen Dementia, depression, delirium, sleep problems, anxiety, suicide

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فالمسن العالمية الصحة لمنظمة طبقاالعمر من بلغ الذي اإلنسان بأنه 65يعرف

. فأكثر ً عاما

) العالمية) الصحة منظمة

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The Young Old, the Old Old, and the Oldest Old

Developmentalists distinguish between subperiods in this stage, although definite age boundaries are not yet agreed upon.

The young old are 65-74 years of age. The old old are 75 years and older. Some distinguish the oldest old as 85 years

and older.

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The Young Old, the Old Old, and the Oldest Old

Many experts prefer to make the distinction based on functioning, rather than age.Functional age: A person's actual ability to function -> the young old = those who regardless of their actual age are vital and active.

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منها الخاصة العربية المصطلحات بعض :وهناك

1 : الخامسة- وحتى الستين سن من عمره يمتد الكهلوالسبعين.

2 : وحتى- والسبعين الخامسة من عمره يمتد الشيخ. والثمانين الخامسة

3 : وحتى- والثمانين الخامسة من عمره يمتد الهرمالمائة.

4. : فأكثر- سنة مائة بلغ من المعمر

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المضطرد و الجسم ضعف بأنها الشيخوخة تعرفالزيا مع ذاته، وقاية في دفي المتصاعدة ة

وقاية في الضعف ونمو الذاتي، الهدم عملياتالمناعي، الجهاز عجز عن ً ناتجا يكون الذات

. التلف ترميم آلية وضعف الذاتي، الهدم وزيادة ال قد الجسم فشيخوخة التعريف لهذا وطبقا

ارتباط عليه المتعارف لكن ، بالسن ترتبط. السن بكبر الشيخوخة

وانما ذاته، حد في ً مرضا ليس السن هو وكبرفسيولوجية، تغيرات فيها تحدث الحياة من فترة

وعقلية ) جسمانية، تشكل( ،وبيولوجية، ونفسيةالمسن وحياة لطبيعة . مشاكل

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Retirement is detrimental to an

individual's health; six months ago he retired

and now he's dead, retirement killed him

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Longevity: Life Expectancy and Life Span

Life span - the upper boundary of life, the maximum number of years an individual can live.

The maximum life span of human beings is approximately 120 years of age.

Life expectancy - the number of years that will probably be lived by the average individual born in a particular year.

The life expectancy of individuals born today in Canada is 78.6 years.

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Sex Differences in Longevity

Today, life expectancy for females is 82, males 76. Beginning at age 25, females outnumber males,

and the gap continues to grow. By the time adults are 75 years of age, more than

61% of the population is female. These differences are due to health attitudes,

habits, lifestyles, and occupation. Biological factors play a role, too, as females

outlive males in virtually all species.

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Variations in Life Span: Factors

Quality of the health care system Quality of food Genetic predispositions Health habits Geographic location Psychological variables: Optimism. Self-esteem.

Concept: Active life expectancy

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فى المسنين عدد األخيرة السنوات فى ارتفعخاصة بصفة ومصر العربي العالم وفي عامة العالم

ل هذا يرجع المتوقع وقد العمر متوسط زيادة. الوالدة معدالت وانخفاض

أنه الدراسات القادمة، أظهرت سنة الخمسين فيأضعاف أربعة نحو السن كبار عدد يزداد إذ .سوف

نحو من بليوني 600يزدادون إلى نسمة مليونتقريبا .نسمة

هم بلغ ي من وأكثر نسبة الستين سن 10حاليا فيالنسبة% وستصل العالم، سكان عدد بحلول من

و% 20حوالى 2050عام ي ، أن المتوقع ثلث كونمنالعالم عمر سكان بحلول في أكثر أو سنة ستين

.2150عام

12

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مصر فى المسنين مالمح حوالى بلغت المسنين السكان% 6نسبة إجمالى من

تعداد لنتائج ً وفقا مصر نتائج, 2006فى تشير كماأن إلى السابقين العقدين خالل للسكان العام التعداد

من ارتفع المسنين إلى 2.7عدد نسمة 4.4مليونعامى بين ما نسمة ومن, 2006و 1986مليون

حوالي إلي تصل أن وإلي 2015عام% 9المتوقععام% 12 . 2030بحلول

) واألحصاء) العامة للتعبئة المركزى الجهاز

أن األحصاء الكلية% 41وأظهرت النسبة منمن العمرية الفئة في يقعون عاماً، 64 -60للمسنين

من العمرية الفئة بنسبة 70-65يليها ً يليها% 27عاما ،ال فوق العمرية بنسبة 70الفئة ً .% 32عاما

( - الوزراء مجلس القرار إتخاذ ودعم المعلومات (مركز

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طب في االبحاث تركزت قد الماضي فيالعلوم على رئيسي بشكل الشيخوخةالفسيولوجية ) التغير¡ات مثل األساسية ) فهم تم لذلك ونتيجة ، الشيخوخة اثناء

. الشيخوخة عملية حول الكثير

أن إلى حاجة في اآلن االهتمام ولكنلتقييم ، الصحية والخدمات للبحوث تدفعالخدمات من االقتصادية والجدوى فعاليةالخدمات في للمساعدة وخطة ، القائمة

. المستقبل في

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Geriatric population increasing

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Aging and the Life Cycle (Erickson)

Young adulthood--intimacy versus isolation

Middle-aged--generativity versus self-absorption

Elderly--Integrity versus despair (Acceptance of mortality, satisfaction with one’s meaning in the world)

Fear of death is usually a mid-life issue

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Challenges of Late LifeCo-morbid medical illness / cognitive disordersSensory lossFinancial worriesRetirementDependencyDying and deathBereavement

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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.

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Physical Changes of AgingHeartMusclesBrainSkinKidneyVision

HearingBonesTaste

~ Pumping effectiveness decreases~ Muscle mass decreases~ Some loss of cell structure and function~ Dryness, slower healing~ Less efficient~ Decreases in depth perception, color

perception, and peripheral vision~ Decreased acuity, esp. higher pitch~ Mineral loss faster than replacement~ Decreased taste buds, saliva production

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Getting older v. living longer Mental changes

Personalityamplification of character traits

Cognition, memorymental slowingtransformed memory structuresummerised experiences

Emotional changesEmotional maturity

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Getting older v. living longer Social changes

Retirement (financial difficulties)Decrease in social statusFacing somatic and mental disfunctioningSomatic diseasesGrief (loss of spouse, brothers or sisters, friends)Social isolationMoving to nursing/residential home

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The Aging Brain

Structural Changes Neurochemical ChangesChanges in Cognitive and Motor

Abilities

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Structural Changes Associated with Brain AgingDecline of brain weight

Neuron loss Neuronal atrophy Synaptic loss Pruning of dendritic trees White matter changes Gliosis

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Neurochemical Changes in Aging

marked changes in dopaminergic neurons

decrease in the levels of markers of the cholinergic system

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Age related changes in the Central Nervous System

Gross brain atrophy Ventricular enlargement Selective regional neuronal loss Remodeling of dendrite, axons &

synapses Appearance of intraneuronal

lipofuschin Selective regional decrease in

neurotransmitter & neuropeptides.

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Contd...........

Selective modification of neurotransmitter metabolism

Possible dysregulation of gaseous neurotransmitter metabolism

Glucocorticoid neurotoxicity Changes in receptors Changes in neurotrophins Changes in signal transduction

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…contd. Impairment of calcium homeostasis Possible changes in cell cycle

regulations (eg, cyclins) Possible changes in extra cellular matrix

proteins (eg. Laminin, proteoglycans) Possible regional decline in cerebral

blood flow Possible regional decline in metabolic

rate Appearance of senile plaque &

neurofibrillary tangle

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Changes in Motor Abilities

Gait slowing   

Reaction time slowing   

Balance changes (vestibular, sensory, motor, and brain)

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Changes in Cognitive Abilities  Mental speed

   Executive function   Retrieval   Episodic memory vs procedural

memory   Free recall worse than recognition

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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.

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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

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Prospects for Healthy Brain Aging

Control hypertension Treat diabetes and

vascular risk factors Mental activity

   Cognitively demanding pastimes   Social networks

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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

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Laboratory Evaluation and Other Investigations Routine Haematological Tests -

Complete Blood cell count Platelets countProthrombin time Serum ElectrolytesBlood glucose level Renal PanelHepatic PanelRoutine Diagnostic Tests -

Lipid Profile, Blood sugar fasting, Electrocardiogram, Chest radiograph,

Optional – EEG, CT Scan, MRI

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PHARMACODYNAMICS AND AGING

Neurotransmitter Pharmacodynamic changes with aging

Dopaminergic system

Dopamine D2 receptor in the striatum

Cholinergic system

Choline acetyl transferase

Cholinergic cell numbers

Contd...........

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Adrenargic system

cAMP production in response to beta-agonists

Beta – adrenoceptor number

Beta – receptor affinity

Alpha 2 – adrenoceptor responsiveness

Gabaminergic system

Psychomotor performance in response to benzodiazepines

? Post – synaptic receptor response to GABA.

Contd...........37

PHARMACOKINTIC CHANGES WITH AGING38

Psychopharmacological Treatment of Geriatric Disorders

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GERIATRIC MANIA

Risk of Mania decline in late life, nonetheless mania and hypomania affect 5-10% of psychiatric patients.Established mood stabilizers Lithium salts Valproate Carbamazepine Calcium channel blockers E.C.T.Putative Mood stabilizes" L. Thyroxine Phosphatidyl choline Progesterone

Clozapine, Olanzapine Magnesium salt

Newer Anticonvulsants Lamotrigine, Gabapentin Topiramate, Tigabine

Omega 3 fatty acid

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Antidepressant Drugs and Dosages Preferred for Use in the Elderly

Geriatric dosage(mg per day)

Side EffectsDrugs

Startingdosage

Maintenancedosage

Sedation Agitation Anticholinergiceffects

Orthostatichypotension

Tricyclic antidepressants

Desipramine 25 50 to 150 Low Low Low Low

Nortriptyline 10 to 25 40 to 75 Moderate Low Low

Selective serotonin reuptake inhibtiors

Citalopram 20 20 to 40 Low Low - -

Fluvoxamine 50 50 to 200 Low Low - -

Paroxetine 10 20 to 30 Low Low - -

Sertraline 25 to 50 50 to 150 Low Low - -

Miscellaneous

Bupropion 100 100 to 400 - Moderate - Low

Nefazodone 100 100 to 600 Moderate -- Low Low

Trazodone 25 to 50 50 to 300 High - Low Moderate

Venlafaxine 75 75 to 350 Low Low Low Low

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Cardiovascular

Renal

Diabetes

Hepatic ?

Hematological

Thyroid

Arthritis

Infectious disorders

Metabolic

Disorders Lithium CBZ VPA

Anticonvulsants in Depression with medical comorbidity42

Psychotic agitation in the elderly with mania

Initial treatment Haloperidol 0.25 to 0.5 mg IM or PO After one hour, administer lorazepam 0.5mg IM or POStabilization Repeat alternating doses every hour until calm Monitor carefully to avoid over sedation Alternative regimen if extra pyramidal symptoms develop Atypical antipsychitic riseperidone (0.5mg), or olanzapine (2.5

- 5 mg) Avoid chlorpromazine and thioridazine due to their

anticholinergic and hypotensive side effects.Chronic medication Daily dose of medication is determined by adding the total

dose of each medication required to calm the patient and dividing it equally throughout the day.

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Adjunctive antipsychotic medicationRisperidone Daily divided doses of .5 to 3mg Monitor patient carefully for orthostatic hypotension

and EPS as dose is increasedOlanzapine Daily doses of 2.5 to 10 mg /day’ Transient elevation in liver enzyme have been

reported Risepeidone plus olanzapine Observe for increased agitation or other manic

symptom because of breakthrough mania with risperidone.

Clozapine Reserved for patients who are intolerant of

risperidone and olanzapine, Daily doses start at 12.5mg, increase to 50mg If history of seizure disorder should be maintained on

an anticonvulsant Monitor for orthostatic hypotension and weekly

complete blood count to assess for evidence of bone marrow toxicity

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ATYPICAL ANTIPSYCHOTICS IN THE ELDERLY

Drug Metabolite t½ (h) CLR and T½changes in

elderly

CYP enzyme involved inmetabolism (potential

drug interactions)

Geriatricdoses mg

per day

Clozapine Norclozapine, clozapineN- oxide (very limitedactivity)

4-12 CLRdecreased

CYP1A2, CYP2D6,CYP3A4 (theophylline,digoxin, warfarin)

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Risperidone 9 hydroxy risperidone(active)

20 CLRdecreasedt½ prolonged

CYP2D6 (inhibitor drugssuch as quinidine) 2

Olanzapine 10-N-glucoranide, N-demethyl-olanzapine(inactive)

30 CLRdecreasedt½ prolonged

CYP2D6 (inhibitor drugssuch as quinidine) 10

Quetiapine Multiple (mainmetabolite is asulphoxide, usuallyinactive)

6' CLRdecreasedt½ prolonged

CYP3A4 (phenytoin,Thioridazine) 200

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COMMON ANTIPSYCHOTIC DRUG INTERACTION IN THE ELDERLY

Combination Effect

TCAs and conventionalantipsychotics

Raises blood antidepressantconcentrations

SSRIs and clozapine Raises blood clozapine concentrations

Risperidone and clozapine Raises blood clozapine concentration

Smoking Lower blood antipsychotic concentration

Cimetidine Lower blood antipsychotic concentration

Anticholinergic drugs Additive memory and delirious effects

Anticonvulsant, antihypertensiveand sedative drugs

Additive sedative and delirious effects

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Psychiatric disorder in old age

OVERVIEW Dementia - BPSDLate Onset PsychosisDepression in late lifeAnxiety in late lifeDeliriumOther types of dementia (Lewy Body, FTD)

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Mental Disorders of old ageMost 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.

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Mental Disorders of old age Most common : cognitive disorders

depressive disorders substances use.

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Cognitive DisordersInclude:

Delirium Dementia Amnestic Disorders Psychiatric disorders due to a

Medical Condition Postconcussional Syndrome

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DeliriumAltered 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

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Treatment of delirium

Look for underlying cause Close supervision, especially by

familyReorient frequentlyTry not to use restraints, as it can

worsen confusion.

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Treatment of deliriumMedication Avoid polypharmacy

Low dose neuroleptic is treatment of choice, unless the delirium is due to withdrawal. If due to withdrawal, use a long-acting benzodiazepine.

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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

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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

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Dementia

ChangesCognition, memory, languagePersonality, abstract thinking, aphasiasHowever, level of awareness and alertness usually intact in early stages (differentiates dementia from delirium)

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Noncognitive symptoms accompanying dementia

Depressive disorder Pathological laughter and

crying Irritability and explosivenessDelusions or hallucinations

occur during the course of dementias in nearly 75%

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Behavior problems in dementia

Agitation, restlessness, wandering, violence, shouting

Social and sexual disinhibition, impulsiveness

Sleep disturbances

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Dementia and treatable conditions

10-15% from: heart disease, renal disease,

and congestive heart failure endocrine disorder, vitamin

deficiency, medication misuse primary mental disorders

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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

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Alzheimer’s Disease General sequence is memory,

language, then visuospatial functionsOn autopsy: neurofibrillary tangles

and neuritic plaquesInvolves cholinergic system arising in

basal forebrainDeath occurs in about 7 yrs

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Vascular Dementia

Second most common type

Can reduce known risk factors: hypertension, diabetes, cigarette smoking, and arrhythmias

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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

HypothyroidismWilson’s disease

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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

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Medicines for behavioral problems

Valproic acid, trazodone, and buspirone may be of benefit

BZDs may aggravate confusion

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Drug treatment for Alzheimer’s Disease Most current ones affect acetylcholine

TacrineDonepezil (Aricept)Rivastigmine (Exelon)Galantamine (Reminyl)Early intervention may prevent or

slow decline

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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

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Depression

May have more somatic complaints such as decreased energy, sleep problems, pain, weakness, GI disturbances

Increases use of primary care medical resources

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Depression

For those with a medical condition, depressive symptoms significantly reduce survival

Increases risk of suicide

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Depression in medical illness

Medicines or the medical illness may cause depression

Rule out medical causesUse psychological symptoms

such as hopelessness, worthlessness, guilt

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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

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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

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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

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Schizophrenia

Usually before 45, but there is a late onset type beginning after age 65

Paranoid type more commonResidual type occurs in 30%

of those affected: Emotional blunting, social withdrawal, eccentric behavior, and illogical thinking predominate

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Delusional DisorderOnset between 40 and 55Persecutory or somatic delusions

most commonMay be precipitated by stress,

loss, social isolation , visual impairment, deafness, immigrant status

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Anxiety Disorders

Very common in elderlyMay occur first time after

age 60, but not usuallyMost common are phobias,

especially agoraphobiaMay be due to medical

causes or depression

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Substances and Alcohol

Brain is more sensitive as agesDue 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

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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

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Sleep disordersAdvanced 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

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80Thanks for your mental

effort