PSYCHIATRIC PROBLEMS AMONG ELDERLY

Who is at risk Elderly Live alone Are economically disadvantages no relatives or friends experienced recent losses Have been ill or have a progressive or

chronic illness experienced a head injury

• Dementia is an acquired global impairment of intellect,memory and personality but without impairment o conciousness

.Primary dementias are those, which the dementia itself is the major sign of some organic brain disease not directly related to any other organic illness. Secondary dementias are caused by or related to another disease or condition,

Prevalence

It affects between 5 to 7 percent of adults over age 65 and 40 percent of those over age 85

Alzheimer’s disease: most common form of dementia (70%)

Depression and/or anxiety are common

Risk factors

• Age • Vascular disease • Diabetes mellitus • Female gender • Sedentary lifestyle

• Low education level

• Race/Ethnicity

• Cardiovascular accident

• Alcohol abuse

• Head trauma

–Marked loss of memory for recent events

–Losing items–Getting lost in ‘familiar’ places–Missing appointments–Loss of ability for abstract

thought; planning and doing complex tasks

–Trouble cooking, paying bills, driving

–Can’t understand books, movies, or news items

Difficulty finding common words and namesSubstitution of approximate phrasesMisidentifying peopleDifficulty inhibiting behaviorImpulsivity‘Thoughtless’ commentsSocially inappropriate behaviors

Treatment

• No single approach

• To identify the precise type and nature of the individual’s disease

• The use of drugsPiracetam produces positive effects on elderly

patients with mild to moderate memory impairment. Psychostimulants such as methylphenidate

hydrochloride also triedNew medications may slow deterioration due to

dementia (Aricept)Tacrine,rivastigmine-cholinesterase inhibitors

Symptomatic relief

benzodiazepines

antidepressants

antipsychotics

anticonvulsants

Early and differential diagnosis is critical

Effective treatment of depression or anxiety

Support for family caregivers helps them

Education to family members

• is a condition of severe confusion and rapid changes in brain function. It is usually caused by a treatable physical or mental illness

• Prevalence: • it is most common in elderly persons

• 30% of older persons during medical hospitalization and in 10 to 50% of older adults during surgical hospitalization.

• 60% of residents in nursing homes may have

delirium

symptoms• Altered awareness, disorientation, clouding

of consciousness • Impaired attention, concentration, and

memory • Inability to process visual and auditory

stimuli • Increased motor activity (e.g., restlessness) • Anxiety, and agitation • Misinterpretation, illusions, delusions, or

hallucinations • Speech abnormalities • Reduced wakefulness; sleep disturbance

Depression

• Poor appetite or weight Loss• Insomnia or hypersomnia• Loss of energy or tiredness• Psychomotor agitation or slowing• Loss of pleasure in usual activities or decrease

in sexual drive• Feelings of self-reproach or excessive guilt • Diminished ability to concentrate • Suicidal ideas, wishes or attempts.

Duke Longitudinal Study of Aging

• 3.7% --- found to have a major depressive disorder requiring treatment.

• Another 4.5% had but without vegetative signs

• 6.5% had dysphoric mood only with severe health problems.

TREATMENT

• Tricyclic antidepressants. A good rule of thumb for elderly patients is to start giving tricyclics and other antidepressants at about a third the dose recommended for younger patients.

• Desipramine hydrochloride (25 mg each night is a reasonable starting dosage)

Other types of antidepressants

Monoamine-oxidase inhibitors(Risk of hypertensive crisis must be weighed carefully in elderly patients who have a baseline hypertension)

Antidepressant treatment with methylphenidate(Ritalin), is another option for a physically frail elderly depressed patient.

• Psychotherapy• Cognitive-behavioral (CBT)• Problem-solving (PST)• Interpersonal

• Psychosocial Interventions:• care management• exercise • intellectual/creative/recreational activity • relationships• dealing with real life problems

• disturbances in thinking emotions,volitions,and faculties in the presence of clear consciousness,which usually leads to social withdrawl.

• It begins in late adolescence or young adulthood and persists throughout life.

• first episodes diagnosed after age 65 are rare, a late-onset type beginning after age 45 has been described.

• Women are more likely to have a late onset of schizophrenia than men.

• greater prevalence of paranoid schizophrenia in the late-onset type.

• About 20 percent of persons with schizophrenia show no active symptoms by age 65; 80 percent show varying degrees of impairment.

• The residual type of schizophrenia occurs in about 30 percent of persons with schizophrenia.

• Because most persons with residual schizophrenia cannot care for themselves, long-term hospitalization is required.

• Older persons with schizophrenic symptoms respond well to antipsychotic drugs.Medication must be administered judiciously

• Psycho education for family members

• Supportive Psychotherapy

• Day Programs (esp. focused on rehabilitation

Delusional disorder

The age of onset of delusional disorder usually is between ages 40 and 55, but it can occur at any time during the geriatric period.

Delusions can take many persecutory” delusions are common

Somatic delusions also can occur in older persons.

In one study of persons older than 65 years of age, pervasive persecutory ideation was present in 4 percent of persons sampled.

• It can occur under physical or psychological stress and can be precipitated by the death of a spouse, loss of a job, retirement, social isolation, adverse financial circumstances, debilitating medical illness or surgery, visual impairment, and deafness.

• Delusions also can accompany other disorders such as dementia of the Alzheimer's type, alcohol use disorders, schizophrenia, depressive disorders, and bipolar I disorder which

• It can also can result from prescribed medications or be early signs of a brain tumor.

A late-onset delusional disorder called paraphrenia is characterized by persecutory delusions.

It develops over several years and is not associated with dementia

Patients with a family history of schizophrenia show an increased rate of paraphrenia.

 

Somatoform disorders It is characterized by physical

symptoms resembling medical diseases, are relevant to geriatric psychiatry because somatic complaints are common among older adults.

More than 80 percent of persons over 65 years of age have at least one chronic disease

After age 75, 20 percent have diabetes and an average of four diagnosable chronic illnesses that require medical attention.

Hypochondriasis is common in persons over 60 years of age, although the peak incidence is in those 40 to 50 years of age.

The disorder usually is chronic

• Repeated physical examinations

• Clinicians should acknowledge that the complaint is real, that the pain is really there and perceived as such by the patient, and that a psychological or pharmacological approach to the problem is indicated

SLEEPING DISORDERS

Advanced age is the single most important factor associated with the increased prevalence of sleep disorders.

Reported more frequently

in older than younger adults

Primary sleep disorders(dyssomnias insomnia, nocturnal myoclonus, restless legs syndrome, and sleep apnoea,

Mental disorders, General medical disorders Social and environmental factors.

• Alcohol can interfere with the quality of sleep

sleep fragmentation and early morning awakening

• Can precipitate sleep apnoea

• Changes in sleep structure among persons over 65 years of age involve both REM sleep and non-rapid eye movement (NREM) sleep.

• The REM changes include the redistribution of REM sleep throughout the night, more REM episodes, shorter REM episodes, and less total REM sleep.

• The NREM changes include the decreased amplitude of delta waves, a lower percentage of stages 3 and 4 sleep, and a higher percentage of stages 1 and 2 sleep. In addition, older persons experience increased awakening after sleep onset.

Management• Pharmacological management Benzodiazepines• Flurazepam• Zolpidem• Trazodone When prescribing sedative-

hypnotic drugs for older persons, clinicians must monitor the patients for unwanted cognitive, behavioral, and psychomotor effects

Cognitive Therapy • Identify attitudes and beliefs about sleep• Explore the validity of self-statements about

sleep• Replace dysfunctional attitudes and beliefs

about sleep with more appropriate self-statements• Worry time – Remove thoughts and general cognitive

activation away from bedtime and moves them to a better period of the day

Addictive disorders 

Risk factors

– Having a mental health disorder

– Having an alcoholic parent(family history)

Alcohol abuseDefinition: A disorder characterized by the excessive

consumption of and dependence on alcoholic beverages, leading to physical and psychological harm and impaired social and vocational functioning

Alcohol withdrawal, which may be a problem in as many as 20% of elderly persons in hospital

When absolutely necessary, diazepam can be used briefly in an elderly person with alcoholism at doses of 2 mg twice a day.

Detoxification: Outpatient/Inpatient Rehabilitation: Community-based or residential Mutual aid/self-help: e.g. AA

 

• Definition: A type of medication known as

tranquilizers. Familiar names include Valium and Xanax. When people without prescriptions take these drugs for their sedating effects, use turns into abuse

• Prevalence: Older adults represent only 14% of the U.S.

population, yet they receive 27% of all prescriptions for anxiolytic benzodiazepines and 38% of hypnotic benzodiazepines

• Risk factors– Medical hospitalization is a significant risk factor

for initiation and continuation of benzodiazepines

Gambling

• Gambling may provide: * Social support to older adults * Excitement *Entertainment * Winnings * Challenge * time pass

• Persons older than age 65 represent high percentage who commit suicide.

• Of all suicides, 20 % are committed by this age group and suicide is the 15th leading cause of death among the elderly .

• Risk group especially appears to be white men.

• Previous suicide attempt(s) • History of -mental disorders -alcohol and substance abuse • Family history of suicide • Family history of child maltreatment • Feelings of hopelessness • Impulsive or aggressive tendencies

• Barriers to accessing mental health treatment

• Loss

• Physical illness

• Easy access to lethal methods

• Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or suicidal thoughts

• Cultural and religious beliefs

• Local epidemics of suicide

• Isolation

Prevention Identify any sign of helplessness or

hopelessness Demonstrations of genuine concern,

interest, and caring; indications of empathy for their fears and concerns;

Effective clinical care for mental, physical, and substance abuse disorders

Arrange for Family and community support

• Support from ongoing medical and mental health care relationships

• Skills in problem solving, conflict resolution, and nonviolent handling of disputes

• Cultural and religious beliefs that discourage suicide and support self-preservation instincts

Identification of risk by “Gatekeepers” Primary care physicians Home health providers Social service workers People in the neighborhood

Depression treatment and care management

Public education

Anxiety disorder

Definition

A psychiatric disorder

involving the presence of anxiety that is so intense or so frequently present that it causes difficulty or distress for the individual

– Excess or undue worry or fear

– Fatigue – Disturbed sleep – Jumpiness, jitteriness,

trembling – Muscle aches, tension – Dizziness,

lightheadedness

symptoms

– Gastrointestinal upset – Dry mouth, sensation of a lump in the

throat, choking sensation Clammy hands, sweating

– Racing heartbeat, chest discomfort – Shortness of breath, or the feeling of being

smothered – Numbness or tingling of hands, mouth, or

feet

Risk factors Personal history of:

• Depression • Anxiety disorder

• Chronic medical illness • Loss of significant person during childhood

• Cognitive impairment • Alcohol abuse/dependence

• Social isolation

– Family history of: • Alcohol abuse • Anxiety disorders • Mood disorders

– Other factors: • Female gender • Exposure to traumatic event

Treatment

Anxiolytics Benzodiazepines

Most common agents Alprazolam (Xanax) Lorazapam (Ativan)

physical symptoms Assist client to identify thoughts

that arouse the anxiety & their bases

Assist client to change unrealistic thoughts to more realistic though

Cognitive-behavioral therapy CBT may involve

relaxation training, cognitive restructuring (replacing anxiety-producing thoughts with more realistic, less catastrophic ones) and exposure (systematic encounters with feared objects or situations).

• CBT can take up to several months and has no side effects.

• Maintain sleep hygiene

• Other treatments effective for some people include

meditation biofeedbackmassage acupuncture