PSYCHOGERIATRY

Dr.Deddy Soestiantoro SpKJ MKes

INTRODUCTION
-The most common mental disorders:
depression,anxiety disorders,sleep disorders,
dementia,delirium,suicide,schizophrenia
-Special characteristic of the elderly:
-Communication gaps with the elderly
-Complexities of treatment
Possible barriers to communications
with older adults
-difficult to talk about aging & the effect of aging
-want us to listen, hear, care and respond, often complain
that nobody is listening
-diminished ability to understand
-major barriers: professional & scientific language / wrong
vocalbulary
-social isolation influences makes difficult to overcome
-younger adult may have different beliefs & systems
-it is still possible to teach anything new /change in health
behavior which is very beneficial

-short-term memory & recall as well as learning speed may be
diminished and therefore:
-attentionspan canbe easily exceeded
-sensory loss or decrements prevent good communication
(auditory loss,vision loss,physical limitation & mobility
problems such as arthritis)

So the relationship mostly influence by communication
difficulty, generation gap and physical & cognitive
limitation.

The best principle is to:
START LOW,GO SLOW & MONITORING FREQUENTLY
this also suitable for treatment.

PSYCHIATRIC EXAMINATION OF THE OLDER PATIENT

-follow the same format as younger adults,
-because of the cognitive disorders, must determine
whether a patient understands the nature and purpose
of examination, and alloanamnesis should be better
-autoanamnesis still necessary to preserve the privacy
of the doctor-patient relationship and to elicit any
suicidal thought or paranoid ideation
-one must remember that older adults differ markedly
from one another
Psychiatric history

-complete identification, chief complaint, history of
present illness, previous illnesses, personal and family
history, a review of medications (including OTC med.)
that is currently using or has used in the recent past.
-childhood & adolescent hystory-information about
personality/coping strategies &defense mech. under
stress, about friends, sports, hobbies, social activity
and works, about future plans / hopes and fears
-family hystory and the socio-economic evaluation
-marital and sexual hystories
MENTAL STATUS EXAMINATION
-General description
-Functional assesment
-Mood, feeling and affect
-Perceptual disturbances
-Language output
-Visuospatial functioning
-Thought
-Sensorium and cognition
-conciousness, orientation, memory, intellectual tasks /
information and intelligence, reading and writing
-Judgment

NEUROPSYCHOLOGICAL EVALUATION
MEDICAL HYSTORY
MENTAL DISORDERS OF OLD AGE

NIMH-ECA USA:----->the most common:
-depressive disorders, phobias,alcohol use, and also
a high risk for suicide and drug-induced psychiatric
symptoms.
-can be prevented especially the reversible cause of
delirium and dementia
-psychosocial risk factors also predispose: loss of social
roles, loss of autonomy, the deaths of friends & relatives,
declining health, increased isolation, financial constraints,
and decreased cognitive functioning.
DEMENTING DISORDERS---->NEUROLOGY
-usually in medical illness and in depression the
cognitive deficits are mild
-some potentially reversible conditions that may
resemble dementia:
-substances:-psychotropic drugs (antipsychotic,
narcotics,sedative hypnotic), polypharmacother.,
corticosteroids, digitalis, anticholinergic and
hypertensive agents,phenitoin, nonsteroidal
antiinflammatory agents,
-psychiatric disorders (anxiety,depression,mania,
delusional / paranoid disorders)
-metabolic and endocrine disorders (hepatic/renal
failure,volume depletion, hyper / hypothyroidisms,
hyper / hyponatremias, etc)
-miscellaneous conditions ( fecal impaction,
hospitalization, impaired hearing or vision)










DEPRESSIVE DISORDERS

-about 15% of all older adult
-risk factors :being widowed and having a chronic medical
illness are associated with vulnerability to depression

-late onset depression is high rate of recurrence
-symptoms:-reduced energy & concentration,early morning/
multiple awakening,decreased appetite,weight loss and
somatic complaints, this maybe different with the younger

-particularly vulnerable to major depressive episodes with
melancholic features, characterized by depression, hypo-
chondriasis,low self-esteem,feelings of worthlessness and
self-accusatory trends with paranoid & suicidal ideation.





















-cognitive impairment is referred to as the dementia
syndrome of depression (pseudodementia),in true
dementia intellectual performance usually is global,
the impairment is consistently poor,here the deficits
are variable in attention and concentration, and less
likely to have language impairment or more likely to
say I dont know

-pseudodementia occurs in 15 % depression in elderly













BIPOLAR DISORDER I

-usually begins in middle adulthood,
-a manic episode late in life maybe as an organic cause
such as an adverse effect of medication or early dementia
-symptoms of mania are similar to those in younger adults
include an elevated,expansive or irritable mood ; a
decreased need to sleep; distractibility; impulsivity and
alcohol intake
-hostile and paranoid behavior
-cognitive impairment ,disorientation,or fluctuating levels of
awareness maybe suspected as an organic cause












SCHIZOPHRENIA

-usually begins in late adolescence or young adulthood
and persist throughout life
-first episodes after 65 are rare
-women are likely to have a late onset than men
-greater prevalence of paranoid schizophrenia in the late-
onset type
-20%of persons with schizophrenia show no active
symptoms by age 65, psychopathology becomes less
marked as patients age
-residual type :30% --long-term hospitalization is required
because cannot care for themselves
-respond well to antipsychotic
DELUSIONAL DISORDER
-age of onset usually is between ages 40-55 but it can occur
at any time during the geriatric period.
-delusions can take many forms,the most common are
persecutory,may become violent toward their supposed
persecutors,some lock them- selves in their rooms
-somatic delusions(believe have a fatal illness)may occur in
older persons
-pervasive persecutory ideation was present in 4%
-occur under physical/psychological stress precipitated by
the dead of a spouse,job loss,retirement,social isolation,
adverse financial circumstances,debilitating medical illness/
surgery,visual impairment & deafness


-delusions may occur with other disorders such as dementia
(Alzheimers type), alcohol use, schizophrenia, depressive
disorders,and bipolar I
-also result from prescribed medications or early signs of a
brain tumor
-prognosis mostly fair to good, best results; combination of
psycho-pharmacology and psychotherapy
-a late onset of delusional disorder called paraphrenia with
persecutory delusions, develops over several years, not
associated with dementia,maybe a variant of schizophrenia
(increased in positive family hystory of schzophrenia)
ANXIETY DISORDERS
-include panic disorder,phobias,obsessive-compulsive
disorders,generalized anxiety disorder,acute and post
traumatic stress disorders
-begin in early or middle adulthood, some appear first time
after age 60
-initial onset of panic disorder is rare but can occur
-ECA:1 month prevalence rate is 5,5% (phobias 4-8%,panic
disorders 1%)
-phobias symptoms less severe but the effects are equally /
debilitating
-may deal with the thought of death with a sense of despair &
anxiety rather than with equaminity and sense of integrity


-the fragility of the ANS may account for the development of
anxiety after a major stressor, physical disability make to
react more severe in post-traumatic stress disorder
-OCD may appear for the first time, although the premorbid
personality has been already seen, when symptomatic
become excessive in desire to orderliness, rituals &
sameness and may become inflexible, rigid and always to
check things again an again; in contrast to OC personality
disorder OCD is characterized by ego-dystonic rituals &
obsessions and may begin late in life
-treatment both pharmacotherapy & psychotherapy are
required, must take to account the bio-psycho-social
interplay.
SOMATOFORM DISORDERS

-physical symptoms resembling medical diseases are
relevant to geriatric psychiatry because somatic complaints
are common among older adults
-more than 80% over 65 years of age have at least one
chronic disease, usually arthritis or CV problems
-after 75, 20% have DM & an average of 4 chronic illnesses


-hypochondriasis is common over 60 (the peak : 40-50),
usually chronic, repeated physical examinations help
reassure patients that they do not have a fatal illness
-unless medically indicated no need for high-risk diagnostic
and invasive procedures
-telling that the symptoms are imaginary to the patients is
counter-productive and usually engenders resentment
-we should acknowledge that the complaint is real, and that a
psychological & pharmacological approach is indicated
ALCOHOL AND OTHER SUBSTANCES USE
DISORDER

-usually began in young or middle adulthood
-usually are medically ill, primarily with liver disease
-20% of nursing home patients in US have alcohol
dependence
-overall 10%of all emotional problems & dependence is
common
-substance-seeking behavior is rarer than in younger adults
-may abuse anxiolytic to allay chronic anxiety or to ensure
sleep
-clinically varies and includes confusion, poor personal
hygiene, depression, malnutrition, and the effects of
exposure and fall


-sudden onset delirium most often caused by alcohol
withdrawl,alcohol abuse also cause chronic
gastrointestinal problems
-misuse OTC substances including nicotine & caffeine,
35% use analgesics,30% laxatives
-unexplained gastrointestinal, psychological, and
metabolic problems maybe because of OTC substance
abuse
SLEEP DISORDERS
-advance age is the single most important factor
-sleep-related phenomena: sleeping problems, daytime
sleepiness,daytime napping and the use of hypnotic drugs
-clinically higher rates of breathing-related sleep disorder and
medication-induced movement disorders
-the causes of sleep disturbances:
-altered regulatory & physiological systems
-primary sleep disorders: dyssomnias esp.primary
insomnia,nocturnal myoclonus, restless legs
syndrome, sleep apnea; parasomnias: esp. REM sleep
behaviour disorder
-other mental disorders,
-general medical disorders,
-social & environmental factors

-interfere conditions : pain,nocturia,dyspnoe & heart burn
-lack of a daily structure,and of social or vocational
responsibilities contributes to poor sleep
-as a result of the decreased lenght of daily sleep-wake cycle,
without daily routines may experience an advanced sleep
phase, in which go to sleep early and awakening during the
night
-alcohol, hypnotics & other CNS depressants causing more
early awakening, alcohol may also precipitate or agravate
obstructive sleep apnea

-when prescribing sedative-hypnotic drugs, monitor for
unwanted cognitive, behavioral and psychomotor effects,
including memory impairment (anterograde amnesia),
residual sedation,rebound insomnia,daytime withdrawal,
and unsteady gait
-changes in sleep structures involve both REM and NREM
-deterioration in the quality of sleep is due to the altered
timing of and consolidation of sleep, have a lower
amplitude of circadian rhythms,a 12-hour sleep-
propensity rhythm and shorter circadian cycles
SUICIDE RISK
-5x higher than that of general population
-1/3 report loneliness as the principal reason for
considering suicide
-10% report financial problems, poor medical health
or depression as reasons for suicidal thoughts
-75% attempted suicide are woman
-60% committed suicide are men
-most commonly depression & do not receive attention
-violent method are more common
-the most common precipitans: illness & loss, most
commonly communicate prior to the act
-should be no reluctance to question about suicide







-
OTHER CONDITION OF OLD AGE

-vertigo
-syncope
-hearing loss










PSYCHOPHARMACOLOGICAL TREATMENT OF
GERIATRIC DISORDERS
-especially usefull to bring in all medications used
-divided doses for psychotropic drugs
-liquid preparations sometimes better
-avoid polypharmacy and use monotherapy
-be carefull with AD reactions
-the most common : psychotropic drugs,CV and diuretics
OTC medications



PSYCHOTROPICS IN OLD AGE

Antipsychotics
Lower risk Moderate risk Higher risk
-Amisulpiride -Buthyrophenones -Clozapine
-Risperidone -Loxapine
-Olanzapine?
-Phenothiazines
-Quethiapine
-Thioxanthenes
-Zotepine
ANTICONVULSANTS

Lower risk Moderate risk Higher risk
-Carbamazepine -Barbiturates -Acetazolamide
-(Sodium valproate) Benzodiazepines -Phenitoins
-Tiagabine -Gabapentine -Vigabantrin
-Topiramate?
-Lamotrigine
-Piracetam?


Antidepressants

Lower risk Moderate risk Higher risk
-Desipramine -Flupenthixol -Tricyclics
-Lovepramine -MAOIs (most)
-Mirtazapine -Mianserine
-Moclobemide -Reboxetine
-Nefazodone -Trazodone
-Nortryptiline?
-SSRIs
-Tryptophan
-Venlafaxine


Anxiolytics & hypnotics

Lower risk Moderate risk Higher risk
-Alprazolam -Clomethiazole -Benzodiazepines
-Buspirone -Flurazepam long acting
-Clobazam -Flunitrazepam -Nitrazepam
-Lorazepam -Propanolol
-Oxazepam -Temazepam
-Oxprenolol -Zolpidem
-Zeleplon
-Zopiclone
Others

Lower risk Moderate risk Higher risk
-Donepezil -Benzhexol -Acamprosate?
-Modafinil -Lithium -Paraldehyde
-Orphenadrine -Procyclidine
-Rivastigmine
PRINCIPLES
-the major goals: to improve the quality of life, maintain in the
community, avoid/delay in nursing homes placement
-basic tenet: individualization of dosage
-alteration dosages required because of the physiological
changes (renal,liver,CV,GI)
-increased risk of orthostatic hypotension from psycho-
tropic drugs is related to reduced functioning of of blood
pressure-regulating mechanisms
-conclusion- dont forget to remember always:
START LOW - GO SLOW and MONITORING FREQUENTLY
ELECTROCOVULSIVE THERAPY
-it can be the most effective treatment option
-lowest risk of complications for older individuals with
comorbid medical conditions likely to produce drug-
disease and drug-drug interactions
-ECT can provide a rapid response, which is vitally
important in serious ill patients, those at risk due to
malnutrition or agitation related to psychiatric ilness,
and those at high risk for suicide
-ECT modification to prevent musculoskeletal seizures
is now considered as safe as, if not safer than,
medication for use in frail elderly patients
PSYCHOTHERAPY FOR GERIATRIC PATIENT

In addition to improving relatioships,psychotherapy
increases self-esteem and self-confidence, decrease
feelings of helplessness and anger, and improves the
the quality of life, geriatric psychotherapy has general
aim of assisting older adult to have minimal complaints,
to help them to make and keep friends of both sexes,
and to have sexual relations when they have interest
and capacity.


PSYCHOTHERAPY FOR GERIATRIC PATIENTS

-Supportive Psychotherapy
-Life Review or Reminiscence Therapy
-Cognitive Behavior Therapy
-Brief ( Time-Limited ) Psychodynamic Psychotherapy
-Insight-Oriented Psychotherapy
-Integrated Therapy: integration of psychotherapies
often is the most effectve way to proceed.
PSYCHIATRIC SYMPTOMS ASSOCIATED WITH
SPECIFIC MEDICAL DISORDERS

-Cerebrovascular disease
-Cardiovascular disease
-Chronic diseases of the lung, kidneys and liver
-Arthritis
-Thyroid disease, malnutrition, and anemia