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 Prevalence Range (%)
delirium
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 mortality
 Increased nursing care
 Increased length of stay
 Increased risk of cognitive decline
 Increased 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 sedative-hypnotics
(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 long-acting
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