OLD AGE PSYCHIATRY

06/1/23
DR. BIRUNGI
OUTLINE
• Definitions
• Background
• Statistics
• Disorders in the elderly
Background

• Provision of specialist and holistic assessment, treatment

and ongoing care for older people experiencing mental
health problems such as dementia, personality disorders
and schizophrenia.
• A patient’s mental health can be affected by any physical
problems they experience, which is why old age
psychiatrists take a holistic approach and need a sound
knowledge of general medicine. Old age psychiatry is
considered the most ‘medical’ of psychiatric specialties.
• 
Background
• You’ll need detailed knowledge of the way in which older people
metabolise medication, since this can change as part of the aging
process. The interaction of physical health medications, as well as the
high rate of polypharmacy (use of multiple medicines) in this population,
means that you’ll also need a high level of pharmacological expertise.
• 
• As part of a holistic approach, you’ll need to understand the legal and
philosophical issues regarding, for example, human rights, end-of-life
decisions and informed consent. As an old age psychiatrist, you’ll balance
clinical decisions with ethics.
Background

• Mental health and social problems often go hand-in-hand. Consequently, you’ll

collaborate widely, for example with clinicians, occupational therapists and
voluntary organisations. 

• The emphasis is on care in the community and delivering care that allows a patient
to remain living at home. You’ll need to work closely with a patient’s family and
carers, promoting independence and choice.

• Mental health problems in older people differ greatly compared to the younger
population. And with an aging population and an increase in dementia and mental
health problems, there is a growing demand for first-class old age psychiatrists.
Statistics
• Worldwide, the proportion of older persons (aged 60 years and
above) stands at 11% and it’s anticipated to double by 2050 (UNDESA
2013).
• In sub-Saharan Africa, older persons comprise 5% of the population
(UNFPA 2012).
• In Uganda, the current population of older persons is estimated at 1.6
million (5% of the population) and it is expected to increase to 5.5
million in 2050 (UBOS and ICF International 2012)
Why?
• Population ageing has become a global concern in the past two
decades (Beard et al. 2015).
• Improvement in the health care systems, decreased fertility rates and
reduction in child mortality have contributed to the phenomenon
(Bloom 2011; Cai 2010).
• There is a remarkable variation across continents, regions and
countries with Western countries contributing to the majority of the
older population (Guzman et al. 2012).
Mental health problems are common among
seniors
• Isolation, affective and anxiety disorders, dementia, and psychosis,
among others. Many seniors also suffer from sleep and behavioral
disorders, cognitive deterioration or confusion states as a result of
physical disorders or surgical interventions.
Triggers

• Chronic pain or other physical health problems

• Reduced mobility
• Social isolation
• Dementia or cognitive decline
• Grief or widowhood
• Malnutrition
• Medication side effects
Why?
• Psychiatric disorders in the elderly include dementia, delirium and
depression. The danger lies not only in the base of the disease, but
also influence the overall health of humans:

• emergence of new diseases,

• worsening of existing disease,
• increasing the frequency of hospitalizations,
• prolongation of hospitalization,
• overall increase in morbidity and mortality.
Common mental health disorders

• Cognitive impairment
• Dementia
• Functional disorders (such as depression or psychosis)
• Organic disorders (such as memory loss)
• Personality disorders
• Schizophrenia
Dementia
• Dementia is a broad term that describes a loss of thinking ability,
memory, attention, logical reasoning, and other mental abilities.
These changes are severe enough to interfere with social or
occupational functioning.

• Many things can cause dementia. It happens when the parts of your
brain used for learning, memory, decision making, and language are
damaged or diseased.
Dementia
• You might also hear it called major neurocognitive disorder. Dementia isn’t
a disease. Instead, it's a group of symptoms caused by other conditions.

• About 5%-8% of adults over age 65 have some form of dementia. This
percentage doubles every 5 years after 65. As many as half of people in
their 80s have some dementia.

• Alzheimer's disease is the most common cause of dementia. Between

60%-80% of people with dementia have Alzheimer's. But there are as
many as 50 other causes of dementia.
Which area is affected?
• Cortical dementias happen because of problems in the cerebral cortex, the outer layer of
the brain. They play a critical role in memory and language. People with these types of
dementia usually have severe memory loss and can't remember words or understand
language. Alzheimer's and Creutzfeldt-Jakob disease are two forms of cortical dementia.

• Subcortical dementias happen because of problems in the parts of the brain beneath the
cortex. People with subcortical dementias tend to show changes in their speed of thinking
and ability to start activities. Usually, people with subcortical dementia don't have
forgetfulness and language problems. Parkinson's disease, Huntington's disease, and HIV
can cause these types of dementia.

• Some types of dementia affect both parts of the brain. For example, Lewy Body dementia is
both cortical and subcortical.
Dementia
• Dementia is a syndrome that can be caused by more diseases,
especially in elderly. It can leads to:

• dehydration,
• malnutrition,
• noncompliance (forgets to take medication),
• loss of self-sufficiency,
• need for help (from family),
• need for institutional care.
Dementia
• Degenerative neurological diseases. These include:

• Alzheimer's disease
• Parkinson's disease
• Huntington's disease
• Some types of multiple sclerosis.

• These diseases get worse over time.

Dementia
• Vascular disorders. These conditions affect the blood circulation in
your brain.

• Traumatic brain injuries caused by car accidents, falls, concussions,

etc.
• Infections of the central nervous system. These include meningitis,
HIV, and Creutzfeldt-Jakob disease.
• Long-time alcohol or drug use
• Certain types of hydrocephalus, a buildup of fluid in the brain
Some reversible causes of dementia include:

• Alcohol or substance use disorder

• Tumors
• Subdural hematomas, blood clots beneath the outer covering of the brain
• Normal-pressure hydrocephalus, a buildup of fluid in the brain
• Metabolic disorders such as a vitamin B12 deficiency
• Low levels of thyroid hormones, called hypothyroidism
• Low blood sugar, called hypoglycemia
• HIV-associated neurocognitive disorders (HAND)
Risk Factors for Dementia

• Certain physical and lifestyle factors can raise your chances of dementia, including:

• Age
• Dementia in your family
• Illnesses including diabetes, Down syndrome, multiple sclerosis, heart disease, and sleep apnea
• Depression
• Smoking, heavy alcohol use, poor diet, and lack of exercise

• Brain injury
• Strokes
• Infection of the brain (for example, meningitis and syphilis)
Symptoms of Dementia

• People with dementia have problems with thinking and remembering that affect their ability to
manage their daily life.

• These are some signs to watch for:

• Short-term memory problems, like forgetting where you put something or asking the same
question over and over
• Communication problems like not being able to come up with a word
• Getting lost
• Trouble with complex but familiar tasks, like fixing a meal or paying bills
• Personality changes, like depression, agitation, paranoia, and mood swings
Stages of Dementia

• Usually, dementia goes through these stages. But it may vary depending on the area of the brain
that’s affected.

• 1. No impairment. Someone at this stage will show no symptoms, but tests may reveal a problem.

• 2. Very mild decline. You may notice slight changes in behavior, but your loved one will still be
independent.

• 3. Mild decline. You'll notice more changes in their thinking and reasoning. They may have trouble
making plans, and they may repeat themselves a lot. They may also have a hard time
remembering recent events.
Stages of Dementia

• 4. Moderate decline. They'll have more problems with making plans and remembering recent
events. They may have a hard time with traveling and handling money.

• 5. Moderately severe decline. They may not remember their phone number or their grandchildren's
names. They may be confused about the time of day or day of the week. At this point, they’ll need
assistance with some basic day-to-day functions, such as picking out clothes to wear.

• 6. Severe decline. They'll begin to forget the name of their spouse. They’ll need help going to the
restroom and eating. You may also see changes in their personality and emotions.

• 7. Very severe decline. They can no longer speak their thoughts. They can't walk and will spend
most of their time in bed.
Dementia Diagnosis

• The doctor will review the patient's history and perform a physical
exam and cognitive testing. Further testing might happen depending
on the history and physical.
 tests

• Blood and urine tests

• Chest X-ray
• Brain scanning (MRI or CT scanning)
• Electroencephalogram (EEG)
• Spinal fluid analysis
Treatment

• To treat dementia, doctors will treat whatever is causing it. About 20% of the causes of dementia are
reversible. If the cause of a person’s dementia is not reversible, treatment will focus on managing
symptoms, particularly agitation and other emotional concerns.

• Aducanumab-avwa (Aduhelm) is the first drug approved by the FDA to treat Alzheimer's disease in
decades. If your loved one is in the early stages of Alzheimer's disease, the most common form of
dementia, their doctor may prescribe this monthly infusion. It's a monoclonal antibody that lessens
the buildup of amyloid plaques in the brain. These plaques are part of what leads to the memory
loss associated with Alzheimer's disease.

• Medicines such as acetylcholinesterase inhibitors (for example, donepezil and galantamine) can
sometimes help to slow the progression of cognitive changes, but quite often the effects of
medicines are only modest and cannot prevent eventual worsening of the underlying condition.
The most often causes of dementia - RECAP:

• Mild cognitive impairment

• Alzheimer's disease
• Vascular –Ischemic dementia
• Dementia with Lewy bodies
• Dementia in Parkinson's disease.
• Lewy body dementia.
• Frontotemporal.
• Creutzfeldt-Jakob.
• Wernicke-Korsakoff.
• Mixed dementia.

• Treatment of Alzheimer's dementia consists primarily in delaying severe stages of disease. Using the brain
acetylcholinesterase inhibitors - donepezil, rivastigmine.
Depression
• Depression in the elderly is generally quite underrated status, which is
based on chronic illness, loss of a loved one (widowhood), life
changing situations, loss of life roles, which is often associated with
moving to a nursing home. As a result of depression leads to
treatment noncompliance (not taking drugs, often intentionally),
dehydration, malnutrition and weight loss on the basis of loss of
appetite. Depression may be presented by sedation or agitation with
aggressive tendencies. In old age also increases the number of
suicides - a jump from heights, hanging. Depression should not be
underestimated, but treated (psychiatric consultation).
Antidepressants in elderly:

• Most preferred are selective serotonin reuptake inhibitors

(sertraline, citalopram),
• Blocking reuptake of serotonin and norepinephrine (SNRI)
• Noradrenergic and specifically serotonergic antidepressants (NASA)
- mirtazapine,
• Unsuitable are tricyclic antidepressants (anticholinergic effects are).
Delirium
• Disturbance of attention (reduced ability to focus, sustain, or shift
attention).
• Develops over a short time (hours or a few days) – a change from
baseline
• attention and awareness, fluctuates in severity in the course of a day.
• An additional disturbance in cognition (such as memory deficit,
disorientation,
• language disturbance).
Delirium
• Delirious states in elderly are often caused by dehydration, change in
environment, or certain drugs (typically antibiotics - florochinolones),
hypoxia, infections, psychosocial stress, but also withdrawal delirium.

• Treatment of acute delirious state:

• adequate hydration,
• neuroleptics - typically tiapridal, risperidone, haloperidol.
Predisposing factors

• Advanced age
• Dementia
• Functional impairment in activities of daily living
• Medical comorbidity
• History of alcohol abuse
• Male gender
• Sensory impairment (blindness, deafness)
Precipitating factors

• • Acute myocardial events

• • Acute pulmonary events
• • Bed rest
• • Fluid and electrolyte disturbance (including dehydration)
• • Drug withdrawal (sedatives, alcohol)
• • Infection (especially respiratory, urinary)
• • Medications (wide range, esp. psychoactive, anticholinergic and opioids)
• • Uncontrolled pain
• • Urinary retention, faecal impaction
• • Indwelling devices (urinary catheters)
• • Severe anaemia
• • Use of restraints
• • Intracranial events (stroke, bleeding, infection)
Pathophysiology

• A range of different pathological circumstances may give rise to

delirium.
• Nevertheless, in more than half the cases, the etiology remains
unknown (Stiefel etal, 1992).
Pathophysiology
• 1. Leaky blood-brain barrier. Recent evidence suggests the blood-brain barrier
• becomes leaky or disrupted as the brain ages, allowing exposure to drugs and
• toxins. Also as a result of distal inflammation.
• 2. Cholinergic deficiency. This is one of the best documented mechanisms. It is
• seen in overdose of anticholinergic drugs, such as atropine. It may also be seen
• with the use of drugs not primarily classified as anticholinergics, but with
• clear cholinergic action: antihistamines, some opioids and antidepressants.
• However, significant anticholinergic activity has been found in the serum of
• patients who are not taking drugs with anticholinergic properties - this
• suggests an endogenous anticholinergic activity may predispose certain
• patients to delirium.
Con’t
• 3. Imbalance of neurotransmitter production. Serotonin is a major CNS
• neurotransmitter. Production depends on transport of tryptophan across the
• blood-brain barrier. Tryptophan competes with the amino acid phenylalanine
• for transport across the blood-brain barrier. Disturbance of the tryptophan:
• phenalanine ratio may increase or decrease the level of serotonin resulting in
• delirium. Disturbance of the tryptophan: phenalanine ratio has been observed
• in post traumatic states and other medical and surgical conditions.
Cont
• 4. Inflammation. Trauma and infection leads to increased production of
• proinflammatory cytokines, which may produce delirium. Peripherally
• secreted cytokines can cause responses from microglia, causing inflammation
• of the brain. Cytokines affect the synthesis and release of a wide range of
• neurotransmitters and also have neurotoxic (Cavallazzi et al, 2013).
• 5. Elevated cortisol. Acute stress has been hypothesized as a cause of delirium.
• This is consistent with the notion that elevated cortisol seen in PTSD results in
• hippocampal shrinkage. The role of cortisol in delirium is under investigation
• (Maclullich et al, 2008).
• 6. Neuronal injury caused by a variety of metabolic or ischaemic insults.
• 7. Other neurotransmitter abnormalities associated with delirium include
• elevated dopamine function (haloperidol is effective in controlling symptoms).
• Possibly, also NA and GABA.