Geriatric Psychiatry

Chapter 56

Geriatric Psychiatry

• derived from the Greek words geros (old age) and iatros (physician)

• deals with preventing, diagnosing, and treating psychological disorders in older adults

• Old age- phase of the life cycle characterized by its own developmental issues– loss of physical agility, and mental acuity, friends

and loved ones, and status and power.

Stressors

• psychiatrists must be able to recognize the physical and mental ills of their patients

• High-ranking stresses of aging include;– acute and chronic medical illnesses– the concomitant use of therapeutic drugs– the complicating drugs “drug and drug- disease

interactions.”• older women are more likely to live alone than

older men

Psychiatric Examination of the Older Patient

• Because of the high prevalence of cognitive disorders in older persons;– psychiatrists must determine whether a patient

understands the nature and purpose of the examination.

• patient still should be seen alone even in cases of clear evidence of impairment– to elicit any suicidal thoughts or paranoid ideation,

which may not be voiced in the presence of a relative

Psychiatric History

• Benign senescent forgetfulness- age associated memory impairments of no significance.

• childhood and adolescent history:– provide information about personality

organization– give important clues about coping strategies and

defense mechanisms used under stress

Mental Status Examination

• offers a cross-sectional view of how a patient – Thinks– feels– behaves during the examination.

General Description

• includes appearance, psychomotor activity, attitude toward the examiner, and speech activity.

• Motor disturbances should be noted• The patient's attitude toward the examiner;

cooperative, suspicious, guarded, can give clues about possible transference reactions.

Functional Assessment

• Patients older than 65 years of age should be evaluated for their capacity to maintain independence and to perform the activities of daily life– which include toileting, preparing meals, dressing,

grooming, and eating.• The degree of functional competence in their

everyday behaviors is an important consideration in formulating a treatment plan for these patients.

Mood, Feelings, and Affect

• Suicide is a leading cause of death of older persons, and an evaluation of a patient's suicidal ideation is essential.

• Loneliness is the most common reason cited by older adults who consider suicide.

• Feelings of loneliness, worthlessness, helplessness, and hopelessness are symptoms of depression, which carries a high risk for suicide.

Perceptual Disturbances

• Hallucinations and illusions by older adults can be transitory phenomena resulting from decreased sensory acuity.

• Because hallucinations can be caused by brain tumors and other focal pathology, a diagnostic workup may be indicated

Language Output

• covers the aphasias, which are disorders of language output related to organic lesions of the brain.

• The best described are nonfluent or Broca's aphasia, fluent or Wernicke's aphasia, and global aphasia.

Visuospatial Functioning

• decline in visuospatial capability is normal with aging

• Asking a patient to copy figures or a drawing may be helpful in assessing the function

Thought

• Disturbances in thinking include neologisms, word salad, circumstantiality, tangentiality, loosening of associations, flight of ideas, clang associations, and blocking

• loss of the ability to appreciate nuances of meaning (abstract thinking) may be an early sign of dementia

Other things to take note of

• Sensorium and Cognition• Consciousness• Orientation• Memory• Intellectual Tasks, Information, and

Intelligence• Reading and Writing• Judgment

Mental Disorders of Old Age

• Dementing Disorders• Depressive Disorders• Schizophrenia• Delusional Disorder• Anxiety Disorders• Somatoform Disorders• Alcohol and Other Substance Use Disorder• Sleep Disorders• Suicide Risk

Other Conditions of Old Age

• Vertigo• Syncope• Hearing Loss• Elder Abuse• Spousal Bereavement

Psychopharmacological Treatment of Geriatric Disorders

• A pretreatment medical evaluation is essential, including an electrocardiogram (ECG).

• It is especially useful to have the patient or a family member bring in all currently used medications– because multiple drug use could be contributing

to the symptoms.

Principles of Psychopharmacological Treatment

• Major goals of the pharmacological treatment of older persons are;– to improve the quality of life– maintain persons in the community– delay or avoid their placement in nursing homes.

Individualization of dosage is the basic tenet of geriatric psychopharmacology.