In the name of God

Geriatric Psychiatry

Mohamad Nadi . MDPsychiatrist

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 illnessMore medicinesCognitive impairmentsIncreased 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

prevalence of delirium

Delirium Prevalence in Multiple Settings

Population Prevalence Range (%)

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

N/A, not available.

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 mortalityIncreased nursing careIncreased length of stayIncreased risk of cognitive declineIncreased risk of functional

decline

Burden of Delirium

Delay in postoperative mobilizationPrevention of early rehabilitationIncreased need for home care

servicesIncreased distress to caregiversBarrier to psychosocial closure in

terminally ill patient

Etiologies of Delirium in Elderly Patients

Systemic illnessesInfections: Pneumonia, urinary tract infection, sepsis, influenza

Cardiovascular conditions: Arrhythmia, congestive heart failure, myocardial infarction, severe hypertension

Etiologies of Delirium in Elderly Patients

MedicationsAnticholinergicsBenzodiazepines, other sedative-hypnotics (e.g., barbiturates)Antiarrhythmics, DigoxinCertain antibiotics (e.g., fluoroquinolones, clarithromycin)Interferons

Etiologies of Delirium in Elderly Patients

Primary brain diseases

Stroke or transient ischemic attackTrauma: Brain injury, subdural

hematomaInfection/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 traumaHip fracture repairOpen 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

familyReorient frequentlyTry 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

ChangesCognition, memory, languagePersonality, abstract thinking, aphasiasHowever, 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 explosivenessDelusions 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 olderMore 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 typeCan 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

HypothyroidismWilson’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 causesUse 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 65Usually more irritable than euphoric,

and paranoid rather than grandioseMay 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 commonResidual type occurs in 30% of those

affected: Emotional blunting, social withdrawal, eccentric behavior, and illogical thinking predominate

Delusional Disorder

Onset between 40 and 55Persecutory or somatic delusions

most commonMay be precipitated by stress,

loss, social isolation , visual impairment, deafness, immigrant status

Anxiety Disorders

Very common in elderlyMay occur first time after age

60, but not usuallyMost common are phobias,

especially agoraphobiaMay be due to medical causes or

depression

Substances and Alcohol

Brain is more sensitive as agesDue 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