Geriatric Psychiatry Anita S. Kablinger MD Associate Professor Psychiatry and Pharmacology
Differentiate between the various cognitive disorders
Know aspects of normal aging
Gain knowledge of the best treatment options for geriatric psychiatric illnesses
Why is it a subspecialty?
Mental disorders may have different manifestations, pathogenesis, and pathophysiology from younger adults
Coexisting chronic medical illness
Increased risk for social stressors, including retirement and widowhood
Geriatric population increasing
2000, estimated that 1 in 5 Americans were over 55 years of age, and 13% over 65 years of age
By 2050, estimates are that 22% will be over the age of 65, and 5% over age 85.
Aging and the Life Cycle (Erickson)
Young adulthood--intimacy versus isolation
Middle-aged--generativity versus self-absorption
Elderly--Integrity versus despair (Acceptance of mortality, satisfaction with one’s meaning in the world)
Fear of death is usually a mid-life issue
Other tasks of elderly
Reminiscence is normative
On-time normative incidents do not usually result in crisis
Fears are usually pain, disability, abandonment, and dependency
Cognition and aging
Cognition includes learning, memory, & intelligence
Learning is the ability to gain new skills and information. It may be slower in elderly, especially verbal learning.
Cognition and aging (continued)
Memory is divided into immediate, short- and long- term memory. Immediate memory remains intact.
Short-term memory is also intact, however, it is 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
Ability to use information in an adaptive way or to apply knowledge to specific circumstances
Crystallized intelligence includes vocabulary, verbal skills, and general information can continue to increase throughout life.
Fluid intelligence consists of recognizing new patterns and creative problem solving. This peaks in adolescence.
Benign senescent forgetfulness
Age associated mild memory problems. May also have cognitive problems due to anxiety.
Examples are forgetting names, misplacing items, and experiencing difficulty with complex problem-solving.
(aging-associated cognitive decline)
See patient alone to assess for suicidal/homicidal ideation even if cognitively impaired
May need info from caretaker
May take extended time due to slower response time
Other important aspects of history
Family history--Alzheimer’s disease is transmitted as an autosomal dominant trait in 10-30% of the offspring of parents with Alzheimer’s disease
Review of all meds, over the counter, prescribed, herbal
Alcohol and substance abuse history
mood, feelings, affect
witzelsucht is caused by frontal lobe dysfunction and is the tendency to make puns and jokes and laugh aloud at them
may be transitory resulting from decreased sensory acuity
types of agnosia (the inability to recognize and interpret the significance of sensory impressions: the denial of illness (anosognosia), the denial of a body part (atopognosia); or the inability to recognize objects (visual agnosia) or faces (prosopagnosia)
nonfluent or Broca’s aphasia--understanding intact but can not speak, speech may be telegraphic
fluent or Wernicke’s aphasia
ideomotor apraxia--can not demonstrate use of simple objects
Visuospatial functioning--some decline is normal with age
MMSE affected by educational level
median score for 9-12 yrs of school is 26, high school diploma 28
less sensitive in those with high intelligence, and less specific with those below average intelligence
MMSE is not used to make a formal diagnosis
WAIS-R vocabulary holds up with age. Performance part is a more sensitive indicator of brain damage than the verbal part.
Depression can impair psychomotor performance, especially visuospatial functioning and timed motor performance. The Geriatric Depression Scale is a useful screening instrument that excludes somatic complaints from its list of items.
Mental Disorders of old age
Most common: depressive disorders, cognitive disorders, phobias, and alcohol use.
High risk of suicide
Risk factors include loss of social roles, loss of autonomy, deaths, declining health, increased isolation, financial constraints, and decreased cognitive functioning.
Psychiatric disorders due to a Medical Condition
Replaces the term “organic disorders”
Note that major psychiatric illnesses may also have changes in cognition, but they are not called cognitive disorders
Usually acute and fluctuating
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
Features of delirium
May be accompanied by hallucinations, illusions, emotional lability, alterations in the sleep-wake cycle, psychomotor slowing or hyperactivity
Causes of Delirium— I WATCH DEATH
Acute metabolic Acute vascular
CNS Pathology Heavy Metals
Note that prescribed medicines may cause delirium
Treatment of delirium
Look for underlying cause “always be suspicious”
Close supervision, especially by family
Treatment of delirium (continued)
Use consistent personnel
Try not to use restraints, as it can worsen confusion.
Medication only if behavioral attempts fail
Low dose neuroleptic is treatment of choice, unless the delirium is due to withdrawal. If due to withdrawal, use a short-acting benzodiazepine.
May be multifactorial
Postcardiotomy delirium occurs 3 or 4 days after surgery
Changes in dementia
Cognition, memory, language
Personality change, abstract thinking, aphasias
However, level of awareness and alertness usually intact in early stages (differentiates dementia from delirium)
Chronic, versus acute
Differs from delirium and dementia because major problem is short-term memory only.
Impairment may be due to hemorrhage in mamillary bodies, or degenerative changes in the dorsal medial nucleus of the thalamus
Most common cause is alcoholism
Transient global amnesia
Transient inability to learn new info
Variable retrograde amnesia that “shrinks” following recovery
Level of conscousness and personal identity intact
Due to transient vascular insufficiency of the mesial temporal lobe, or medicines, tumors, arrhythmias, cerebral embolism
Also have risk problems for stroke
Follows a history of head trauma resulting in cerebral concussion
LOC, posttraumatic amnesia, less commonly, post-traumatic seizures
Impairment in attention, concentration, performing simultaneous cognitive tasks, and in learning new information, or recalling information shortly after the injury
Not a form of dementia
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
Most common causes: Alzheimer’s disease, vascular dementia, alcoholism, and a combination of these 3
Risk factors are age, family history, and female sex
Noncognitive symptoms accompanying dementia
Mood disorders--dementia and depressive symptoms can coexist and the depression responds to treatment
Pathological laughter and crying occurs
Irritability and explosiveness
Other noncognitive symptoms in dementia
Excessive emotional outbursts that occur after task failure are “catastrophic reactions” and can be avoided by educating family members to avoid confrontation
Delusions or hallucinations occur during the course of dementias in nearly 75%