Mental Health Problems of       Older AdultsDr. Peter Brown RN, DNE, BA Hons,MA, PhD, FRCNA, ACMHNAssociate ProfessorActin...
Mental Health Problems in Old             Age1. Mental health problems which occur at a   younger age and carry over into ...
DeliriumDSM IV-TR• a) Disturbed consciousness, reduced ability     to focus, sustain, shift attention• b) Change in cognit...
DeliriumDSM IV (Cont’d)d) History, physical examination, lab findings:  - related to a general medical    condition; or  -...
Delirium in Older AdultsIntroduction - results of systematic review• Often overlooked & misdiagnosed• Poorly recognised by...
Delirium• Confusion may be obvious or not so  obvious (‘Quiet’ confusion)• Acute confusion (Delirium)• Chronic confusion (...
DeliriumWhy does it occur in older adults? Disruptions to neurological pathways &  neurotransmitter systems; Medications...
Disruptions to neurological pathways &       neurotransmitter systems
Delirium: Predisposing factors•   Age 70 years & over•   Pre-existing cognitive impairment•   Severe medical illness; infe...
DeliriumMedications• 25% -31% of all medication  use over 65 years of age• 60-90% community elderly  use medication• Over ...
DeliriumEnvironmental Causes- Restraints- Unfamiliar environment- Sensory deprivation- Sensory overload- Sleep deprivation
ASSESSMENT: HOW TO RECOGNISE DELIRIUM• Obtain an accurate history• Ongoing assessment to check variability• Abbreviated Me...
DELIRIUM                           DEMENTIAONSET         acute                              usually insidiousDURATION     ...
Nursing Management1) Environment – as quiet as possible, reduce   stimulation; safety; not too restrictive;   night light2...
Nursing Management3) Protective needs – over-activity; injury;   exhaustion; impulsivity; aggression; observation;   speci...
Delirium: ManagementPatients experiencing severe behavioural &/or  emotional symptoms  - one on one nursing  - encourage f...
Delirium: Management1. Discharge planning & follow-up- Patient & family education- Follow-up, professional monitoring &  t...
DementiaDementia is a syndrome (has lots of symptoms)which is acquired (genetic or age-related),chronic (lasts months or y...
DEMENTIATypes:•   Alzheimer’s (53%)•     Vascular dementia (17%)•    Alzheimer’s and Vascular dementia  (19%)•     Parkins...
DEMENTIA (con’t)Dementia facts1. 2001 – 210,000 60 yrs & over - mod. To  severe dementia2. Nos. are expected to increase b...
ALZHEIMER’S DISEASEDSM IV(1) multiple cognitive deficits (eg. memory     loss)(2) 1 or more of following:      * aphasia –...
ALZHEIMER’S DISEASE           (con’t)(3) (1) & (2) cause significant impairment in     social & occupational functioning(4...
Alzheimer’s disease (con’t)Levels1. Mild   - 2 to 4 yrs; lack spontaneity;   - 120,000; most at home   - poor decision mak...
ALZHEIMER’s DISEASE          (con’t)2. Moderate   - 4-7 yrs from onset; 2 to 10 years   - forgets to eat; wanders; forgets...
ALZHEIMER’S DISEASE          (cont’d)3. Severe   - 7-10 yrs from onset; 3 or more years   - dependent on care; unable to f...
ALZHEIMER’S DISEASE           (con’t)** Exact cause is unknown1. Genetic:   - non-identical twins - 8% risk    - identical...
ALZHEIMER’S DISEASE           (con’t)Risk factors1. Increasing age - prevalence doubles every 5  years (eg. 60-64 - .7%; 6...
ALZHEIMER’S DISEASE           (con’t)Histologic features1. Neurofibrillary tangles   - consist of protein tau - found insi...
Plaques and Tangles
ALZHEIMER’S DISEASE           (con’t)2. Senile plaques   - deposits of amyloid protein in the spaces      between nerve ce...
Shrinkage of Hippocampus
ALZHEIMER’S DISEASE           (con’t)Neuroimaging in AD1. CT - increased ventricular size & cortical         atrophy2. MRI...
Positron Emission Tomography (PET) of   a person with Alzheimer’s disease
Single-photon emissioncomputerised tomography
ALZHEIMER’S DISEASE           (con’t)2 or more diseases1. Early onset   - more aphasia, apraxia, agnosia,     more rapid r...
ALZHEIMER’S DISEASE           (con’t)Neuropsychological deficits in AD1. Memory - encoding & retention; for               ...
ALZHEIMER’S DISEASE            (con’t)Behavioural Symptoms1. Personality change; depression2. Wandering; suspiciousness; d...
VASCULAR DEMENTIADSM IV-R1. As for AD (1), (2), (3)2. Focal neurological signs & symptoms   or laboratory evidence3. Stepw...
Vascular dementia: Clinical features1. Second most common cause of dementia2.Gait disturbance; unsteadiness & falls
Vascular dementia: Clinical Features3. Urinary frequency & urgency4.Depression, emotional lability5. Psychomotor slowing6....
VASCULAR DEMENTIA          (con’t)1. 25% of patients with cerebrovascular  disease develop demented2. Cognitive impairment...
VASCULAR DEMENTIA          (con’t)Aetiology1. Occlusion of major cerebral artery2. Minor multiple infarctions3. Small vess...
DEMENTIA (con’t)DEMENTIAEarly warning signs1. Memory - recalling data, recall events,     losing items, repetitive questio...
DEMENTIA (con’t)3. Behavioural changes - withdrawal &/or  inertia; inflexible attitude; irritability;   reduced planning &...
DEMENTIA (con’t)Diagnostic process for dementia1. Serious cognitive loss or normal ageing?2. Is the cognitive loss psychia...
DEMENTIA (con’t)Challenging Behaviours Related to Dementia* Wandering* Sleep disturbances* Eating disorders* Agitation; Ag...
LEWY BODY DISEASEA syndrome in which Parkinsonismoverlaps with features of Alzheimer’sdisease & psychiatric phenomena. Bra...
Lewy Body
COGNITIVE SYNDROMES  ASSOCIATED WITH LB DISEASELewy body variant of AD/SD of the LB type1. Onset after 65 yrs of age2.Mild...
Drug Therapy and DementiaDrug Therapy1. Age-related decline2. Favourite drugs3. Low initial dose; incremental increase5. H...
The Carer: The ‘Second Patient’* primary carer, eg. wife, adult daughter* physical, social & financial burdens;  depressiv...
Dementia: Legal IssuesLegal Issues* loss of capacity to consent treatment -  need to obtain permission to continue  treatm...
Dementia: Legal aspectsDriving1. Mild dementia - ask to stop driving or   confine themselves to familiar routes2. Mod. To ...
Alzheimer’s Disease:           Pharmacological1. Cholinesterase boosters:  - Donepezil; Exelon; Rivastigmine;    Galantami...
Vascular Dementia:Treatment• No drugs as such• Treatment of stroke risk factors (eg.  smoking & hyperlipidemia; diabetes, ...
Depression in Old Age# Depression in older people is under-  researched# As common in old age as for other groups# Complex...
Depression in Old Age: Risk             Factors# Most common mental illness in older adults (40%  of all new cases)# Risk ...
Depression in Old Age: Risk Factors              (cont’d)  6.   Physical illness  7.   Pain & disability  8.   Substance a...
Depression in Old Age: SequelaeSequelae:  - unnecessary suffering  - excess physical & social disability  - exacerbation o...
Depression in Old Age: Severe Depression1. Major depressive disorder & Bipolar   Depression   - feeling of despair; hopele...
Depression in Old Age: Moderate         Depression (Dysthymia)Dysthymia• Feelings of sadness; dejection; low self-  esteem...
Depression in Old Age: PTSDPost-traumatic Stress Disorder - upsetting event - fear, helplessness, horror - event is persis...
Depression in Older AdultsDepression in older adults- Common in elderly living at home- Common in nursing homes- 60% inapp...
Depression in Old Age:           AssessmentAssessment Traps - physical illness may cause identical   features - physical i...
Depression in Old Age:          AssessmentAssessment Traps - ‘pseudodementia’ - depression & dementia occurring   together...
Depression in Old Age:           AssessmentAssessment: History - look depressed’? - decreased thought & movement - ‘frozen...
Depression In Old Age: SuicideAssessment: Suicidal ideas - don’t be afraid to ask about suicidal   thoughts - look for the...
Depression in Old Age: SuicideAssessment: Suicide The following are not necessarily suicidal ideas: - older people are pre...
Depression in Old Age:             Treatments•   Antidepressants               +++•   ECT                           +++•  ...
Nursing Management•   Observation (eg. for suicide)•   Safety issues•   Food and fluids•   Constipation•   Patient/Family ...
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Delirium, dementia, depression

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  • 10 – 15% of older people entering hospital 5-40% develop delirium while in hospital 30-40% pts in surgical wards 37-72% never recognised by drs. and nurses Higher mortality rates; longer stays in hospital; more nursing hours – greater cost
  • * Younger age in Indigenous population
  • HOW TO RECOGNISE DELIRIUM OBTAIN AN ACCURATE HISTORY - What has changed?, eg. new medication, infection, dehydration, constipation ONGOING ASSESSMENTS TO CHECK VARIABILITY, does clinical picture fluctuate MINI MENTAL STATUS EXAMINATION (MMSE) IDENTIFIES COGNITIVE IMPAIRMENT
  • DELIRIUM DEMENTIA ONSET acute usually insidious DURATION usually < 1 month at least 1 month usually much longer ORIENTATION faulty, at least for a time; may be correct in mild tendency to mistake cases unfamiliar with familiar THINKING disorganised impoverished MEMORY recent impaired both recent and remote impaired ATTENTION invariably disturbed, may be intact hard to direct or sustain AWARENESS always reduced, tends to usually intact fluctuate during daytime & be worse at night ALERTNESS increased or decreased normal or decreased PERCEPTION misinterpretations often misinterpretations often present absent SLEEP/WAKEFUL always usually normal for age
  • Delirium, dementia, depression

    1. 1. Mental Health Problems of Older AdultsDr. Peter Brown RN, DNE, BA Hons,MA, PhD, FRCNA, ACMHNAssociate ProfessorActing Head, School of HealthCharles Darwin University
    2. 2. Mental Health Problems in Old Age1. Mental health problems which occur at a younger age and carry over into old age2. Mental health problems occurring in old age, eg. delirium, dementia, depression3. Old age, people 65 years and over
    3. 3. DeliriumDSM IV-TR• a) Disturbed consciousness, reduced ability to focus, sustain, shift attention• b) Change in cognition or perceptual disturbance• c) Develops over a short period of time & fluctuates over the day
    4. 4. DeliriumDSM IV (Cont’d)d) History, physical examination, lab findings: - related to a general medical condition; or - symptoms related to substance intoxication; or - medication use
    5. 5. Delirium in Older AdultsIntroduction - results of systematic review• Often overlooked & misdiagnosed• Poorly recognised by nurses• Nurses perform superficial mental status assessments• Documentation of patients’ cognitive status is seldom accurate (Steis & Flick, 2008)
    6. 6. Delirium• Confusion may be obvious or not so obvious (‘Quiet’ confusion)• Acute confusion (Delirium)• Chronic confusion (Dementia)• Acute on chronic (Delirium on Dementia) eg. Older person with dementia experiences a urinary tract infection
    7. 7. DeliriumWhy does it occur in older adults? Disruptions to neurological pathways & neurotransmitter systems; Medications interfere with cholinergic neurotransmission Pathophysiology is not well understood;
    8. 8. Disruptions to neurological pathways & neurotransmitter systems
    9. 9. Delirium: Predisposing factors• Age 70 years & over• Pre-existing cognitive impairment• Severe medical illness; infection• Depression (subjective confusion)• Abnormal sodium levels• Visual impairment• 3 or more medications• Surgical procedures
    10. 10. DeliriumMedications• 25% -31% of all medication use over 65 years of age• 60-90% community elderly use medication• Over 50% take more than one medication• On average 2-4 medications
    11. 11. DeliriumEnvironmental Causes- Restraints- Unfamiliar environment- Sensory deprivation- Sensory overload- Sleep deprivation
    12. 12. ASSESSMENT: HOW TO RECOGNISE DELIRIUM• Obtain an accurate history• Ongoing assessment to check variability• Abbreviated Mental Test (AMT)• Confusion Assessment Method (CAM) - When – Day 1, 6 and after discharge - Patients considered at high risk - All patients over 75 - Sudden change in behaviour or cognition
    13. 13. DELIRIUM DEMENTIAONSET acute usually insidiousDURATION usually < 1 month at least 1 month usually much longerORIENTATION faulty, at least for a time; may be correct in mild tendency to mistake cases unfamiliar with familiarTHINKING disorganised impoverished (thinking is reduced)MEMORY recent impaired both recent and remote impairedATTENTION invariably disturbed, may be intact hard to direct or sustainAWARENESS always reduced, tends to usually intact fluctuate during daytime & be worse at nightALERTNESS increased or decreased normal or decreasedPERCEPTION misinterpretations often present misinterpretations often absentSLEEP/WAKE- always usually normal for ageFULNESS
    14. 14. Nursing Management1) Environment – as quiet as possible, reduce stimulation; safety; not too restrictive; night light2) Physical needs – adequate nutrition and fluids; oral hygiene; care of skin & oral hygiene; bowels; observations; comfort needs3) Non-pharmacological strategies
    15. 15. Nursing Management3) Protective needs – over-activity; injury; exhaustion; impulsivity; aggression; observation; specialling; reduce restraints4) Orientation needs – reality orientation; clocks & calendars; providing information; speak in clear voice; identify self & context, others & the person by name; glasses & hearing aids; personal mementos; sustained nursing interactions (at least 10 minutes);
    16. 16. Delirium: ManagementPatients experiencing severe behavioural &/or emotional symptoms - one on one nursing - encourage family members attendance - consistent staff members - specialised delirium rooms - expert psychiatric consultation - caution with antipsychotic medication
    17. 17. Delirium: Management1. Discharge planning & follow-up- Patient & family education- Follow-up, professional monitoring & treatment- Post-delirium counselling2. Staff education
    18. 18. DementiaDementia is a syndrome (has lots of symptoms)which is acquired (genetic or age-related),chronic (lasts months or years), global (not justmemory problems), impairment of higherbrain function (frontal, parietal & temporal lobeinvolvement) in an alert patient (looks okay)which interferes with the ability to copewith daily living
    19. 19. DEMENTIATypes:• Alzheimer’s (53%)• Vascular dementia (17%)• Alzheimer’s and Vascular dementia (19%)• Parkinson’s disease (10%) • Diffuse Lewy Body Disease (up to 30%)• Fronto-temporal dementia (up to 10%)
    20. 20. DEMENTIA (con’t)Dementia facts1. 2001 – 210,000 60 yrs & over - mod. To severe dementia2. Nos. are expected to increase by 65% by year 2040 (460,000)2. Prevalence of mod.-severe 4% for 60+; 16% for 80+; 24% for 85+
    21. 21. ALZHEIMER’S DISEASEDSM IV(1) multiple cognitive deficits (eg. memory loss)(2) 1 or more of following: * aphasia – difficulty taking in info * apraxia – inability to carry out purposive activities * agnosia – inability to recognise ‘things’
    22. 22. ALZHEIMER’S DISEASE (con’t)(3) (1) & (2) cause significant impairment in social & occupational functioning(4) gradual onset & continuing cog. decline(5) not due to other CNS condition or systematic condition(6) doesn’t occur during course of delirium(7) not another Axis I disorder, eg. depression
    23. 23. Alzheimer’s disease (con’t)Levels1. Mild - 2 to 4 yrs; lack spontaneity; - 120,000; most at home - poor decision making; memory changes - repetitious - blame others when things go wrong
    24. 24. ALZHEIMER’s DISEASE (con’t)2. Moderate - 4-7 yrs from onset; 2 to 10 years - forgets to eat; wanders; forgets names - neglects personal hygiene - forgetful of recent events - easily frustrated - just over half live in community
    25. 25. ALZHEIMER’S DISEASE (cont’d)3. Severe - 7-10 yrs from onset; 3 or more years - dependent on care; unable to feed - unable to recognise others - wanders - aggressive
    26. 26. ALZHEIMER’S DISEASE (con’t)** Exact cause is unknown1. Genetic: - non-identical twins - 8% risk - identical twins - 43% - Down’s syndrome >35 yrs of age - Chromosome 14 & 21 (early onset, familial) - Chromosome 19 - late onset
    27. 27. ALZHEIMER’S DISEASE (con’t)Risk factors1. Increasing age - prevalence doubles every 5 years (eg. 60-64 - .7%; 65-69 – 1.4% etc)2. Family history - increased risk 2-4 fold3. Sex - women at greater risk than men4. Head trauma - increases risk5. Education - lower level of  greater risk
    28. 28. ALZHEIMER’S DISEASE (con’t)Histologic features1. Neurofibrillary tangles - consist of protein tau - found inside nerve cells (resembles pairs of threads wound around each other in a helix)
    29. 29. Plaques and Tangles
    30. 30. ALZHEIMER’S DISEASE (con’t)2. Senile plaques - deposits of amyloid protein in the spaces between nerve cells - swollen nerve terminals - found in hippocampus & cerebral cortex3. Neuronal loss/synaptic loss - 90% in hippocampus - correlated with number of tangles & duration & severity of AD
    31. 31. Shrinkage of Hippocampus
    32. 32. ALZHEIMER’S DISEASE (con’t)Neuroimaging in AD1. CT - increased ventricular size & cortical atrophy2. MRI - hippocampal atrophy3. SPECT - temporoparietal hypofusion4. PET - temporoparietal & frontal hypometabolism (glucose)
    33. 33. Positron Emission Tomography (PET) of a person with Alzheimer’s disease
    34. 34. Single-photon emissioncomputerised tomography
    35. 35. ALZHEIMER’S DISEASE (con’t)2 or more diseases1. Early onset - more aphasia, apraxia, agnosia, more rapid rate of progress; family history2. Late onset - more muscle rigidity, gait disorder
    36. 36. ALZHEIMER’S DISEASE (con’t)Neuropsychological deficits in AD1. Memory - encoding & retention; for visuospatial skills2. Visuospatial functioning3. Word store; comprehension; reading4. Problem solving; Flexibility; Awareness5. Praxis; Anosognosia (lack of awareness of illness
    37. 37. ALZHEIMER’S DISEASE (con’t)Behavioural Symptoms1. Personality change; depression2. Wandering; suspiciousness; delusions3. Hallucinations; disruption of sleep/wake cycle4. Inappropriate behaviour, sexual disinhibition5. Controlling emotions
    38. 38. VASCULAR DEMENTIADSM IV-R1. As for AD (1), (2), (3)2. Focal neurological signs & symptoms or laboratory evidence3. Stepwise deteriorating course with patchy distribution of deficits
    39. 39. Vascular dementia: Clinical features1. Second most common cause of dementia2.Gait disturbance; unsteadiness & falls
    40. 40. Vascular dementia: Clinical Features3. Urinary frequency & urgency4.Depression, emotional lability5. Psychomotor slowing6. Abnormal executive functioning
    41. 41. VASCULAR DEMENTIA (con’t)1. 25% of patients with cerebrovascular disease develop demented2. Cognitive impairment & dementia depend on: a. extent of area of infarction b. location of lesions, their bilaterality & volume rather than their cause
    42. 42. VASCULAR DEMENTIA (con’t)Aetiology1. Occlusion of major cerebral artery2. Minor multiple infarctions3. Small vessel disease - white matter4. Perfusion disturbances - cardiac arrest5. Cerebral haemorrhage
    43. 43. DEMENTIA (con’t)DEMENTIAEarly warning signs1. Memory - recalling data, recall events, losing items, repetitive questioning2. Cognitive problems - problems with complex activities, difficulty recognising familiar people & objects, language problems
    44. 44. DEMENTIA (con’t)3. Behavioural changes - withdrawal &/or inertia; inflexible attitude; irritability; reduced planning & decision making4. Specific incidents - confusion while on holiday; inability to recognise familiar faces; neglect of long-established behaviours
    45. 45. DEMENTIA (con’t)Diagnostic process for dementia1. Serious cognitive loss or normal ageing?2. Is the cognitive loss psychiatric in origin?3. Is it attributed to delirium?4. Does it affect more than one part of the brain?5. If dementia - what is the underlying condition?
    46. 46. DEMENTIA (con’t)Challenging Behaviours Related to Dementia* Wandering* Sleep disturbances* Eating disorders* Agitation; Aggression* Sexual inappropriateness* Other?
    47. 47. LEWY BODY DISEASEA syndrome in which Parkinsonismoverlaps with features of Alzheimer’sdisease & psychiatric phenomena. Brainpathology shows Lewy bodies identical tothose in Parkinson’s Disease but scatteredthroughout the cortex
    48. 48. Lewy Body
    49. 49. COGNITIVE SYNDROMES ASSOCIATED WITH LB DISEASELewy body variant of AD/SD of the LB type1. Onset after 65 yrs of age2.Mild extrapyramidal signs; unexplained falls; hallucinations4.Dementia precedes or accompanies motor symptoms5. Neuroleptic sensitivity
    50. 50. Drug Therapy and DementiaDrug Therapy1. Age-related decline2. Favourite drugs3. Low initial dose; incremental increase5. Hypnotics for night wandering6.Neuroleptics7.Anti-depressants (?); Review regularly
    51. 51. The Carer: The ‘Second Patient’* primary carer, eg. wife, adult daughter* physical, social & financial burdens; depressive disorders (up to 30%)* need to be vigilant about their health* Alzheimer’s Association* respite, day care
    52. 52. Dementia: Legal IssuesLegal Issues* loss of capacity to consent treatment - need to obtain permission to continue treatment from carer or guardian* assign enduring power of attorney early in the illness* alter Will early in illness
    53. 53. Dementia: Legal aspectsDriving1. Mild dementia - ask to stop driving or confine themselves to familiar routes2. Mod. To Severe - ‘DO NOT DRIVE’3. Dispute - refer to local RTA4. If endanger others through work - drs, engineers
    54. 54. Alzheimer’s Disease: Pharmacological1. Cholinesterase boosters: - Donepezil; Exelon; Rivastigmine; Galantamine2. Non-cholinesterase inhibitors: - ginko biloba; vitamin E; NSAIs
    55. 55. Vascular Dementia:Treatment• No drugs as such• Treatment of stroke risk factors (eg. smoking & hyperlipidemia; diabetes, hypertension)• Galantamine ( a memory enhancing drug)
    56. 56. Depression in Old Age# Depression in older people is under- researched# As common in old age as for other groups# Complex interplay between vascular factors, physical illness, disability, socio-cultural risk factors (eg. Unemployment; divorce)
    57. 57. Depression in Old Age: Risk Factors# Most common mental illness in older adults (40% of all new cases)# Risk factors: 1. Female gender 2. Divorced or separated 3. Low socioeconomic status 4. Poor social supports 5. History of depression
    58. 58. Depression in Old Age: Risk Factors (cont’d) 6. Physical illness 7. Pain & disability 8. Substance abuse 9. Medication 10. Personality 11. Grief
    59. 59. Depression in Old Age: SequelaeSequelae: - unnecessary suffering - excess physical & social disability - exacerbation of co-existing illness - earlier death (eg. Suicide) - overuse of services
    60. 60. Depression in Old Age: Severe Depression1. Major depressive disorder & Bipolar Depression - feeling of despair; hopelessness; apathy - delusional thinking; inability to concentrate; suicidal thoughts - sluggish digestion; constipation; amenorrhoea; urinary retention; anorexia; weight loss
    61. 61. Depression in Old Age: Moderate Depression (Dysthymia)Dysthymia• Feelings of sadness; dejection; low self- esteem; difficulties experiencing pleasure• Psychomotor retardation; slowed speech; self- destructive behaviour• Retarded thinking; difficulty thinking; sleep disturbances; decreased libido; low energy levels
    62. 62. Depression in Old Age: PTSDPost-traumatic Stress Disorder - upsetting event - fear, helplessness, horror - event is persistently experienced - avoidant of stimuli - increased arousal - many depressive symptoms
    63. 63. Depression in Older AdultsDepression in older adults- Common in elderly living at home- Common in nursing homes- 60% inappropriately or inadequately treated- Associated with treatment refusal- Treatable
    64. 64. Depression in Old Age: AssessmentAssessment Traps - physical illness may cause identical features - physical illness can trigger depression - response to physical illness seen as a natural response but may need anti- depressants
    65. 65. Depression in Old Age: AssessmentAssessment Traps - ‘pseudodementia’ - depression & dementia occurring together - assuming that the current picture has been present for a long time/short time
    66. 66. Depression in Old Age: AssessmentAssessment: History - look depressed’? - decreased thought & movement - ‘frozen’ face (expression- less) - ‘Omega’ sign (fixed, furrowed forehead)
    67. 67. Depression In Old Age: SuicideAssessment: Suicidal ideas - don’t be afraid to ask about suicidal thoughts - look for the right moment to ask - “Do you sometimes feel that life is not worth living?” - if the answer is “yes” try to explore
    68. 68. Depression in Old Age: SuicideAssessment: Suicide The following are not necessarily suicidal ideas: - older people are prepared to talk about death in general - content to go when time comes - inpatient for the time to come
    69. 69. Depression in Old Age: Treatments• Antidepressants +++• ECT +++• CBT +++• Interpersonal psychotherapy ++• Psychodynamic psychotherapy ++• Reminiscence ++• Exercise ++
    70. 70. Nursing Management• Observation (eg. for suicide)• Safety issues• Food and fluids• Constipation• Patient/Family education• Medication

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