Psychological issues in elderly


Published on

theories of ageing and psychological disorders in elderly

Published in: Health & Medicine
No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Psychological issues in elderly

  1. 1. Dr. DOHA RASHEEDY ALY Lecturer of Geriatric MedicineDepartment of Geriatric and Gerontology Ain Shams University
  2. 2. Ageing Aging is a process of general, irreversible, and progressive physical deterioration that occurs over time.This process usually occurs after sexual maturation and continues up to the time of maximum longevity (life span) for members of a species.Death is the final event.
  3. 3.  Biologically, ageing is defined as a deteriorative process. Socially too, ageing appears as a time of loss of roles and relationships. Thus it is not surprising that consideration of adjustment should have such a prominent role in the psychological study of ageing.
  4. 4.
  5. 5. Definition (Conceptual) Normal Ageing  without biological or mental pathologyOptimal Ageing’ Successful ageing’  Ageing under development enhancing and age-friendly environmental conditionsPathological Ageing  Ageing process determined by pathological processes.
  6. 6. Conceptions of Age  Chronological age—number of years elapsed since person’s birth Biological age—age in terms of biological health Psychological age—individual’s adaptive capacities Social age—social roles and expectations related to person’s age
  7. 7. Theories of ageing  Aging processes occur at the biological, psychological and social levels. There are any number of different theories of aging, which are generally specific to each discipline. The truth is, no one is really certain why we age, although we are beginning to identify different processes which regulate or govern the rate of aging.
  8. 8. Psychological Theories of ageing Life span Selective optimization: Socioemotional selectivity Cognition and aging Personality and aging
  9. 9. Life Span Development Theory  Life-Course Theories ·Eriksons developmental stages, which here approaches maturity as a process. Within each stage the person faces a crisis or dilemma that the person must resolve to move forward to the next stage, or not resolve which results in incomplete development
  10. 10.
  11. 11. Psychological Theories of ageing  Life spanSelective optimization: Socioemotional selectivity Cognition and aging Personality and aging
  12. 12. Selective Optimization With Compensation Theory  Optimization = Engagement in behaviors that will enrich ones life and help people age successfully.
  13. 13. Psychological Theories of ageing  Life span Selective optimization:Socioemotional selectivity Cognition and aging Personality and aging
  14. 14. Socioemotional Selectivity Theory  The theory that social exchanges and interactions are reduced over time. As one ages a person may become more selective with whom they choose to spend their time with. Emotional closeness may become more important with significant others. The idea to which one can selectively choose with whom they want to dedicate their time for becomes more important as ones ages. * (quality verses quantity)
  15. 15. Psychological Theories of ageing  Life span Selective optimization: Socioemotional selectivityCognition and aging Personality and aging
  16. 16. Cognitive and Aging Theories  ―The theory of cognition is the age-related decline in fluid cognitive performance (the efficiency or effectiveness of performing tasks of learning, memory, reasoning and spatial abilities.) However, crystallized abilities are more stable across the life span and may even increase with age. (Representing social cultural influences on general world knowledge)‖. (Bonder, 2009)
  17. 17. Cognitive and Aging Theories  Cognitive changes with aging are well documented and affect a broad range of functions. There are at least three fundamental cognitive-processing affected: the speed at which information can be processed, working memory, and sensory and perceptual skill.
  18. 18. Processing Speed  Perhaps the most predictable of all cognitive changes is the reduced speed of information processing and response. Slowed execution of component perceptual and mental operations can affect attention, memory, and decision making and can influence performance even on tasks that have no obvious speed requirements (Salthouse 1996).
  19. 19. Working Memory  Working memory refers to short-term retention and manipulation of information held in conscious memory, Examples include consciously recalling a telephone number long enough to write it down, mentally calculating the sale price of an item that is reduced by 15%. Information fades from working memory within about 2 seconds, so to keep details ―alive‖ for a longer time requires active rehearsal or continuing refocusing of attention. Aging is associated with a decline in working memory skills, especially when active manipulation of information is required (e.g., repeating numbers backward as opposed to forward). Reductions in working memory, in turn, place limits on other complex cognitive skills, including reasoning and other executive processes, and learning and recall of new information
  20. 20. Sensory and Perceptual Changes  Most older adults experience decrements in visual and auditory acuity and other perceptual changes. Some, but not all, of the age-related visual changes can be corrected by glasses, and although hearing aids help with detection of low-frequency tones, they often amplify background noise. In effect, many older adults find it hard to hear or see well, especially with competing background noise and poor lighting conditions. Recent studies suggest a strong correlative link between sensory and perceptual changes and cognitive performance in old age
  21. 21.  These changes increase the likelihood of processing overload in circumstances that may have once presented little challenge. In advanced old age, even basic activities such as walking or maintaining postural control become less automatic, with the result that older persons must devote more conscious cognitive resources to these activities.
  22. 22.
  23. 23.
  24. 24. moderating variables  Genetic factors About 50% of cognitive variability in old age can be traced to genetic factors. Health Optimally healthy elderly persons outperform those with medical illnesses on many cognitive tests. Education Education accounts for up to 30% of cognitive variability in old age. Mental activity Mentally stimulating activities correlate with higher cognitive performance and reduced longitudinal decline. Physical activity Aerobic fitness is associated with better cognitive performance in old age. Expertise Aging experts may develop compensatory strategies to maintain a high level of performance despite some erosion in underlying cognitive skills. Personality and mood Depression correlates with self-perceived memory failure and with performance impairments if symptoms are severe. Social and cultural milieu Everyday memory lapses may be judged more critically when experienced by older people than by young adults. Cognitive training Cognitively unimpaired older persons benefit from practice and training in specific cognitive skills. Sex differences Cognitive aging trends are similar for the two sexes, but women may show decrements on spatial tasks at an earlier age than men, and men may show decrements on verbal tasks at an earlier age than women. Racial and ethnic differences Performance differences favoring elderly white persons have been reported on some cognitive tests, but when education is equated across groups, these differences are reduced or eliminated.
  25. 25. Psychological Theories of ageing  Life span Selective optimization: Socioemotional selectivity Cognition and agingPersonality and aging
  26. 26. Personality & Aging Theories  Theories focus on the nature and extent of personality stability and how they change over a persons life span. Developmental Explanations and Personality Trait Explanations based on the ―big five‖: 1) neuroticism 2) extroversion 3) openness to experience 4) agreeableness 5) conscientiousness Many believe that personality traits are more stable later in life whereas ―goals, values, coping styles and control beliefs‖ are more that likely to change. (Bonder, 2009)
  27. 27. Personality and Emotional Changes  Personality and emotions have not been studied as thoroughly as cognition in old age. Moreover, it is unknown whether observations about personality made within the confines of a particular generation and culture can be generalized to other places and times. Core features of personality remain stable throughout adulthood, and any marked change in mood or social behavior may indicate a disorder. However, more subtle reordering of personal priorities and shifts in coping styles are common with normal aging. It is particularly important not to measure older people’s coping by youthful standards. Emotion-focused coping may be a sign of personality development rather than regression, particularly if the problem being faced (e.g., bereavement or serious illness) is difficult to resolve through action.
  28. 28.  In one study comparing the emotions of younger to older people, volunteers were asked to state how often in the previous year they had experienced each of 46 different emotions. The results showed that older people experience stronger direct feelings of anxiety in the form of fear or being scared, whereas younger people tend to experience more guilt-related anxiety. Older people also report fewer experiences of depression, hostility or shyness. So, the overall structure of emotion between older and younger people seems similar, but the strength the relationship and frequency of emotional experience does differ.
  29. 29.  It appears that older people do experience less intense emotions. It may also help to explain why they find the emotional dysregulation of early stage Alzheimers so troubling. In some situations the elderly may show very little or no emotion where some might be expected; in other situations they may be moved to tears in a display of emotion that may seem out of place. Variation in emotional pattern is something that needs to be considered in any assessment of the elderly by younger people. Caution against using phrases such as, flattened affect, or emotionally labile, should be exercised in the realization that what is being observed is, in fact, perfectly normal.
  30. 30. Hanighurst stated that for older people to progress they must meet the following tasks 1. Adjust to declining health & physical strength.2. Adjust to retirement & reduced income.3. Adjust to the death of a spouse or family members.4. Adjust to living arrangements different from what they are accustomed.5. Adjust to pleasures of aging i.e. increased leisure & playing with grandchildren
  31. 31. Psycho-Social Theories of AgingDisengagement TheoryActivity TheoryContinuity Theory
  32. 32. Disengagement Theory  developed by Cummings and Henry in late 1950’s. ―aging is an inevitable, mutual withdrawal or disengagement, resulting in decreased interaction between the aging person and others in the social system he/she belongs to.‖
  33. 33. Activity Theory  in the 1960’s. developed by Robert Havighurst supports the maintenance of regular activities, roles, and social pursuits. persons who achieve optimal age are those who stay active. as roles change, the individual finds substitute activities for these roles.
  34. 34. Continuity Theory  proposed by Havighurst and co-workers in reaction to the disengagement theory ―basic personality, attitudes, and behaviors remain constant throughout the life span‖
  35. 35. Developing psychopathology (Psychodynamic models)  Busse & Pfeiffer 1969: Loss people, roles, physical capacity, opportunity. (nb depression is no greater in elderly) Gutmann 1992: losses in later life re-enact losses in childhood Vaillant 1993:Immature defence mechanisms provide insufficient defence against problems of old age Gutmann 1992: loss of physical, cognitive, emotional strengths undermine functioning of ego.
  36. 36. • Stressors faced by older people• Mediators shaping a person’s response to stress• Moderators that act on the stressor to lessen its intensity or buffer its effect
  37. 37. Stressors  Demands that call forth a physiologic, behavioral, or emotional response TYPES OF STRESSORS: Chronic  May be health-related (eg, the pain and mobility limitation of arthritis)  May be psychologic (eg, the prolonged worry over a chronically ill spouse) Acute  May be health-related (eg, a newly diagnosed medical condition)  May be psychologic (eg, experiencing the unexpected death of a close friend
  38. 38. Examples OF STRESSORS   Caregiving  Loss and Grief  Role Loss ( spouse , friends, work) and Acquisition (Grandparenthood and great-grandparenthood) provide both new demands and opportunities.  Social Status  Changes in social identity: due to role loss in retirement  Losses in physical capacity and reserve  Functional losses may place older persons in help- seeking rather than help-providing roles
  39. 39. Mediators  The internal and external resources a person can bring to bear to:  Assess and interpret a stressor  Assess his or her capacities for addressing it  Formulate a coping response Often modifiable through interventions such as psychoeducation and family counseling
  40. 40. Types of Mediators SELF-EFFICACY BELIEFS: Sense of one’s own ability to manage situations. Strong self-efficacy beliefs:  Contribute to good choice-making, good performance, and persistence of effort (especially in women)  Contribute to increased productivity COPING STRATEGIESCommon coping strategy: selection, optimization, compensation  Elderly select activities based on what they already do well  They do the selected activities more often and derive optimal credit for doing them  As performance diminishes, they employ compensatory strategies to put remaining capacities in the best light possible SOCIAL INVOLVEMENT: there is an association between lack of social involvement and affective disorders such as depression.
  41. 41. MODERATORS (Buffer)  Behaviors or components of a person’s life that affect the demands of stressors May be in place before the onset of a stressor or may be developed in response to it Three major types:  Social involvement  Spiritual or religious activity  Engaging in healthy lifestyle behaviors
  42. 42. Coping with PsychosocialChanges & Developmental Crises Support SystemCommunity ResourcesCounselingPrayer/Religion
  43. 43. Spirituality and Religiosity  confused. These concepts are frequently Studies have found that nurses tend to avoid addressing spiritual needs of patients.
  44. 44. Spirituality is the:  which all other―totality of man’s inner resources, the ultimate concerns around values are focused,the central philosophy of life that guides conduct,and the meaning-giving center of human life which influences all individual and social behavior‖ (Moberg, 1979)―trust & faith in a power greater than oneself‖ (levin & Taylor, 1997)
  45. 45. Religion is:  only one aspect of spirituality; an organized practice of beliefs; may or may not fill an individual’s spiritual needs eg. spiritual needs are much broader & more personal than any particular religious persuasion
  46. 46. Ageing and mental disorder Mental illness is not a manifestation of ageingApproximately 88% of people over the age of 65 do not suffer from mental disorderExcluding cognitive impairment means that people over the age of 65 have the lowest prevalence of mental disorder by age group.
  47. 47. Mood disorders Anxiety disordersPsychotic disordersPersonality disorders
  48. 48. Depression 
  49. 49. Is depression a normal response to the aging process? NO
  50. 50. EPIDEMIOLOGY Prevalence over 65 ▫ 1.4% ▫ 0.4% ▫ 1% overall ▫ Higher in institutional setting: Up to 25-40% in a general hospital setting and in long term care
  51. 51.  Depression is under-reported: WHY? Communication issues (eg. hearing impairment) Presence of dementia  Symptom overlap Stigma of aging  Depression is ―normal‖ Symptoms ―masked‖ by co-morbid illnessTHEREFORE YOU MUST SCREEN IN THOSE AT HIGHER RISK! Geriatric Depression Rating Scale
  52. 52. What are risk factors for depression in the elderly? Recently bereaved Female gender Single/widowed (recently) Stressful life events (eg. prolonged hospitalization, recent move to nursing home) Social isolation Persistent complaints of memory difficulties, diagnosis of dementia Chronic disabling illness or recent major physical illness (eg. Parkinson’s disease, stroke) Chronic sleep problems or anxiety
  53. 53.  Does depression look different in the elderly?• ―Depressed mood‖ may be less prominent• More anxiety• More likely to express somatic complaints ▫ 65% have hypochondriacal symptoms• Less likely to report guilt feelings• Cognitive impairment more common• Psychosis more common ▫ Typical delusions – more common  Somatic, persecution, nihilism, poverty
  54. 54. DSM-IV DIAGNOSTIC CRITERIA • 5 or more symptoms lasting >2 wk, change from previous functioning: ▫ Depressed mood and/or loss of interest ▫ Altered sleep, loss of energy, appetite change or weight loss, feelings of worthlessness/guilt,psychomotor changes, loss of concentration and focus, recurrent thoughts of death
  55. 55. Medical Conditions Mask or Cause Depression • Autoimmune • DRUGS ▫ Propranolol• Cerebrovascular ▫ Cimetidine• Chronic pain ▫ Clonidine• Degenerative Disease ▫ Benzodiazepines• Endocrine ▫ Steroids• Metabolic ▫ Tamoxifen ▫ Many more...• Neoplasms• Infections
  56. 56. Depression &Parkinson’s Disease  About 50% of patients develop depression Useful treatment includes TCA’s ECT helps depression and PD sx’s:  tremors, rigidity, & bradykinesia improved with 3-4 sessions  depression improved after 7-9 sessions
  57. 57. Depression in Early Alzheimer’s  Presents with:  insomnia  fatigue  agitation  psychomotor retardation  decreased interest & energy  concentration problems 50% of AD pt’s have depressive sx’s (15-20% with major depression)
  58. 58. Vascular Depression  Cerebrovascular disease can precipitate or perpetuate depression Caused by ischemia (―silent strokes‖) in prefrontal cortex and basal ganglia; motor & sensory deficits usu. not found. Marked apathy Lack of insight into depression Less depressed ideation Executive dysfunction Treatment resistance
  59. 59. Pseudodementia “dementia of depression” cognitive decline that clears if depression is treated however, dementia rate in these patients is still 20%/year even after full recovery of intellectual function.
  60. 60. SUICIDE IS A REAL RISK  25% of all completed suicides are > 65 Suicide rate for depressed men over 65 is 5 times higher than for younger men 20% of older people who committed suicide saw a physician that day Increased risk: financial problems, physical illness, recent loss, abuse, isolation
  61. 61. ASSESSMENT 1-History: Recent symptom profile Recent changes/ how long? Past psychiatric history Past medical history Current medications Any recent medication changes
  62. 62. ASSESSMENT  Social history/ Personal history(include interests and hobbies) Functional ability/level of care Any recent changes in ADL’s / IADL’s Any stressors (past/new)2-Screening tool: Geriatric Depression Rating Scale Mini- Mental Status Exam3-medical work-up (includes blood work, urines, CT Scan, X-Rays etc..)
  63. 63. INTERVENTIONS  Seek out medical illness Recognize medical side effects Rehab services to maximize remaining function and retrain impaired iADL’s Involve family and caretakers Counselling: role transitions, grief, dependency Medications / ECT
  64. 64. MEDICAL THERAPY IN GERIATRIC DEPRESSION  Select based on symptoms, prior response, concurrent illness, side effect profile Reassess after 4-6 weeks:  Increase dose, augment with second agent, add psychotherapy  Consider psychiatric consult/referral
  65. 65. Guidelines for Starting Antidepressants: “Start low, go slow”  Start at half the dose of younger people Aim to reach an average dose at one month
  66. 66. Guidelines for Switching Antidepressants Change if: No improvement in symptoms after at least 4 weeks at maximum tolerated or recommended dose Insufficient improvement after 8 weeks at maximum tolerated or recommended doseWhen recovery is incomplete after an adequate trial, consider: Further 4 weeks of treatment, with or without augmentation (meds or psychotherapy) Switching to another antidepressant  When switching, it is safe to reduce the first medication while starting the alternate (cross-over titration)  Consider specific interaction profiles
  67. 67.  Long-term Treatment Guidelines: After 1st episode continue to treat for at least a year Monitor for recurrence up to 2 years Medication discontinuation should be slow (over months) Patients with partial resolution of symptoms, more than 2 episodes, severe or difficult to treat depression, or treatment requiring ECT, should receive indefinite treatment Treatment response in nursing home patients should be evaluated monthly after initial improvement, and at quarterly care conferences and annual assessment once remission is achieved Consider tolerance of treatment versus risks of discontinuation
  68. 68. ANTIDEPRESSANTS TOAVIOD IN THE ELDERLY  Too many side effects: Older TCA’s:  amitriptyline, clomipramine, doxepin, imipramine, protriptyline, trimipramine MAOI’s:  phenelzine, tranylcypromine
  69. 69.  PROGNOSIS?Similar response rates to younger patients
  70. 70. Other Treatments CounselingElectro-convulsive therapy (ECT)Support GroupsDay Hospital Treatment programsSocial/ Community groupsCombination of medications and above itemsVolunteer workHobbiesPet therapy
  71. 71. Other Treatments  Music therapy Humor therapy Reminiscence Depression education Bereavement therapy
  72. 72. Electroconvulsive Therapy  Relatively safe (complication rate 1 in 1400 treatments, mortality rate 1 in 10,000) Effective - about 80% respond, although this drops to 50% if all other modalities have been tried Particularly useful for active suicidal ideation, psychotic depression, Parkinson’s-related depression, and for medication failures Very effective short term, but with high relapse rates over next 6-12 months. Drug therapy can reduce relapse
  73. 73. PSYCHOTHERAPY  Cognitive-behavioral therapy (CBT), problem- solving therapy (PST), and interpersonal psychotherapy (IPT) are effective treatments for major depression either alone or in combination with pharmacotherapy.
  74. 74. Personality disorders 
  75. 75. Ageing & Personality  There is no clear answer to the question of whether or not personality changes with age. Several studies have demonstrated remarkable stability of personality factors with aging. Others have shown age-related changes in certain personality traits, including decreases in extraversion and an increase in harm-avoidance. It is possible that the apparent stability of personality with age relates to genetic factors and environmental stability. The changes reported in some studies may reflect adaptations to changing life-roles, medical co-morbidity and social circumstances. The issue is complex, as changes in behavior do not necessarily reflect shifts in personality.
  76. 76.  personality disorders as persistent, pervasive patterns of inner experience and behaviour that begin in childhood or adolescence, continue into adulthood and are stable over time. These disorders manifest in cognitive, affective and behavioural patterns that deviate markedly from cultural norms and lead to distress or impairment. None of the instruments for assessment of personality disorder have been validated for use in elderly.
  77. 77.
  78. 78.
  79. 79.
  80. 80.  Cross-sectional studies of personality disorder in old age suggest that there is a lower prevalence of cluster B disorders and a higher prevalence of cluster C disorders. However, some suggest that features of borderline personality disorder are relatively dormant in middle life and re-emerge in old age.
  81. 81. Anxiety disorder 
  82. 82. Anxiety disorder  Determining the epidemiology and prevalence of anxiety disorders in old age is complicated by the fact that anxiety is a symptom of most psychiatric and many medical conditions in old age. Classes of Anxiety Disorders  Panic Disorder  Phobic Disorders  Obsessive-Compulsive Disorder  Posttraumatic Stress Disorder  Generalized Anxiety Disorder
  83. 83. ASSESSMENT DIFFICULTIES  Medical comorbidity Difficulty in differentiating anxiety from depression Falsely high scores on anxiety rating scales due to cardiac and respiratory problems Tendency of older patients to resist psychiatric evaluation
  84. 84. PANIC DISORDER Panic attack:   Acute, discrete episode of intense anxiety  Reaction to some perceived threat  Lasts between a few minutes and a half hour Symptoms may include:  Trembling, dizziness, sweating, nausea  Accelerated heart rate, chest pain, shortness of breath  Sense of detachment from surroundingsSlide
  85. 85. DIAGNOSIS OF PANIC DISORDER  Recurrent and unpredictable panic attacks   Have occurred for at least 1 month  Patient spends time in worried anticipation of possible recurrence  Onset after age 55:  Fewer panic symptoms  Less avoidance  Lower score on somatization measures  Less likely to persist into old ageSlide
  86. 86. SPECIFIC PHOBIA  Involves a distinct trigger, such as a specific person,  animal, place, object, event, or situation that results in symptoms of anxiety  Commonly, the patient’s anxiety level increases instantly when the feared trigger is encountered  Patient is able to identify this fear as unrealistic and unsupported, even though the cognitive and physiologic responses persistSlide
  87. 87. SOCIAL PHOBIA  Fear of reactions that are embarrassing in social situations, such as:   Trembling, Blushing, Sweating profusely  Feared situations include:  Giving public speeches, Socializing with others at a function or partySlide
  88. 88. OBSESSIVE-COMPULSIVE DISORDER   Obsessions: persistent thoughts or ideas that come to mind in a particular situation  Compulsions: behaviors performed in an effort to decrease the anxiety experienced as a result of the obsessions  Chronic and often disabling  New onset in late life is unlikelycommonly associated with a depressive syndrome or early dementiaSlide
  89. 89. POSTTRAUMATIC STRESS DISORDER   Common symptoms:  Re-experiencing of the traumatic event  Avoidance of associated stimuli (both cognitively and behaviorally)  Hyperarousal (eg, difficulty falling or staying asleep,  Often comorbid with depression, panic disorder, and substance abuse  Diagnosis requires presence of symptoms for 1 month and clinically significant distress or functional impairmentSlide
  90. 90. GENERALIZED ANXIETY DISORDER  Distinctive symptoms:   Feeling easily tired  Muscle tension  Trouble sleeping through the night  Difficulty concentrating on a task  Feeling irritable or on edge  Diagnosis requires:  Presence of symptoms for at least 6 months  Sense that one cannot control the anxietySlide
  91. 91. COMORBIDITY  Mixed Anxiety and Depression Anxiety and Agitation in Dementia Anxiety and Medical DisordersSlide
  92. 92. Management Pharmacological Antidepressants are probably the treatment of choice. Studies in older adults are limited but citalopram and venlafaxine have been shown to be effective and well tolerated. Benzodiazepines are effective in treating the symptoms of anxiety but at the cost of confusion, sedation, falls, tolerance and dependence. Use of benzodiazepines is limited to low doses for short periods and is generally avoided. Buspirone has been shown to be effective in the treatment of GAD and does not cause sedation or dependence. It may be less effective than antidepressants in the treatment of anxiety. Response delayed for 2-4 wks. Beta-blockers are sometimes prescribed to treat the physiological symptoms of anxiety.but in elderly patients the benefit is likely to be outweighed by the risk of side effects.
  93. 93. Non-pharmacological  CBT is effective in elderly patients. but less so than in younger adults. Nondirective supportive therapy may be as effective as CBT in the elderly.
  94. 94. Psychotic disorders 
  95. 95. PSYCHOTIC SYMPTOMS  Hallucinations are abnormal perceptions that can affect any of the 5 sensory modalities (auditory, visual, tactile, olfactory, gustatory) Delusions are false fixed believes that can be:  Suspicious (paranoid)  Grandiose  Somatic  Self-blaming  Hopeless
  96. 96. Differential diagnosis PERSON WITH PSYCHOTIC SYMPTOMS  Delirium Dementia Delusional disorder Primary mood disorder and Schizoaffective disorder Schizophrenia Temporal lobe epilepsy Medications Isolated Suspiciousness Syndromes of Isolated Hallucinations  Charles Bonnet Syndrome  Organic Hallucinations
  97. 97.  Only after other causes are excluded should the diagnosis of a schizophrenia-like state be made  Delirium, most often superimposed on an underlying dementia, is the most common cause of new-onset psychosis in late life• Next, consider a primary mood disorder
  98. 98. PSYCHOTIC SYMPTOMS IN DELIRIUM  Hallucinations, particularly visual hallucinations, can be a symptom of delirium, even when it is mild Onset is usually acute, and there is often an identifiable metabolic or infectious cause Mental status examination reveals:  Multiple cognitive impairments  Diminished or waxing and waning level of consciousness
  99. 99. PSYCHOTIC SYMPTOMS IN MOOD DISORDER  Delusions are ―mood congruent‖ In patients with depression:  Delusional content usually reflects self-deprecation, self-blame, hopelessness, or the conviction of ill health In patients with mania:  Delusions are grandiose.
  100. 100. PSYCHOTIC SYMPTOMS IN DEMENTIA  Patients with dementia experience both hallucinations and delusions  Usually less complex than the delusions seen in schizophrenia or mood disorder Common delusions in dementia:  Belief that one’s belongings have been stolen  Conviction that one is being persecuted  Belief that one’s spouse is unfaithful
  101. 101. ISOLATED SUSPICIOUSNESS  Suspiciousness is a personality trait (common to all humans but varying in its prominence) May become more common in those 65 Distinguished from psychotic disorders by:  The understandable nature of the ideas (for example, excessive worry about safety)  The absence of other psychotic symptoms
  102. 102. CHARLES BONNET SYNDROME  The criteria for this syndrome are:  Visual impairment  Visual hallucinations  Partially or fully intact insight (the patient is aware that the perceptions cannot be real but still reports that they appear absolutely real and vivid)  Lack of evidence of brain disease or other psychiatric disorder Affects 10%–13% of patients w/ bilateral acuity <20/60Reassure the patient that the hallucinations are a sign of eye disease, not mental illness
  103. 103. SCHIZOPHRENIA  Chronic psychiatric disorder characterized by both positive and negative symptoms Examples of positive symptoms:  Hallucinations  Delusions  Thought disorder Examples of negative symptoms:  Social dilapidation  Apathy Exclude mood disorder and cognitive disorder
  104. 104. SCHIZOPHRENIA-LIKE SYNDROMES OF LATE LIFE  Onset after age 44 Female:male ratio ranges from 5:1 to 10:1 Prominent persecutory (paranoid) delusions and multimodal hallucinations Differences from early-onset schizophrenia:  Much lower incidence of thought disorder  Personality often intact
  105. 105.  Unlike individuals with early-onset schizophrenia, many persons with late-onset schizophrenia-like psychosis have been able to:  hold responsible jobs  work efficiently But premorbid symptoms are common:  Isolation  ―Schizoid‖ (socially isolated personality) traits For that reason, can be confused with frontotemporal dementia (formerly called Pick’s disease)
  106. 106. NONPHARMACOLOGIC TREATMENT OF LATE-ONSET SCHIZOPHRENIA  Establish trusting therapeutic relationship Empathize with distress caused by symptoms Encourage patient to maintain important relationships Ask permission to discuss source of symptoms with close family members or friends
  107. 107. PHARMACOLOGIC TREATMENT OF LATE-ONSET SCHIZOPHRENIA  Antipsychotic drugs are as effective in late-onset schizophrenia as in early-onset cases Increase dose semiweekly or weekly, as needed  Responders should continue for at least 6 months  For patients who relapse on treatment or when the dose is lowered, maintain treatment for at least 1 to 2 years Monitor for extrapyramidal side effects (EPS), such as tremor, dystonic reactions, and bradykinesia  Avoid polypharmacy by reducing or switching medication rather than adding a medication for EPS
  108. 108.