Psychological Disorders in Older people And Nursing Perceptive

1. Dr RAJESH G KONNUR
PRFESSOR
SGRDCON
VALLH AMRITSAR

2. The older population will more than double to
70 million ( WHO 2013).
The 85+ population will increase from 4.8
million in 2010 to 8.9 million.
Now India’s elderly population is 8.6% , would
go about 20% by 2050( U N 2012 Tribune
23rd Dec 2013).
Punjab – 4th in India with 10.2% , Kerala –
12.6%; Goa – 11.2 %, T N – 10.3%.
India – 3.7 million suffering from dementia &
this figure will double by 2030 to about 7
million persons. (NBRC 2013 ).

3. INTRODUCTION
Ageing gracefully is an art and science.
→Ageing is a universal , normal , progressive and
irreversible process.
→Inevitable physio- psychosocial phenomenon.
→ Stable Intellectual functioning
Capacity for change → Normal Ageing
Productive Engagement with life

4. Decline in sensory- motor and socio-
ecological factors impact the psyche of the
old. The common psychological problems
are observed in intellectual / memory,
mood , learning and sleep.
Inferiority complex due to diminished
capacities and decreased financial status.
Irritation in trivial matters
Obstinacy
Neglect
Drug abuse

5. Risk Factors for psychological
disequilibrium include -
- loss of social roles
- loss of autonomy
- deaths
- declining health
- increased isolation
- financial constraints
- decreased cognitive functioning.

6. When people are getting older, they have
to forgo several things and habits in their
life.
This may change person’s self image.
In these kinds of situations persons may
feel that he cannot control his life and that
his life is now meaningless.

7. Delirium
Altered state of consciousness and
change in cognition.
Decrement in attention, thinking and
awareness of surroundings.
Decrement in memory, orientation in time
and person.
Usually acute and fluctuating.

8. C/ F of delirium
- Accompanied by hallucinations, illusion, emotional
liability, alterations in sleep wake cycle, psychomotor
slowing or hyperactivity.
Prevalence of delirium
- 10- 35% of hospital admission
- Prevalence increases with multiple factors such as age,
medication use and comorbidities.
Burden Of Delirium
- Increased morbidity
- Increased nursing care
- Increased length of stay
- Increased risk of cognitive decline
- Barriers to early PSR

9. Etiologies of Delirium in Elderly : Multiple
Medications
- Anticholinergics ,BDZ’s , other sedative
hypnotics ( e.g. barbiturates,
antihistamines, Digoxin, certain antibiotics
(e.g. fluroquinolones, interferons.
- Metabolic derangements.
- Dehydration, hypoxia, hypoglycemia,
hyperammonemia, uremia, hyponatrimia,
thiamine deficiency, hyper thyroidism.

10. Primary brain diseases
- Stroke or transient ischemic attack
- Trauma : Brain injury, subdural hematoma
- Infections/ inflammation : Abscess, meningitis
, encephalitis
SURGERY or Trauma
- Hip # or repair
- Open heart surgery (CABG)
WITHDRAWL states
- Alcohol
- BDZ’s , other sedative & hypnotics

11. Treat the treatable cause.
Avoid polypharmacy.
Low dose neuroleptic is Rx of choice ,
unless the delirium is due to withdrawal.
If due to withdrawal, use a long acting
BDZ’s.
Close and compact supervision.
Reorient frequently.
Least restrictive use of restraints, as it
worsen confusion.

12. Dementia/ Alzheimer’s disease
1907 – Dr Alosis Alzheimer – German pathologist.
8 – 15% of people over 65.
Alzheimer’s dementia accounts for 50- 75% of all
dementias.
Known as “ silent tsunami”.
Client is disabled by acalculia, apraxia and loses
the ability to discriminate between left and right.
Deficits in language , object recognition and
executive functioning.
Psychosis, agitation , depression and wandering.
Evidence of decline from a previous higher
level of functioning.

13. Normal Possible Alzheimer’s
Temporarily forgetting a friend name Not being able to remember the
name later
Forgetting placement of keys Forgetting that the meal was ever
prepared /burning of food on stove
Unable to find the right word but
using a fit suitable
Uttering incomprehensible sentences
Forgetting for a moment where you
are
Getting lost on known street
Talking on the phone & temporarily
forgetting the topic
Forgetting the topic with no recall at
all
Having trouble balancing a cheque
book
Not knowing what the numbers mean

14. Normal Possible Alzheimer’s
Misplacing the wristwatch
until the steps are retraced
Putting the wrist watch in a
sugar bowl / spectacles in a
glass for wash
Gradual change in
personality
Drastic personality change
Having a bad day Having rapid mood swings
Tiring of housework but
getting back to it
Not knowing or caring about
house work that needs to be
done

15. Treatment and Nursing care:
Symptomatic : Care ˃ Cure.
Drugs . E.g.. Tacrine , Donepezil.
Vitamin supplements – Vit B and E.
Adequate nutrition, personal hygiene, fluid maintaince ,
prevention of accidents.
Neurobics : - learning new instrument, memorizing
poetry, cross word puzzle etc..
Smell the sandal wood to increase memory.
Do the tango to strengthen cognitive abilities: learning
the Cha- Cha- cha / dance.
Good sleep to boost memory.

16. Become feisty to protect brain ( Dr. Abhilash
Desai , Director St Louis Univ )
Food : natural foods, drinks, herbs, cacco
beans, green tea, berries, coffee beans.
Exercise: Daily aerobic , regular exercises.
Intellect: Taking on new and intellectually
challenging activities.
Sleep: Sleep without distortion Treatment
: Treat other conditions
Yes: Yes to opportunities.

17. Depression in the later life
Incidence : 2.4 − 5.4 % globally .
Accounts for 50% of older adult admissions
to a psychiatric facility.
Neither recognized nor treated.
Causes:
→ Health problems
→ Loneliness and Isolation
→ Reduced sense of purpose
→ Fears
 Empty Nest Syndrome
 For those with a medical condition ,
depressive symptoms significantly reduce
survival …>>> Increased risk for SUCIDE.

18. Clinical Features in Elderly
- Sadness, Fatigue, reduced energy and
concentration.
- ↓ appetite- -- → weight loss
- Early morning awakening and frequent
awakenings.
- Somatic complaints.
- Pseudo dementia.
- Episode with ‘melancholic features’,
hypochondriasis, hopelessness, feelings of
worthlessness , paranoia, suicidal ideation.

19. - Anhedonia
- Social withdrawal
- Loss of self worth
- ↑ use of alcohol / other drugs
- Fixation on death
- May have delusions which are usually
persecutory or hypochondriacal in nature.
Management:
- Management of treatable causes including
loss.
- Antidepressants--- SSRI, MAOI.
- Vit supplements : Vit E , A and B12.
- Psychotherapeutic interventions .
- ECT : More effective for “biological”
depression.

20. I) The psychosocial Assessment.
2) Nursing Interventions to enhance mental
alertness
- Allow the client to do as many tasks for
himself as possible.
- Encourage use of the mind in problem
solving / calculations.
- Encourage creative activities (E.g.
Painting, Story telling, cross word solving..)
- Plan teaching new information.

21. Nursing role to Increase Self Esteem
Develop a trusting relationship.
Treat the elderly with dignity and respect.
Allow sufficient time for the performance of
ADL.
Encourage verbalization.
Practice Active listening.
Give positive reinforcement for progress.
Use reminiscence therapy ( encourage the
elderly to recall or remember past events).
Encourage socialization.

22. Elder Abuse
Prevalence :- 1 – 2 %
Women > Men
Delhi has the third highest rate of abuse after
Hyderabad & Kolkata.(Help Age 2013 )
75% of victims are physically frail ; 50% are
unable to care for themselves ; many are
confused or disoriented – some or most of the
time.
Majority occurs in home setting.
Majority of perpetrators are family members
usually a spouse or adult child.

23. Cont>>>
Punjab – 11% of elder population is facing abuse
in the form of disrespect , neglect and in economic
& physical terms (23/12/13 Tribune).
Types: Physical abuse ,sexual abuse,
emotional/psychological abuse, financial
exploitation/victimization /undue influence ,
neglect, abandonment and self neglect.
Most common type of elder abuse :- Depriving an
elder of something needed for daily living &
property.
Second most common type – Psychological abuse
Third most common type :- Financial exploitation

24. Risk Factors
Older age ( >75)
Female
Unmarried / widowed / divorced.
Lack of access to resources.
Social isolation/ minority status /low education
Functional debility /substance abuse
Psycho –physiological disorders/cognitive impairment
Caregivers burnout and frustration
Fear of change of living situation (home-to-old age
home )
Reasons for abuse
- lack adjustment
- Increasing longevity
- economic dependency

25. Very common type of abuse in India
(Help Age 2013 )
- disrespect
- verbal abuse
- neglect
- beating/ slapping
Management :
Admission to hospital.
Legal aid and proceedings.
Community supportive services.
Counseling.

26. Suicide
Risk factors
- Men are greater risk than women.
- Over age 60.
- Marital status: widowed/divorced/single
than married.
- Substance abuser.
- H/o psychological illness/ previous suicide
attempt.
- Fire arm(s) in the home.

27. Predicting suicide is VERY difficult BUT
failure to assess for suicidality is the key to
liability ; asking about suicide does NOT
increase the risk.
Etiology :
Reduction in CSF- 5 hydroxy indoleascetic
acid (5 HIAA) & homovanilic acid (HVA)
Increased platelet type 2 serotonin (5HT2)
.

28. Predicting suicide is VERY difficult BUT
failure to assess for suicidality is the key to
liability ; asking about suicide does NOT
increase the risk.
Etiology :
Reduction in CSF- 5 hydroxy indoleascetic
acid (5 HIAA) & homovanilic acid (HVA)
Increased platelet type 2 serotonin (5HT2)

29. Suicidal Assessment (SAD PERSONS - -- a
mnemonic)
- Sex: male
- Age (older) – beginning at age 60.
- Depression.
- Previous h/o homicide / suicidal attempts
- Etiology of disease/ disorders.
- Rational thinking loss ( psychosis).
- Social supports lacking.
- Organized plan to commit suicide.
- No spouse ( divorced>widowed>single)..
- Sickness ( physical+ psychiatric).

30. Identifying the ‘ high- risk’ cases.
Talk Therapy.
Social support network services :
www.maithrikochi.org
Tele help services / suicide hotlines:
E.g. : +91- 3324744704 Kolkata
Hot line : 23389090 Delhi
+91- 2227546669 Mumbai
Toll free : 8002738255
Practicing spiritual and religious values.
Counseling .
Use of media and on - line help.

31. Above 60 years constitute 25% of the
population with BMD.
Mania associated with medical conditions.
Clinical features :
Confusion
Disorientation
Distractibility
Irritation rather than elevated, positive mood
Inflated self esteem
Psychotic features
Sleep disturbances
Aggressiveness
May be due to secondary / medical causes.

32. Mood stabilizers :
Lithium compounds : Li carbonate : 300 mg TID
Anticonvulsants : Divalproex - first choice
Carbamazepine 100 mg BD
Benzodiazepines : Clonazepam 0.25 mg BD
Antipsychotics : Olanzapine 2.5 mg
Respiridone 0.25 mg
ECT : In agitation and aggressiveness.

33. Prevalence of Insomnia by age groups
Age 18 – 34 - - - 14%
Age 35 – 49 - - - 15%
Age 50 – 64 ---- 20 %
Age 65 – 79 ----- 25%

34. Insomnia
Medications
Primary
sleep
disorders
Psychosocial
factors
Medical
conditions
Psychiatric
conditions
Poor sleep
hygiene

35. Difficulty in sustaining attention and slowed
response time.
↓ability to accomplish daily tasks.
Impairments in thinking, memory and
concentration.
↑consumption of health care resources.
Higher incidence of depression and anxiety
↑risk of falls.
Shorter survival /↑institulization rate.
Inability to enjoy social relationships/ ↓QOL.
↑incidence of pain.

36. Treat the underlying disease /cause.
Manage medications.
Limit alcohol and drug consumption
Behavioral interventions tend to be more
effective over time = GOOD SLEEP
HYGIENE.
Teaching sleep Hygiene :
- sleep scheduling
- Diet
- Environment and activity

37. Stimulus Control Measures :( Bootzin, 2000)
Aim : To strengthen one’s association with bed as a
cue for sleep
a) lie down at night only when you are sleepy.
b) use the bed only for actual sleep ( not reading,
watching TV..)
c) get out of bed if you wake up at night & are
unable to quickly fall asleep.
d) avoid napping.
e) adhere to strict rising time.

38. Relaxation as a Therapeutic Tool:
- Relax by silence.
- Eat 3-4 hours before sleep.
- Use and maintenance of healthy relationships.
Drugs :
BDZ’s : E.g. : Eszopiclone (Luesta)
Zolpidum (Ambien)
Zaleplon (Sonata)
Antidepressants: Atypical : Trazodone (Desyrel)
Nefazodone (Serzone)
TCA’s : AMT, Nortriptyine (Avatyl)
Use of Complementary Therapies:
- Bright light Therapy
- Exercise
- Massage

39. - 6- 9% minimum- At risk drinking- (more
than 2 drinks/day for a man and more than
1 drink/day for a woman).
- Up to 17% of older adults (over age 60)
misuse alcohol or prescription of drugs.
- Approximately 2/3rd of alcohol problems
are “long standing ”while 1/3rd are a late –
onset problem appearing for the 1st time
later in life POSSIBLY associated with
retirement, bereavement or depression.

40. LEGAL ILLEGAL
- Laxatives Marijuana
- Antihistamines Cocaine
- Stimulants & herbals Amphetamines
- Antibiotics Hallucinogens
- BZD’s & other sedatives Phencyclidine
- Opoids
- Analgesics
- - Many adults die before they reach an older
age because of overdose ,deterioration in
health or violence.

41. Do not present as : substance seeking behavior
such as characterized by crime,
manipulativeness and antisocial behavior.
Presentations vary but may include : marital
discord , falls , confusion , poor personal
hygiene , depression , anxiety, sleep complaints
, malnutrition ,delirium and dementia.
Management:
- Anta abuse management.
- Counseling: Individual, Group and Family /
CBT.
- PSR

42. Relieving stress without drugs: Exercising,
meditation, yoga, …..
Building a meaningful drug free life :
-- Pick a new hobby
-- Adopt a pet
-- Social networking
-- Set meaningful goals
-- look after health

43. 50% of adults older than 60 suffer from pain.
Pain may be ac / chronic, physical/psychological in nature.
EFFECTS:
- Physical Functioning/ QOL.
- Ability to perform ADL’s.
- Sleep disturbances
- Psychological Morbidity: -- depression
-- anxiety
-- anger
-- loss of self esteem

44. Social Consequences:
- Relationship with friends and family
- Intimacy/sexual activity
- Social isolation
- Health care costs
- Disability
- Lost work days
Management:
-- Medications: Analgesics, opoids .
-- Psychotherapeutic interventions-
- Psychotherapy
- Prayer / Meditation
- Attention diversion techniques
- Use of complementary therapy :- reki,
acupressure, pranic & magnitotherapy.

45. Long standing / recent onset.
Annual incidence:- 17-23/ 1 lakh elders.
15-20% older have late onset
schizophrenia.
Risk factor : Isolated elder.
S/S: -- marked by both + & -ve symptoms.
-- more difficulty in learning new
information & performing executive
functions.
Mgt: - Atypical Antipsychotics.
- Cognitive Behavior therapy.

46. Sexual Problems
- Older men report more interest in sex than
women. Availability of sexual partner and
good health is essential for maintaining
sexual activity-- ↓ causes ---→
masturbation / depression & other
psychological problems.

47. Communication and Education.
Teaching safe sex practices .
Encourage family meetings with open discussion.
Reminiscence nursing care:
- Thinking about past & reflecting on it.
- Better mental health.
- Helps to maintain losses and self esteem.
- Life review provides older adults with an
opportunity to come to grips with guilt and regrets
& to emerge feeling good about themselves.

48. Treat the treatable cause / disease.
Comprehensive /Holistic nursing approach
including ‘ the appreciation of death’.
Activity:
ADL should follow with exercises e.g..
aerobic,…
Participating in activities that enjoy.
Take care of a pet.
Create opportunities to laugh / Humor
therapy.

49. Fitness Training:
-- Games
-- Yogic exercises – Asanas &
Pranayama
-- Surya Namaskaras
-- Pavanamuktasana
-- Ardha matsyendrasanas
-- Savasana
Social Involvement / networking:
- less risk of early death
- better physical & mental health
- less risk of disability or decline in ADL.
- buffered impact of major life events.
- greater feeling of personal control.

50. Teaching healthy behaviors:
- Positive effects of well being.
- eating a health diet.
- abstain from alcohol / drugs.
- Practicing relaxation / stress
reduction techniques.
Spiritual / Religious nursing intervention:
- Involve the older people in religious
activities --→overall benefits –social
interaction & involvement.

51. Gero – Empowerment :
- Authority to do what needs to be done to get the job done
at that time.
- The power ’to’, not the power “over ’’.
- Allow the client and family to make the choice that
empowers them in their own care.
- Setting up a national help for older persons based on
model of Child line.
- Setting up Helplines in state to provide different types of
services by joint effort of NGO and the local government.
- Helplines in old age homes must come up under the
Maintenance of Welfare of Parents & Services Citizen’s
Act ,2007 .

52. The needs of the elderly are unique & distinctive,
as they are vulnerable. Health ,economic &
psychological needs are most important. They
need a broader based – interdisciplinary
approach to manage their psychological
problems. If tackled by the health fraternity
alone, it touches only the tip of the iceberg. So ,
it is the responsibility of each & every citizen of
India including govt & community to involve , to
make the elder to live happy long life.

53. “Our society must make it right and possible for old people
not to fear the young or be deserted by them,
for the test of civilization is the way that it cares for its
helpless members”
Pearl S Buck.

54. MANY THANKS
MANY THANKS