Geriatric Psychiatry

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Geriatric Psychiatry

  1. 1. Geriatric Psychiatry Anita S. Kablinger MD Associate Professor Psychiatry and Pharmacology
  2. 2. Objectives: <ul><li>Differentiate between the various cognitive disorders </li></ul><ul><li>Know aspects of normal aging </li></ul><ul><li>Gain knowledge of the best treatment options for geriatric psychiatric illnesses </li></ul>
  3. 3. Why is it a subspecialty? <ul><li>Mental disorders may have different manifestations, pathogenesis, and pathophysiology from younger adults </li></ul><ul><li>Coexisting chronic medical illness </li></ul><ul><li>More medicines </li></ul><ul><li>Cognitive impairments </li></ul><ul><li>Increased risk for social stressors, including retirement and widowhood </li></ul>
  4. 4. Geriatric population increasing <ul><li>2000, estimated that 1 in 5 Americans were over 55 years of age, and 13% over 65 years of age </li></ul><ul><li>By 2050, estimates are that 22% will be over the age of 65, and 5% over age 85. </li></ul>
  5. 5. Aging and the Life Cycle (Erickson) <ul><li>Young adulthood--intimacy versus isolation </li></ul><ul><li>Middle-aged--generativity versus self-absorption </li></ul><ul><li>Elderly--Integrity versus despair (Acceptance of mortality, satisfaction with one’s meaning in the world) </li></ul><ul><li>Fear of death is usually a mid-life issue </li></ul>
  6. 6. Other tasks of elderly <ul><li>Reminiscence is normative </li></ul><ul><li>Loss </li></ul><ul><li>On-time normative incidents do not usually result in crisis </li></ul><ul><li>Fears are usually pain, disability, abandonment, and dependency </li></ul>
  7. 7. Cognition and aging <ul><li>Cognition includes learning, memory, & intelligence </li></ul><ul><li>Learning is the ability to gain new skills and information. It may be slower in elderly, especially verbal learning. </li></ul>
  8. 8. Cognition and aging (continued) <ul><li>Memory is divided into immediate, short- and long- term memory. Immediate memory remains intact. </li></ul><ul><li>Short-term memory is also intact, however, it is affected by concentration which may be less in older adults. </li></ul><ul><li>Long-term memory is most affected by aging. Retrieval is less efficient; the elderly need more cues </li></ul>
  9. 9. Intelligence <ul><li>Ability to use information in an adaptive way or to apply knowledge to specific circumstances </li></ul><ul><li>Crystallized intelligence includes vocabulary, verbal skills, and general information can continue to increase throughout life. </li></ul><ul><li>Fluid intelligence consists of recognizing new patterns and creative problem solving. This peaks in adolescence. </li></ul>
  10. 10. Benign senescent forgetfulness <ul><li>Age associated mild memory problems. May also have cognitive problems due to anxiety. </li></ul><ul><li>Examples are forgetting names, misplacing items, and experiencing difficulty with complex problem-solving. </li></ul><ul><li>(aging-associated cognitive decline) </li></ul>
  11. 11. Psychiatric Evaluation <ul><li>See patient alone to assess for suicidal/homicidal ideation even if cognitively impaired </li></ul><ul><li>May need info from caretaker </li></ul><ul><li>May take extended time due to slower response time </li></ul>
  12. 12. Other important aspects of history <ul><li>Family history--Alzheimer’s disease is transmitted as an autosomal dominant trait in 10-30% of the offspring of parents with Alzheimer’s disease </li></ul><ul><li>Review of all meds, over the counter, prescribed, herbal </li></ul><ul><li>Alcohol and substance abuse history </li></ul>
  13. 13. MSE <ul><li>General description </li></ul><ul><li>mood, feelings, affect </li></ul><ul><li>witzelsucht is caused by frontal lobe dysfunction and is the tendency to make puns and jokes and laugh aloud at them </li></ul>
  14. 14. MSE (continued) <ul><li>perceptual disturbances </li></ul><ul><ul><li>may be transitory resulting from decreased sensory acuity </li></ul></ul><ul><ul><li>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) </li></ul></ul>
  15. 15. MSE (continued) <ul><li>Language output </li></ul><ul><ul><li>nonfluent or Broca’s aphasia--understanding intact but can not speak, speech may be telegraphic </li></ul></ul><ul><ul><li>fluent or Wernicke’s aphasia </li></ul></ul><ul><ul><li>global aphasia </li></ul></ul><ul><ul><li>ideomotor apraxia--can not demonstrate use of simple objects </li></ul></ul><ul><li>Visuospatial functioning--some decline is normal with age </li></ul>
  16. 16. MMSE affected by educational level <ul><li>median score for 9-12 yrs of school is 26, high school diploma 28 </li></ul><ul><li>less sensitive in those with high intelligence, and less specific with those below average intelligence </li></ul>
  17. 17. Neuropsychological Assessment <ul><li>MMSE is not used to make a formal diagnosis </li></ul><ul><li>WAIS-R vocabulary holds up with age. Performance part is a more sensitive indicator of brain damage than the verbal part. </li></ul><ul><li>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. </li></ul>
  18. 18. Mental Disorders of old age <ul><li>Most common: depressive disorders, cognitive disorders, phobias, and alcohol use. </li></ul><ul><li>High risk of suicide </li></ul><ul><li>Risk factors include loss of social roles, loss of autonomy, deaths, declining health, increased isolation, financial constraints, and decreased cognitive functioning. </li></ul>
  19. 19. Cognitive Disorders <ul><li>Include: </li></ul><ul><ul><li>Delirium </li></ul></ul><ul><ul><li>Dementia </li></ul></ul><ul><ul><li>Amnestic Disorders </li></ul></ul><ul><ul><li>Psychiatric disorders due to a Medical Condition </li></ul></ul><ul><ul><li>Postconcussion Syndrome </li></ul></ul><ul><li>Replaces the term “organic disorders” </li></ul>
  20. 20. <ul><li>Note that major psychiatric illnesses may also have changes in cognition, but they are not called cognitive disorders </li></ul>
  21. 21. Delirium <ul><li>Usually acute and fluctuating </li></ul><ul><li>Altered state of consciousness (reduced awareness of and ability to respond to the environment) </li></ul><ul><li>Cognitive deficits in attention, concentration, thinking, memory, and goal-directed behavior are almost always present </li></ul>
  22. 22. Features of delirium <ul><li>May be accompanied by hallucinations, illusions, emotional lability, alterations in the sleep-wake cycle, psychomotor slowing or hyperactivity </li></ul><ul><li>Usually abrupt </li></ul>
  23. 23. Causes of Delirium— I WATCH DEATH <ul><li>Infectious Deficiencies </li></ul><ul><li>Withdrawal Endocrinopathies </li></ul><ul><li>Acute metabolic Acute vascular </li></ul><ul><li>Trauma Toxins/drugs </li></ul><ul><li>CNS Pathology Heavy Metals </li></ul><ul><li>Hypoxia </li></ul><ul><li>Note that prescribed medicines may cause delirium </li></ul>
  24. 24. Treatment of delirium <ul><li>Look for underlying cause “always be suspicious” </li></ul><ul><li>Close supervision, especially by family </li></ul><ul><li>Reorient frequently </li></ul><ul><li>Adequate lighting </li></ul>
  25. 25. Treatment of delirium (continued) <ul><li>Use consistent personnel </li></ul><ul><li>Try not to use restraints, as it can worsen confusion. </li></ul><ul><li>Medication only if behavioral attempts fail </li></ul><ul><ul><li>Avoid polypharmacy </li></ul></ul><ul><ul><li>Low dose neuroleptic is treatment of choice, unless the delirium is due to withdrawal. If due to withdrawal, use a short-acting benzodiazepine. </li></ul></ul>
  26. 26. ICU Syndrome <ul><li>May be multifactorial </li></ul><ul><li>Postcardiotomy delirium occurs 3 or 4 days after surgery </li></ul>
  27. 27. Changes in dementia <ul><li>Cognition, memory, language </li></ul><ul><li>Personality change, abstract thinking, aphasias </li></ul><ul><li>Visuospatial functioning </li></ul><ul><li>However, level of awareness and alertness usually intact in early stages (differentiates dementia from delirium) </li></ul><ul><li>Chronic, versus acute </li></ul>
  28. 28. Amnestic Disorders <ul><li>Differs from delirium and dementia because major problem is short-term memory only. </li></ul><ul><li>Impairment may be due to hemorrhage in mamillary bodies, or degenerative changes in the dorsal medial nucleus of the thalamus </li></ul><ul><li>Most common cause is alcoholism </li></ul>
  29. 29. Transient global amnesia <ul><li>Transient inability to learn new info </li></ul><ul><li>Variable retrograde amnesia that “shrinks” following recovery </li></ul><ul><li>Level of conscousness and personal identity intact </li></ul><ul><li>Due to transient vascular insufficiency of the mesial temporal lobe, or medicines, tumors, arrhythmias, cerebral embolism </li></ul><ul><li>Also have risk problems for stroke </li></ul>
  30. 30. Postconcussion syndrome <ul><li>Follows a history of head trauma resulting in cerebral concussion </li></ul><ul><li>LOC, posttraumatic amnesia, less commonly, post-traumatic seizures </li></ul><ul><li>Impairment in attention, concentration, performing simultaneous cognitive tasks, and in learning new information, or recalling information shortly after the injury </li></ul><ul><li>Not a form of dementia </li></ul>
  31. 31. Dementing Disorders <ul><li>Only arthritis more common in geriatric population </li></ul><ul><li>5% have severe dementia, and 15% mild dementia in those over 65 </li></ul><ul><li>Over 80, 20% have severe dementia </li></ul><ul><li>Most common causes: Alzheimer’s disease, vascular dementia, alcoholism, and a combination of these 3 </li></ul><ul><li>Risk factors are age, family history, and female sex </li></ul>
  32. 32. Noncognitive symptoms accompanying dementia <ul><li>Mood disorders--dementia and depressive symptoms can coexist and the depression responds to treatment </li></ul><ul><li>Pathological laughter and crying occurs </li></ul><ul><li>Irritability and explosiveness </li></ul>
  33. 33. Other noncognitive symptoms in dementia <ul><li>Excessive emotional outbursts that occur after task failure are “catastrophic reactions” and can be avoided by educating family members to avoid confrontation </li></ul><ul><li>Delusions or hallucinations occur during the course of dementias in nearly 75% </li></ul>
  34. 34. Behavior problems in dementia <ul><li>Agitation, restlessness, wandering, violence, shouting </li></ul><ul><li>Social and sexual disinhibition, impulsiveness </li></ul><ul><li>Sleep disturbances </li></ul>
  35. 35. Dementia and treatable conditions <ul><li>10-15% from: </li></ul><ul><ul><li>heart disease, renal disease, and congestive heart failure </li></ul></ul><ul><ul><li>endocrine disorder, vitamin deficiency, </li></ul></ul><ul><ul><li>medication misuse </li></ul></ul><ul><ul><li>primary mental disorders </li></ul></ul>
  36. 36. Subcortical dementia <ul><li>Subcortical dementias are associated with movement disorders, gait apraxia, psychomotor retardation, apathy, akinetic mutism. </li></ul><ul><li>Alert, but slowly responsive and inactive </li></ul><ul><li>Not fluent in language, but comprehends </li></ul><ul><li>Often dysarthric, difficulty with forming complex sentences </li></ul><ul><li>Difficulty with executive function </li></ul>
  37. 37. Subcortical dementia <ul><li>Causes: </li></ul><ul><li>Huntington’s disease, Parkinson’s disease, NPH, multi-infarct dementia, Wilson’s disease </li></ul>
  38. 38. Cortical dementias-- <ul><li>Ex: Alzheimer’s, CJD, and Pick’s disease </li></ul><ul><li>Involve aphasia, agnosia, apraxia </li></ul><ul><li>Fluent, moderately attentive, normally responsive to questions, and normally active in his environment </li></ul>
  39. 39. Human prion disease <ul><li>result from dicing mutations of the prion protein gene and may be inherited, acquired, or sporadic. </li></ul><ul><li>They include familial CJD, Gerstmann-Straussler-Scheinder syndrome, and fatal familial insomnia. </li></ul><ul><li>Autosomal dominant </li></ul>
  40. 40. Sporadic CJD <ul><li>Accounts for 85% of human prion diseases </li></ul><ul><li>Occurs world-wide with a uniform distribution and incidence of around 1 in 1 million per annum </li></ul><ul><li>A mean age of onset of 65 </li></ul><ul><li>Rare in those less than 30 </li></ul>
  41. 41. Dementia of the Alzheimer’s Type (DAT) <ul><li>50-60% of patients with dementia </li></ul><ul><li>5% of those who reach 65 have DAT </li></ul><ul><li>15-25% of those 85 or older </li></ul><ul><li>More common in women </li></ul><ul><li>Occupy 50% of all NH beds </li></ul>
  42. 42. DAT <ul><li>General sequence is memory, language, then visuospatial functions </li></ul><ul><li>Death occurs in about 7 yrs </li></ul><ul><li>On autopsy: neurofibrillary tangles and neuritic plaques with an amyloid core and deposition of amyloid in blood vessels </li></ul><ul><li>Involves cholinergic system arising in basal forebrain, nucleus basalis of Meynert--reductions in brain acetylcholine, and the adrenergic system </li></ul>
  43. 43. DAT (Genetics) <ul><li>Chromosome 21 </li></ul><ul><li>Most severe form associated with chromosome 14 </li></ul><ul><li>Genetically heterogeneous disease caused by 2 or more genes located on 2 or more chromosomes (14, 19, 21) </li></ul><ul><li>Slow virus? </li></ul><ul><li>Deposition of aluminum </li></ul>
  44. 44. PET Scans of DAT <ul><li>Decreased metabolic rate of glucose in temporoparietal area, and in frontal regions in more severe cases </li></ul>
  45. 45. Pick’s Disease <ul><li>Slowly progressive </li></ul><ul><li>Focal cortical lesions, primarily frontal that produce aphasia, apraxia, and agnosia. </li></ul><ul><li>Lasts 2-10 yrs., average duration 5 yrs </li></ul>
  46. 46. CJD <ul><li>Usual course one year </li></ul><ul><li>Not associated with aging </li></ul><ul><li>Incidence decreases after age 60 </li></ul><ul><li>Terminal stage: severe dementia, generalized hypertonicity, and profound speech disturbance </li></ul><ul><li>Typical burst pattern on EEG </li></ul>
  47. 47. Vascular Dementia <ul><li>Second most common type </li></ul><ul><li>Can reduce known risk factors: hypertension, diabetes, cigarette smoking, and arrhythmias </li></ul>
  48. 48. Huntington’s <ul><li>Basal ganglia and cerebral cortex </li></ul><ul><li>Progressive dementia, muscular hypertonicity, and bizarre choreiform movements </li></ul><ul><li>Death in 15-20 yrs </li></ul><ul><li>On the G8 fragment of chromosome 4 </li></ul><ul><li>Screening test available </li></ul>
  49. 49. NPH <ul><li>Dementia </li></ul><ul><li>Ataxia </li></ul><ul><li>Incontinence </li></ul>
  50. 50. Dementia due to Parkinson’s Disease <ul><li>Motor dysfunction, frontal lobe symptoms, and memory deficit </li></ul><ul><li>Nearly 1/2 are depressed, and depression is most common mental disturbance in Parkinson’s </li></ul><ul><li>Increased risk for anxiety </li></ul><ul><li>Levodopa, amantadine, and bromocriptine can cause psychosis and delirium </li></ul>
  51. 51. HIV (AIDS)-Related Dementia <ul><li>Involvement of CNS is a primary symptom of the illness and may occur before signs of systemic infection </li></ul><ul><li>In later stages may be result of fungal, parasitic, viral, or neoplastic disease </li></ul><ul><li>Initial infection involves the brain--headache, bells palsy, seizures, flu symptoms, or aseptic meningitis </li></ul><ul><li>Later stages may show abnormal reflexes </li></ul>
  52. 52. Other types of dementia <ul><li>Multiple sclerosis is characterized by multifocal lesions in the white matter. May show early mood lability </li></ul><ul><li>Vitamin B12 deficiency--neurologic changes may occur before megaloblastic changes </li></ul><ul><li>Hypothyroidism </li></ul><ul><li>Wilson’s disease </li></ul>
  53. 53. Diagnostic evaluation of dementia <ul><li>B12 and folate </li></ul><ul><li>VDRL and FTA </li></ul><ul><li>CT/MRI </li></ul><ul><li>EEG is sensitive for delirium </li></ul><ul><li>Consent and counseling for HIV </li></ul>
  54. 54. Treatment of behavior problems <ul><li>Neuroleptics should not be first choice, unless the patient is psychotic and should be on a “prn” basis </li></ul><ul><li>Consider the likelihood of depression and anxiety first </li></ul><ul><li>Consider using behavioral methods if at all possible </li></ul>
  55. 55. Medicines for behavioral problems <ul><li>Valproic acid, trazodone, and buspirone may be of benefit </li></ul><ul><li>BZD’s may aggravate confusion </li></ul>
  56. 56. Social Recommendations <ul><li>Refer to Alzheimer’s group or other support groups </li></ul><ul><li>Continue preventive care--vision, dental, etc. </li></ul><ul><li>Consider caregiver stress </li></ul>
  57. 57. Drug treatment for DAT <ul><li>Most current ones affect acetylcholine </li></ul><ul><ul><li>Tacrine </li></ul></ul><ul><ul><li>Aricept </li></ul></ul><ul><ul><li>Exelon </li></ul></ul><ul><ul><li>Reminyl </li></ul></ul><ul><li>Early intervention may prevent or slow decline </li></ul>
  58. 58. Depression <ul><li>15% of all older adult community residences and nursing home patients </li></ul><ul><li>Accounts for 50% of older adult admissions to a psychiatric facility </li></ul><ul><li>Age is not a risk factor, but widowhood and chronic medical illness are </li></ul>
  59. 59. Depression <ul><li>May have more somatic complaints such as decreased energy, sleep problems, pain, weakness, GI disturbances </li></ul><ul><li>Increases use of primary care medical resources </li></ul><ul><li>For those with a medical condition, depressive symptoms significantly reduce survival </li></ul><ul><li>Increases risk of suicide </li></ul>
  60. 60. Depression in medical illness <ul><li>Medicines or the medical illness may cause depression </li></ul><ul><li>Rule out medical causes </li></ul><ul><li>Use psychological symptoms such as hopelessness, worthlessness, guilt </li></ul><ul><li>Pseudodementia occurs in about 15% of depressed older patients, and 25 to 50% of patients with dementia are depressed </li></ul>
  61. 61. Depression in older adults <ul><li>May have delusions which are usually persecutory or hypochondriacal in nature </li></ul><ul><li>Need treatment with both an antidepressant and an antipsychotic </li></ul><ul><li>ECT may be treatment of choice </li></ul>
  62. 62. Bereavement <ul><li>Normal grief starts with shock, proceeds to preoccupation, then to resolution </li></ul><ul><li>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 </li></ul>
  63. 63. Bipolar Disorder <ul><li>Episodes persist into old age </li></ul><ul><li>Do organic workup if onset is over 65 </li></ul><ul><li>Usually more irritable than euphoric, and paranoid rather than grandiose </li></ul><ul><li>May have dysphoric mania , with pressured speech, flight of ideas, and hyperactivity, but thought content is morbid and pessimistic </li></ul>
  64. 64. Treatment of bipolar <ul><li>Lithium is an effective treatment, but decreased renal clearance and neurotoxic effects may be more common </li></ul><ul><li>Valproic acid is also helpful for behavioral disturbances </li></ul>
  65. 65. Schizophrenia <ul><li>Usually before 45, but there is a late onset type beginning after age 65 </li></ul><ul><li>More likely in women </li></ul><ul><li>Paranoid type more common </li></ul><ul><li>Psychopathology less marked with age </li></ul><ul><li>Residual type occurs in 30% of those affected: Emotional blunting, social withdrawal, eccentric behavior, and illogical thinking predominate </li></ul>
  66. 66. Delusional Disorder <ul><li>Onset between 40 and 55 </li></ul><ul><li>Persecutory or somatic delusions most common </li></ul><ul><li>In one study of people older than 65, 4% had pervasive persecutory ideation </li></ul><ul><li>May be precipitated by stress, loss, social isolation , visual impairment, deafness, immigrant status </li></ul>
  67. 67. Anxiety Disorders <ul><li>Very common in elderly </li></ul><ul><li>May occur first time after age 60, but not usually </li></ul><ul><li>Most common are phobias, especially agoraphobia </li></ul><ul><li>Elderly more likely to use anxiolytics </li></ul><ul><li>May be due to medical causes or depression </li></ul>
  68. 68. Somatoform Disorders <ul><li>More than 30% over age 65 have at least one chronic disease. After 75, 20% have diabetes mellitus and an average of 4 diagnosable chronic illnesses </li></ul>
  69. 69. Hypochondriasis <ul><li>Hypochondriases peak incidence in 40-50 yr range. Repeat exams, but not invasive and high risk tests </li></ul><ul><li>Hypochondriasis may be a secondary symptom of depression </li></ul>
  70. 70. Alcohol and substance abuse <ul><li>20% of nursing home patients have alcohol dependence </li></ul><ul><li>Sudden onset delirium in hospitalized patients usually from withdrawal </li></ul><ul><li>Consider in patients with GI problems </li></ul><ul><li>May misuse OTC </li></ul><ul><li>35% use analgesics, and 30% use laxatives </li></ul>
  71. 71. Alcohol <ul><li>Brain more sensitive as ages </li></ul><ul><li>Due to changes in metabolism, a given amount may produce a higher blood alcohol level than in a younger individual </li></ul><ul><li>May worsen normal changes in sleep and sexual functioning </li></ul><ul><li>Interacts with other medicines </li></ul>
  72. 72. Alcohol detoxification <ul><li>Use lorazepam and oxazepam if needed for detox in elderly because of rapid metabolism </li></ul>
  73. 73. Personality disorders <ul><li>Borderline, narcissistic, and histrionic personality disorders may become less intense </li></ul><ul><li>Before diagnosing a personality disorder, verify that it is not an improperly treated Axis I disorder </li></ul><ul><li>Some personality traits may become more pronounced </li></ul>
  74. 74. Sleep disorders <ul><li>Advanced age is single most important factor associated with increased prevalence of sleep disorders </li></ul><ul><li>REM sleep behavior disorder occurs almost exclusively among elderly men </li></ul><ul><li>Advanced sleep phase--go to sleep early, and awaken during night </li></ul><ul><li>Alcohol can interfere with sleep </li></ul><ul><li>Dementia associated with more arousals, increased stage I sleep; decreased stages 3/4 </li></ul>
  75. 75. Other disorders of old age <ul><li>Vertigo--antivert may be of benefit. Usually has psychological component </li></ul><ul><li>Syncope </li></ul><ul><li>Elder abuse--about 10% over age 65 abused </li></ul>
  76. 76. Psychopharmacology <ul><li>Evaluate physically first, including EKG </li></ul><ul><li>Bring in all meds </li></ul><ul><li>Should give meds 3-4 times over 24 hrs. </li></ul><ul><li>Washout of psychotropic meds sometimes beneficial </li></ul><ul><li>Major goals are to improve quality of life, maintain in community, and delay or avoid nursing home placement </li></ul><ul><li>start at lower doses </li></ul>
  77. 77. Psychopharmacology <ul><li>Watch for all drug interactions </li></ul><ul><li>Compliance may be a problem </li></ul><ul><li>Cognitive dysfunction may require help with medication regimen </li></ul>
  78. 78. Metabolism changes <ul><li>Decrease in lean body mass and total body water </li></ul><ul><li>Increase in body fat, prolongs half life </li></ul><ul><li>Hepatic metabolism decreases, as well as production of albumin </li></ul><ul><li>Decreased renal function </li></ul>
  79. 79. 25% of all prescriptions are for people over 65 <ul><li>40% of all hypnotics are for over 65 </li></ul><ul><li>75% of older people use OTC </li></ul>
  80. 80. Psychostimulants <ul><li>May be of benefit in depressed older patients </li></ul><ul><li>Amphetamines may augment analgesia for patients on pain meds </li></ul>
  81. 81. Antipsychotics <ul><li>Used for psychosis and behavioral disturbances </li></ul><ul><li>Can have side effects at lower doses </li></ul><ul><li>Give a 4 week trial at least </li></ul><ul><li>No need to use prophylactic antiparkinsonian agents, but the risk of EPS increases with age </li></ul>
  82. 82. Antipsychotics <ul><li>Low potency agents (mellaril, thorazine) have increased effects such as orthostatic hypotension, sedation, cognitive impairment </li></ul><ul><li>Atypicals may be of most benefit (clozapine, olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole) </li></ul>
  83. 83. Anxiolytics <ul><li>Rate of use high </li></ul><ul><li>May cause anterograde amnesia </li></ul><ul><li>May accumulate in tissues if long acting so may increase ataxia, insomnia, and confusion </li></ul><ul><li>If necessary, oxazepam and lorazepam are drugs of choice </li></ul><ul><li>Buspirone may be of benefit. Takes several weeks to work </li></ul>
  84. 84. Geriatric psychotherapy <ul><li>Goals are to have minimal complaints, make and keep friends of both sexes, have sex if interested and capable </li></ul><ul><li>Grief and loss are central issues </li></ul><ul><li>Example: retirement and self-esteem </li></ul><ul><li>Group therapy directly lessens the elder’s sense of isolation </li></ul><ul><li>Family support is crucial </li></ul>
  85. 85. Institutional Care <ul><li>50% stay less than 3 months </li></ul><ul><li>Skilled nursing facilities vs. intermediate-care facilities </li></ul><ul><li>70% proprietary, 30% governmental </li></ul><ul><li>State hospitals now exclude people with dementia </li></ul>
  86. 86. Restraints <ul><li>40% nursing home patients placed in restraints last year </li></ul><ul><li>Without restraints, have better muscle tone, less rage, greater sense of mastery </li></ul>
  87. 87. Competence <ul><li>Legal decision </li></ul><ul><li>May be competent for some procedures, and incompetent for others </li></ul>
  88. 88. Pearls <ul><li>Evaluate any change in cognition. It is not normal </li></ul><ul><li>Rule out drug interactions, alcohol abuse, or medical problems if depressed or anxious </li></ul><ul><li>The dose of antidepressant that gets the patient well is the dose that keeps the patient well </li></ul>
  89. 89. Pearls <ul><li>The elderly generally require less medication for the same symptoms--start low, and go slow </li></ul>

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