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Geriatric psychiatry
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- 3. Ageing is aprogressive deterioration of physiological function, an intrinsic age- related process of loss of viability and increase in vulnerability. Ageing
- 4. • Normal statein the age is physical and mental health, not illness and debilitating. • Old age or Late Adulthood begins at – Age 65 yrs. • The aging process or senescence is characterized by gradual decline in functioning of body SYSTEMS- CVS, RS, CNS, GIT, GUT, Endocrine and Immune System.
- 5. Ageing: Demographic Scenario AdvancingAge : Birth of Elderly o Steady rise in the population of elderly globally o In India - increasing longevity o Improvement in Health Care Services o Consequently increasing life expectancy Males Females 1951 32.45 31.66 2001 62.80 63.80 2011 68.90 69.50 o Census 2011 population: o India- 1220 m; Elderly - 92 m
- 6. Dimensions of HealthyAgeing
- 7. Indicators Healthy Ageing Nophysical disability over the age of 75 as rated by a physician; Good subjective health assessment (i.e. good self-ratings of one's health); Length of un-disabled life; Good mental health; Objective social support; Self-rated life satisfaction in different domains; Marriage; income-related work; children; friendship and social contacts; hobbies; community service activities; religion and recreation/sports.
- 8. Concerns/Life Events ofElderly Retirement Economic Insecurity Decreasing Health Dependency Chronic illnesses Lack of caregiver Lowered Self Esteem Loss of Control Abuse/Neglect and Isolation Loss and Loneliness So many Medications Boredom Reminiscence is normative On-time normative incidents do not usually result in crisis
- 9. Ageing and Diseases Diseasesdue to the Ageing Process The “biological age” of a person is not identical with his “chronological age”. Years may wrinkle the skin, but worry, doubt, fear, anxiety, tension, and self-distrust wrinkle the soul. With the passage of time, certain changes take place in an organism. The following disabilities are considered as incident to it: o Senile cataract o Failure of special senses o Osteoporosis affecting mobility o Alzheimer’s disease o Nerve deafness o Glaucoma o Bronchitis o Rheumatism o Dental problems
- 10. Ageing and Diseases(contd.) Major Mental Health Disorders Impaired memory, rigid outlook and resistance to change are some of the mental changes in the elderly. Major mental health problems of older adults are: Organic Disorders Late Life Functional Diseases: Mood (Affective) Disorders Neurotic, Stress Related and Somatoform Disorders Schizophrenia, Schizotypal and Delusional Disorders (Functional Psychoses) Psychoactive Substance Use Disorders Suicidal Behaviors in the Elderly Loneliness
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- 12. Triple Ds inElderly (Most Common in Elderly) A-Depression B-Delirium C-Dementia
- 13. Other Psychiatric disordersof old age Psychosis Anxiety-Phobias Alcohol use. High risk of suicide
- 14. Risk factors include Loss of social roles Loss of autonomy Deaths Of loved ones Declining health Increased isolation Financial constraints Decreased cognitive functioning
- 15. Persistent depressionin older adults ---- enormous individual and family burden. Increases mortality both from suicide and concurrent medical illness. Under-recognized in primary care settings, general hospitals and nursing homes. Different presentation---- Happily sad, suffering with smile A- Depression Common but Different presentation
- 16. Late life Depression Lateonset Depression- First time after age 50 Vascular Depression Post Stroke Depression Psychotic Depression
- 17. Phenomenology “Depression withoutsadness” Lack of feeling or emotion Prominent cognitive complaints Prominent somatic complaints (eg: preoccupation with bowel function)
- 18. Phenomenology (contd..) Unexplainedhealth worries, unknown fear Heightened pain experience/complaints Multiple Physician/Hospital visits without resolution of the problem Irritability
- 19. Phenomenology (contd..) Problemsin initiative, self care, household maintenance, transportation and communication. Social withdrawal, avoidance of social interaction Prominent loss of interest and pleasure in activities Signs of functional impairment or otherwise unexplained functional decline
- 20. Epidemiology Classical majordepression is less frequent in older adults (prevalence of 1%) 15 to 25 % experience depressive symptoms that do not meet criteria for a specific depressive syndrome but cause distress and significant dysfunctioning. Confused Clinician
- 21. Theories behind lowprevalence of major depression in elderly “Resilience” – capacity to adjust and recover from stressors without loss of equanimity. Shared experience or “generational temperament” give rise to variation in prevalence across generations Flaws in the diagnostic approaches and interview techniques.
- 22. Risk factors Medicalillness- parkinson’s disease, stroke, Alzheimer’s disease, hypothyroidism, malignancies. Past history, spousal death, separation, lack of social contact, death of loved ones and bereavement. Staying in nursing homes, cognitive decline, pain problems, under- nutrition.
- 23. Suicide Rates arehigh First episode of major depression which was not diagnosed or untreated Psychotic depression, alcohol, recent loss or bereavement, loss of spouse, abuse of sedatives and hypnotics.
- 24. Major depression inelderly Same criteria as for young population Disturbances in sleep, appetite and sexual functioning are not always reliable indicator. Use of HAM-D, MMSE and GDS are useful in elderly in primary care settings for screening.
- 25. Symptoms favoring major depression Guilt about things other than actions taken or not taken by the survivor around the time of the death Thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person Morbid preoccupation with worthlessness
- 26. contd... Marked psychomotorretardation Prolonged and marked functional impairment Hallucinatory experiences other than thinking that he or she hears the voice or footsteps, or transiently sees the image, of the deceased person
- 27. Age of onset: early vs late Early onset depression : childhood, adolescence or earlier adulthood. Late onset depression is with first onset in the second half of life at age of 50.
- 28. Contd... Early onsetdepression have more first degree relatives with depression (genetic loading) Late onset depression have More chronic physical illness, Less complete response to treatment, and Chronic course, Poorer prognosis, Increased mortality and Frontal and temporal atrophy on scans.
- 29. 1-Depression with reversible dementia Depression in elderly is associated with cognitive impairments “Pseudodementia of depression” or “depression with reversible dementia” is now considered obsolete. Brain dysfunction is “unmasked” by depression or its just beginning of dementing process
- 30. 2-Vascular dementia depression Cerebrovascular diseases both cortical and sub cortical (chronic microvascular). Frontostriatal disconnection : executive dysfunction, reduced interest in activities, psychomotor retardation, cognitive impairment and impaired insight. Impairment in instrumental activities of daily living and poor prognosis.
- 31. 3-Post stroke depression Depression developing a year or more after a stroke is strongly influenced by impairment in social and physical functioning. Depression after a 3 to 6 months period of stroke have more vegetative features and larger lesion volumes.
- 32. Delusions inpsychotic depression involve guilt, jealousy, paranoia, or somatic symptoms (e.g., beliefs in suffering a serious or a fatal medical illness). Patients frequently complain bitterly of somatic symptoms without medical explanation, and can express profound nihilistic beliefs and hopelessness, but hallucinations are relatively infrequent. Some patients are unable to urinate or defecate and require urgent, separate intervention for these problems. 4-Depression with psychosis
- 33. Depression with psychosis Respond not at all to placebos, poorly to antidepressants used alone, and more often to combinations of antidepressant and antipsychotic medications Hospitalization is typically indicated and electroconvulsive therapy (ECT) is the treatment of first choice when agitation, starvation, dehydration, or suicidality threaten survival.
- 34. 5-Post-bereavement and depression Many elderly people experience a great deal of loss, not only in the form of death (e.g., spouse, friends, relatives, loved pets), but also in other spheres of life such as loss of Physical ability, Financial income, Social status, Mobility, Life ambitions, and Independence
- 35. 6-Chronic medical illness Increased medical burden increases depressive symptoms, and long-term depressive symptoms increase medical burden and mortality Depression lowers self-rated health and intensifies physical symptoms including amplifying the perception of pain, and chronic pain worsens depression.
- 36. MANAGEMENT OF DEPRESSION psychotherapy -first-line treatment for depression in older adults. Cognitive-behavioral therapy (CBT) and problem-solving therapy (PST), interpersonal therapy (IPT) has role. Various obstacles to use psychotherapy in elderly. PSYCHOTHERAPY
- 37. Pharmacotherapy SSRI -drug of choice. Common adverse effects are GI distrtess, agitation, akathisia, insomnia, sexual dysfunction and occasionally parkinson like motor side effects Risk of serotonin syndrome Hyponatremia – inappropriate ADH, urinary retention
- 38. TCA- anticholinergicside effects Nortriptyline and desipramine have less SE. TCA better for chronic pain management Venlafaxine, desvenlafaxine, mirtazapine, bupropion, duloxetine and MAOIs can be used. Psychostimulants.
- 39. ECT ECT isthe most important of the non- pharmacological somatic treatments It is the treatment of choice in certain older patients with severe depression due to poor tolerance of psychotropic medications, psychotic features, significant comorbid medical conditions, or marked disability or urgent risk to life.
- 40. COURSE AND PROGNOSIS Left untreated, late-life major depression tends to remit spontaneously after 12–48 months, but patients with first-episode depression with onset after age 60 have a 70% chance of recurrence within 2 years.
- 41. B-Delirium Usually acuteand fluctuating Altered state of consciousness (reduced awareness of and ability to respond to the environment) Cognitive deficits in attention, concentration, thinking, memory, and goal-directed behavior are almost always present
- 42. Prevalence of Delirium ICU: up to 70% Roughly 83% patients near death
- 43. That is whatdelirium is ….. Agitation Confusion Sedation Compulsive Searching OR Combination HallucinationsDistractions
- 44. Features of delirium May be accompanied by Inattention Hallucinations, Illusions, Emotional lability, Alterations in the sleep-wake cycle, Evening worsening of symptoms Fluctuations in Symptoms Psychomotor slowing or hyperactivity, Searching and picking behavior Removing clothes, life support equipments (like IV line, Catheter, Nasogastric tube, Ventilator support) Usually abrupt and resolution is also rapid when underlying cause is corrected.
- 45. Types of delirium Types: Hyperactive : almost always consultation Hypoactive: no consultation Mixed: Fluctuation between hyperactive and hypoactive
- 46. Causes of Delirium:I WATCH DEATH Infectious Withdrawal Acute metabolic Trauma CNS Pathology Hypoxia Deficiencies Endocrinopathies Acute vascular Toxins/drugs Heavy Metals Note that prescribed medicines may cause delirium
- 47. The Mortality ofDelirium The mortality outcome for delirious patients was three times higher than general patients. 25 percent of delirious postoperative patient had a lethal outcome; control population 13%
- 48. Burden of Delirium Increased mortality Increased nursing care Increased length of stay Increased risk of cognitive decline Increased risk of functional decline
- 49. Treatment of delirium Look for underlying cause “always be suspicious” Close supervision, especially by family Reorient frequently Adequate lighting
- 50. Treatment of delirium(continued) Use consistent personnel Try not to use restraints, as it can worsen confusion. Medication only if behavioral attempts fail Avoid polypharmacy Low dose neuroleptic is treatment of choice, unless the delirium is due to withdrawal. If due to Alcohol withdrawal, use a short-acting benzodiazepine. (Lorazepam)
- 51. Treatment Dose Route Reps Haloperidol0.25 -1 mg POIM bid/tid Every 30-60 min Risperidone 0.25 - 0.5 mg PO bid/tid Every 30-60 min Olanzapine 2.5 – 5 mg PO/IM Every 30-60 min Quetiapine 25 – 50 mg PO Every 30-60 min For excessive agitation
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- 53. Dementia isa syndrome due to disease of the brain, usually of a chronic or progressive nature. There is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement. Dementia produces an appreciable decline in intellectual functioning, and usually some interference with personal activities of daily living, such as washing, dressing, eating, personal hygiene, excretory and toilet activities. What is dementia?
- 54. AD isthe most common cause of dementia amongst people aged 65 and older Prevalence among people over 60 years–5% to 8 % Starting with 0.5% prevalence at 55 yrs., it goes on doubling every five years (60yrs-1%; 65yrs. – 2%; 70 yrs. - 4%; 75yrs.-8% and so on) Risk at the age of 80 years is around 15 to 20% At present nearly 35.6 million people worldwide with dementia. Expected to double by 2030 and triple by 2050. About 7.7 million new cases of dementia each year. A new case detected in every 4 seconds somewhere in world. (WHO) Epidemiology
- 55. Common Types ofDementias Type of Dementia % in total Cases Alzheimer’s Dementia 50-55 Vascular Dementia 30-35 Lewy body Dementia 5-7 Pick’s Dementia 3-5 Other Dementias 10-15
- 56. Age: 60-70years Gender: female Prior stroke Atherosclerosis Heart disease High blood pressure Diabetes Diet Risk Factors for Dementia • Cholesterol problems • Atrial fibrillation • Smoking • Low Education • Family history
- 57. Neurodegenerative Diseases Alzheimer’s disease Parkinson’s disease Diffuse Lewy body disease Progressive supra-nuclear palsy Multisystem atrophy Huntington’s disease Frontotemporal dementias – e.g. Pick’s disease Etiological classification of dementia
- 58. Structural Diseaseor Trauma Normal pressure hydrocephalus Neoplasms Dementia pugilistica Vascular Disease Vascular dementia Vasculitis Heredo-metabolic Disease Wilson’s disease Other late-onset lysosomal storage diseases Etiological classification of dementia
- 59. Demyelinating orDemyelinating Disease Multiple sclerosis Infectious Disease Human immunodeficiency virus, type 1 Tertiary syphilis Creutzfeldt-Jakob disease Progressive multifocal leukoencephalopathy Whipple’s disease Chronic meningitis – e.g. Cryptococcal Etiological classification of dementia
- 60. Nutritional deficiency: Vitamin B12 deficiency, Folate deficiency, thiamine deficiency. Organ failure: Uremic and hepatic encephalopathy Endocrine disease: Diabetes mellitus, hyper/ hypothyroidism, Cushing's syndrome etc. Etiological classification of dementia
- 61. D = Drugs,Delirium E = Emotions (depression) & Endocrine Disease M=Metabolic Disturbances E = Eye & Ear Impairments N =Nutritional Disorders T =Tumors, Toxicity, Trauma to Head I = Infectious Disorders A= Alcohol, Arteriosclerosis Irreversible / Reversible dementias • Alzheimer’s Dementia • Lewy Body Dementia • Pick’s Disease (Frontotemporal Dementia) • Parkinson’s • Heady Injury • Huntington’s Disease • Creutzfeldt- Jacob Disease
- 62. Complete BloodCount, ESR Serum Urea, Creatinine, Electrolytes Thyroid function tests Serum B 12 & Folate Electrocardiogram Chest X-ray CT Scan of head/ MRI head Lumber Puncture (if suspicion of infectious etiology) Tests for syphilis, HIV Drug screen if appropriate Brain biopsy (for confirmatory diagnosis) Lab and other tests for dementia
- 63. Diffuse brainatrophy Enlargement of ventricles Widening of sulci and gyri Atrophy more prominent in hippocampus There can also be evidences of strokes, lacunar infarcts, and white matter hyper intensities. These complicate the picture. Neuroimaging
- 64. Characteristics Alzheimer’s DiseaseVascular Dementia Sex Women Men Age Generally over age 75 years Generally over age 60 years Onset & progression Gradually progressive Stuttering or episodic, with stepwise deterioration History of hypertension Less common Common History of stroke(s),transient ischemic attack(s),or other focal neurological symptoms Less common Common Hypertension Less common Common Focal neurological signs Uncommon Common Emotional lability Less common More common Cognitive deficits Uniform patchy Alzheimer’s Disease Vs Vascular Dementia
- 65. Treatment of Dementia •Multi-modal Approach • Pharmacotherapy: • Central choline esterase inhibitor – Donepezil, Rivastigmine, Galatamine (Mild to Moderate Dementia) • NMDA Receptor Antagonist – Memantine ( Moderate to Severe Dementia) • Diet and nutritional supplements • Caregiver Support • Psychosocial Interventions
- 67. Reference • Synopsis ofPsychiatry, 11th Edition – Chapter 33 • Comprehensive Textbook of Psychiatry, - Vol. 2, Chapter 57.