This document provides information on geriatric psychiatry and aging-related mental health issues. It discusses several key topics: 1. Age-related changes in physiological functioning can increase vulnerability over time. Late adulthood begins around age 65 and is characterized by gradual decline in functioning of body systems. 2. Life expectancy has been increasing in India and globally, leading to growth in the elderly population. Common concerns for elderly include retirement, economic insecurity, declining health, and loss of independence. 3. Major mental health disorders in elderly include depression, delirium, and dementia. Late-life depression can present differently than depression in younger populations. Delirium is an acute change in mental status that commonly affects hospital

2. GERIATRIC PSYCHIATRY

3. Ageing is a progressive deterioration of
physiological function, an intrinsic age-
related process of loss of viability and
increase in vulnerability.
Ageing

4. • Normal state in 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
Advancing Age : 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 Healthy Ageing

7. Indicators Healthy Ageing
No physical 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 of Elderly
 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
Diseases due 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

11. Fears of elderly
Pain
Disability
Abandonment
Dependency

12. Triple Ds in Elderly
(Most Common in Elderly)
A-Depression
B-Delirium
C-Dementia

13. Other Psychiatric disorders of
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 depression in 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
Late onset
Depression- First time
after age 50
Vascular
Depression
Post Stroke
Depression
Psychotic
Depression

17. Phenomenology
 “Depression without sadness”
 Lack of feeling or emotion
 Prominent cognitive complaints
 Prominent somatic complaints (eg:
preoccupation with bowel function)

18. Phenomenology (contd..)
 Unexplained health worries,
unknown fear
 Heightened pain
experience/complaints
 Multiple Physician/Hospital visits
without resolution of the problem
 Irritability

19. Phenomenology (contd..)
 Problems in 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 major depression 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 low prevalence 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
 Medical illness- 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 are high
 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 in elderly
 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 psychomotor retardation
 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 onset depression 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 in psychotic 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- anticholinergic side 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 is the 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 acute and 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 what delirium 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 of Delirium
 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
Haloperidol 0.25 -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

52. C-

53.  Dementia is a 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 is the 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 of Dementias
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: 60-70 years
 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 Disease or 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 or Demyelinating 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 Blood Count, 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 brain atrophy
 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 Disease Vascular 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 of Psychiatry, 11th Edition –
Chapter 33
• Comprehensive Textbook of
Psychiatry, - Vol. 2, Chapter 57.