This document discusses the multidisciplinary approach to managing geriatric mental health issues. It involves both pharmacological and non-pharmacological management by professionals like psychiatrists, psychologists, social workers, physiotherapists and others. Non-pharmacological approaches focus on social support, activities, exercise and addressing behavioral issues. Specific techniques discussed include reality orientation, validation therapy, reminiscence therapy and behavior therapies to improve symptoms like aggression, agitation and coping skills. The goal is to enhance quality of life through both medical and psychosocial interventions.

1. Dr Rakesh Kumar Tripathi
Assistant Professor cum Clinical Psychologist
Department of Geriatric Mental Health,
King Georg’s Medical University, Lucknow, UP, India

2. Multidisciplinary approach
1. Pharmacological Management
˃ Psycho-geriatrician (Psychiatrist)
˃ Physician
2. Non-pharmacological Management (NPM)
˃ Clinical Psychologist (trained Psychologist)
˃ Trained Social Worker (Psychiatric/Geriatric Mental Health)
˃ Physiotherapist
˃ Occupational therapist
˃ Dietician
˃ Yoga therapist
˃ Care by Nurses
˃ Care by carers

3. » Some limitations of pharmacological treatment
» Drugs give only modest symptomatic improvement in
cognition
» Always risk of adverse effects
» Patients in the older age groups vary in their response
» Age is associated with decreased renal clearance and slowed
hepatic metabolism
» Older patients often take several medications so drug
interactions and side effect are likely
» Anti-cholinergic side effect may worsen cognitive impairment
and lead to delirium
» Age also is associated with diminished vascular tone, which
increases susceptibility to orthostasis and falls
» Involvement of other available resources in the management
plan

4.  Enhance quality of life, maximize functional performance by
improving cognition, mood, and behavior.
 Enhance coping skills, solving interpersonal conflicts,
develop insight
 NPM rely on a person-centered approach, respecting the
individual, and should be used irrespective of whether
medication is also required
 Focuses on social support, recreational therapy, physical
exercise, mental stimulation and a variety of other non-
medical treatment options as a means to improving the well
being of older adults with mental health problems
 Reduces caregiver’s burden and maintains strength & dignity
 To take care of legal, financial and other such issues

5. » Activities of Daily living
» Cognitive functions
» Behavioural and psychological abnormalities
» Premorbid functioning/personality
» Conflicts
» Interpersonal relationship
» Stressors
» Family dynamics
» Physical environment
» Diet pattern
» Caregiver burden

6. » Calm, reassuring tone of voice
» Explain what you are going to do prior to moving into the patient’s
personal space to implement care/assessment
» Use a non-threating posture
» Do not approach the patient from behind
» Touch and care should be in a respectful, careful and unhurried
manner
» Use short words and simple sentences
» Ask one question at a time
» Don’t ask ‘why’
» Give adequate time for response
» Repeat questions and instructions if necessary
» Speak slowly and clearly
» Use of aids (hearing, vision, physical) by the patient
Sing I & Tripathi SM (2013). Management of BPSD. In Tiwari SC & Pandey NM (eds.) Geriatric Mental
Health at a Glance ,pp 81-95. Ahuja Publishing House , New Delhi , India.

7. » Psycho-social management/Psychotherapy
» Physiotherapy
» Occupational therapy
» Diet therapy
» Nursing care
» Care by caregivers
» Other

8. » Supportive psychotherapy
» Psychodynamic and psychoanalysis
» Humanistic and Existential Therapies
» Cognitive therapy
» Behaviour therapy
» Family therapy
» Group therapy
Reconstructive
Re-educative

9. Deals with external factors of the problem,
strengthening of existing defences, elaboration of
new and better mechanisms of maintaining
control
» Guidance
» Suggestion
» Emotional catharsis
» Reassurance
» Environmental manipulation

10. Unravelling the dynamics of problem behaviour and helping
the client achieve insight into those dynamics
» Psychoanalysis (Free association, Resistance
transference, dream interpretation, working through,
insight , termination)
» Contemporary psychoanalysis
» Jung, Adler and Horney: focus on a underlying causes of a
disorder and strive for insight (self development in social
context)
˃ Analytical therapy (need for ‘individuation’, self realization)
˃ Individual therapy (social and interpersonal factors, personal freedom and a
fulfilling ‘style of life’)
˃ Horney’s approach (help to identify maladaptive interpersonal strategies,
constructive interpersonal styles and greater self reliance)

11. Special emphasis on sharpening the individual’s self awareness
and self acceptance
Shaping one’s own existence
» Humane client therapist relationship
1. Empathy, 2. sensitive, unconditional positive regard, 3. never criticizing, always accepting , 4. do
not judge, probe or disapprove, 5. be genuine, open, spontaneous and caring
» Client-centered therapy:
˃ discrepancies between “ideal” and “real” selves
˃ Aim to reduce these discrepancies and associated pain
» Gestalt Therapy: (Fritz Perls)
“The past is no more and the future is not yet”; thus “to me nothing exist except the now”
-To make people ‘whole’ by encouraging them
- Accepting responsibility , focus on “here and now”
» Existential therapy: (Viktor Frankl & Rollo May)
˃ To emphasize that the client can have control over the problem and is thus responsible for
overcoming it.

12. Maladaptive behaviours comes from maladaptive
ideas, or cognitions, and therapy focuses on modifying
these cognitions- ‘cognitive restructuring’
» Ellis’s Rational Emotive therapy (1950)
˃ Reveal and breakdown irrational beliefs that leads to stress
˃ Reciprocal interactions among cognition, emotion and behaviour: ‘cause-effect
relationship’ (REBT,1993)
» Beck’s Cognitive Therapy
» Meichenbaum’s self instructional training
˃ Self instructional training to replace maladaptive cognitions with rational,
positive thoughts in stressful situation

13. » Recognizing and changing negative thoughts and
maladaptive beliefs
» “Automatic thoughts”- personalized notions that are
triggered by particular stimuli that leads to a
emotional responses
» Cognitive distortions:
˃ Arbitrary inferences (without evidence)
˃ Selective abstraction (conclusions from isolated detail of an event)
˃ Overgeneralization
˃ Magnification or minimization
˃ Personalization
˃ Labelling and mislabelling
˃ Polarized thinking (all or none)

14. Assumptions:
» Psychological problems that come about through
learning or conditioning can be undone via the same
processes
» Measurement of behaviour and behaviour change
» Do not believe “unconscious conflicts” or “mental
illness”
» They view their clients as suffering from acquired
behaviour patterns – and need to be unlearned
» Learn more adaptive alternatives

15. » Instrumental or operant conditioning
˃ Functional analysis of behaviour (A-B-C)
˃ Identifying positive and negative reinforcers
˃ Extinction
˃ Differential reinforcement
˃ Shaping
˃ Token economy
˃ Punishment
˃ Covert sensitization
» Classical conditioning
˃ Systematic desensitization
˃ Flooding
˃ Aversion therapy
» Social learning

16. To address:
» Inability to resolve conflicts, make decisions or solve
problems
» Chaotic family organization and lack of agreed upon
responsibilities
» Too rigid an organization resulting in an ability to respond
the changing circumstances and stress
» Over closeness to the point that individual family
members may lose a sense of individuality
» Lack of emotional ties and communication among family
members
» Failure of the parents to agree on child rearing practices

17. Features:
» Self disclosure
˃ In front of group members
» Acceptance and support
˃ From the group members
» Norm clarification
˃ One’s problem is neither unique nor serious
» Social learning
˃ Being able to relate constructively and adaptively within the group
» Vicarious learning
˃ Learning about oneself by observation of group members and therapist
» Self understanding
˃ Finding out one’s behaviour in the group setting and the motivations
contributing the behaviour

19. )(

20. • Rule out delirium
• Search for the treatable common cause:
– Constipation
– pain/ discomfort
– infection (UTI/pneumonia)/ other medical cause
– Side-effects of medications
– Sleep disturbances
– Change in routine schedule/ environment
– Lack of meaningful activity/stimulus
– bad-mannered behaviour of staff/caregiver

21. ‘Unmet needs model for agitation’
» Behaviours to obtain or meet a need…
» Behaviours to communicate a need…
» Behaviours that result from an unmet need…

22. » Identify trigger & remove it
» Establish a routine
» Familiar atmosphere
» Clear & simple
communication
» Involve in useful activities
» Regular exercise
» Distraction
» Avoid punishment
» Be consistent with a strategy
» Be realistic about the goals
» Avoid creating discomfort

23. Small changes can result in major gains!
•Medications
•Foot wear
•Walking aides
•Surface heights
•Chairs/bed
•Wall bars
•Lighting
•Flooring/mats

24. Standard therapies
» Behavioural therapy
» Reality orientation
» Validation therapy
» Reminiscence therapy
Alternative therapies
 Art therapy
 Music therapy
 Activity therapy
 Aromatherapy
 Bright-light therapy
 Multi sensory therapy
 Spiritual therapy

25. Psychotherapeutic Intervention modules to improve quality of life of urban elderlies
with cognitive deficits (Tripathi and Tiwari, 2009)
Cognitive deficit Psychotherapeutic Intervention
Approaches
Aggression, screaming, incontinence, wandering,
stereotypical behaviours, and agitation
Behaviour oriented approach
 Wandering  Stimulus Control
 Disruptive vocalization  Differential reinforcement of other
behaviours
 Disruptive vocalization  Non-contingent Reinforcement
(NCR)
 Disruptive behaviours  Differential reinforcement of low
rates of behaviour intervention
(DRL)
 Personal care  Token economy
 Problems in Dressing, Bathing, Fooding  Contingency management
Coping skills, memory & mood, insight, isolation Emotion oriented approaches:
 enhance the strengths and coping skills of both patients
and caregivers
 Supportive psychotherapy
 stimulates memory & mood in the context of the patients’
life history
 Reminiscence therapy
 contentment, negative affect and behavioural
disturbance, insight, external reality
 Validation therapy
 Social Isolation  Simulated presence therapy
Redress cognitive deficits
 disorientation & confusion, verbal orientation
Cognition oriented approaches:
 Reality orientation
Agitation, social isolation, and mood, Stimulation oriented approaches:
 Behavioural problems i.e. agitation, social isolation and
mood
 Recreational therapy (Music &
Dance)
 Behavioural problems i.e. agitation, social isolation and
mood
 Art therapy
Memory, Orientation & executive functions (Cognitive
decline)
Cognitive stimulation therapy:
Safety measures in all respect Environmental intervention:
 stressed, unsafe, unfriendly, uncomfortable, inconstant,
unfamiliar, unlighted and obstacle physical environment
 Physical

 daily living activity schedule, adequate exposure to light
& sleep hygiene
 Temporal
 Hearing and vision checkups  Sensory consideration
 Helping at meal time  Nutritional consideration
Helping entire family to cope, to plan, to participate in the
management of elderly dementia patients at home as well
as in institutional setup
Family therapy

26. » People are oriented to their environment using a range of
materials and activities
» Involves consistent use of orientation devices such as
signposts, notices and other memory aids
» debate regarding the efficacy of the approach
» Favorable review of the six randomised controlled trials of this
therapy (Spector et al’s 2002a)

27. » Attempt to communicate
by empathizing with the
feelings and meanings
hidden behind their
confused speech and
behavior.
» It is the emotional
content of what is being
said that is more
important than the
person’s orientation to
the present.

28. » A way of increasing levels of well-being and providing
pleasure & cognitive stimulation.
» Involves helping a person to relive past experiences,
especially those that might be positive and
personally significant.
» Improvements in behaviour, well-being, social
interaction, self-care and motivation

29. Good Ideas:
» Places to wander, Digital or hidden locks
» Electronic bracelets/wander guards
» Double bolts on doors, Half doors
» Stage appropriate toys, books, puzzles, TV shows
» Give meals in a style that suits ability- ie may need to
use finger foods
» Flexible routine, Things to do!!!, Music
Not a good idea:
» Highly patterned wallpaper
» Mirrors
» Loud call bells/paging systems
» Frequent room changes/redesign

30. » A-Antecedent:
» B-Behavior:
» C-Consequence: the response to behavior.
What happened? Who did what to whom?
Very important to document both successful
and unsuccessful interventions.

31. Check :
» akathesia (which increases need to pace), Was this
person a habitual walker/runner/doer? Is this
behavior really a “problem”, Who’s problem?
At home:
» Double locks on doors/move lock out of sight,
Wandering Registry, Adequate daytime physical
activity, Things to do/distraction, If planning a move
involve the less demented pt.
» In a more impaired pt you want to move the person
quickly with little fuss

32. » Where’s my wife? What do I do now? Etc Etc….
˃ Consistently ignoring repeated questions works for
some
˃ Distraction with food, presence, activity
˃ React/respond to the emotional content rather than
the words
˃ Controversy over the “therapeutic use of lies”

33. » Screaming usually occurs in the later stages of dementia
» Broken brain
» Careful assessment if new onset
» May result from lack of/excess of environmental stimulation
» Little efficacy of medication
Non-pharmacological management:
» Increase socialization if appropriate
» Increase auditory stimulation (if decrease is suspect)—music
works well
» Monitor behavior carefully for triggers and rectify accordingly

34. » Try to intervene early
» Try to avoid situations that are known to
be provoking for the individual
» Use a calm and reassuring voice
» Avoid arguing or confrontation when agitated
» Approach slowly, from the front

35. » Use touch judiciously-can be perceived as
comforting or provoking
» Use non-threatening stance-should be at eye
level
» Use distraction
» Avoid the use of physical restraints

36. » 4-6% in dementia
» Consider etiology:
˃ Uncomfortable clothing
˃ Need to toilet
˃ UTI/Rash
˃ Soiled
» If found undressed calmly bring a robe or
blanket
» If found masturbating
˃ Do not react with upset or ridicule
˃ Gently lead to a private place
˃ You may (or may not) wish to distract with a tactile object
May not be sexually related

37. » Snoezelen or controlled multisensory environment
(MSE) is a therapy for people with autism or
developmental disabilities.
» It consists of placing the person in a soothing and
stimulating environment, called the "Snoezelen room".
» These rooms are specially designed to deliver stimuli to
various senses, using lighting effects, color, sounds,
music, scents, etc.
» Snoezelen therapy is used for people with autism and
other developmental disabilities, dementia, brain
injury and even toddlers.
» However, research on the benefits of treatment is
scarce, based on variable clinical study designs.

38. The ultimate aim of physiotherapy is the restoration of fullest
functional activity as possible.
and
1) To reduce pain by using heat therapy (I.R., S.W.D. Hot pack’s , Wax
bath and TENS )
2) To increase local metabolic activities (Ultrasonic therapy, U.V.R.,
Therapeutic Laser)
3) To increase or to maintain joint mobility by exercise
4) To maintain or increase muscle power by using resisted exercises
(weight cuffs , dumbbells , thera bands , roll , balls )
5)To reduce Complication, contracture and deformity
6) To enhance the vital capacity of the patient (breathing exercises ,
chest physiotherapy)

39. » Fall's
» Incontinences
» Osteoporosis
» Muscle wasting
» Lack of concentration
» Gait disturbance
» In co-ordination
» Pain
» Constipation
• Mal nutrition
• Forget to eat
• Vitamin B12, D3
• Nuts, fruits, vegetables
• Milk and milk product
• Avoid tobacco and
alcohol
• Coffee and tea
• Supplements on advice

41.  C compassionate
 A affectionate
 R reliable
 E energetic
-------------------------
 G goal directed
 I involves others
 V variety in approaches
 E enjoys his work
 R relaxes the milieu

42. » Spouse
» Daughter- in – law
» Son / Daughter
» Other family members
» Servant
» Nurse
» Trained / Skilled caregiver personnel

43.  Depression
 Exacerbation of existing physical disease
 Marital Disharmony
 Social withdrawal
 Isolation
 Financial distress
 High rate of psychological morbidity
 Anxiety
 Insomnia
 Exhaustion
 Reduced concentration
 Poor relation with other family members

44. 1) Although I cannot control the disease process, I need to
remember I can control many aspects of it
2) I need to take care of my self, so that I can continue doing
the things that are most important
3) I need to simplify my lifestyle so that my tine and energy
are available for things that are really import at this time
4) I need to cultivate the gift of allowing others to help me
because caring for my relative is too big a job done by one
person
5) I need to take one day at a time rather than worry about
what may or may not happen in future
6) I need to structure my day because a consistent schedule
makes like easier for me and my relative.

45. 7) I need to have a sense of humor because laughter helps to
put things in a more positive perspective
8) I need to remember that my relative is not being difficult
on purpose; rather that his behavior an emotions are
distorted by illness
9) I need to focus on and enjoy what my relatives can still do
rather than constantly lament over what is gone
10) I need to increasingly depend upon other relationship for
love and support
11) I need to frequently remind myself that I am doing the
best that I can at this very moment
12) I need to draw upon higher power, which I Believe is
available to me

46. Overview of problems of an Elderly and management
strategies

47. • Person centered approach
• Work with systems
– families
– professionals
– Caregivers
– organizations
• Think of Underlying unmet needs
• Underlying co-morbid conditions often un-recognized: treat
them
» Need research to know effectiveness of NPM
• Involve culture appropriate methods
» Many are simple, inexpensive and easy to implement, both in
the home and institutional setting, and can do much to improve
the quality of life and possibly even reduce the need for
medications

48. Contact:
Dr R.K. Tripathi
rastripathi@gmail.com
91+9454202905