2. Mental health and older people prepared by hassan abu rahma prepared by hassan abu rahma Supervised by : Dr. Abd Al Kareem Radwan

3. Background and epidemiology Background and epidemiology AGEING AND HEALH AGEING AND HEALH Older people mental health prevalence and impact of mental health problems Older people mental health prevalence and impact of mental health problems Prevalence 0f mental disorder 1n relation to demographic factors Inter-relation between physical and mental disorder Prevalence 0f mental disorder 1n relation to demographic factors Inter-relation between physical and mental disorder Inter-relation between disability and mental disorder Inter-relation between disability and mental disorder Older hospital setting patient in general Older hospital setting patient in general Older people in nursing and residential homes Older people in nursing and residential homes

4. Background and epidemiology Improved living standard and success in combating many diseases have led to increase life expectancy Improved living standard and success in combating many diseases have led to increase life expectancy industrialized societies people are living healthier and longer than ever before industrialized societies people are living healthier and longer than ever before In the UK between 1971and2003 the number of people over 65 changed 28% and 2002 life expectancy for female 81 years and 76 for male In the UK between 1971and2003 the number of people over 65 changed 28% and 2002 life expectancy for female 81 years and 76 for male People aged 85 are fastest rising population People aged 85 are fastest rising population England currently over6000 people over 100 yrs England currently over6000 people over 100 yrs

5. STAGE POPULATION POPULATION STRUCTURE STAGE POPULATION POPULATION STRUCTURE 1-THE FIRST AGE OF SOCIOLIZATION 1-THE FIRST AGE OF SOCIOLIZATION 2- SECOND AGE OF WORK AND CHILD- REARING 2- SECOND AGE OF WORK AND CHILD- REARING 2_THIRD AGE POST EMPLOYMENT 2_THIRD AGE POST EMPLOYMENT THIRD AGE SECON D AGE FIRT AGE BIRTH DECAD E 376211900 1167211950 2155241990 ACENTURY OF CHANGE PRECNTAGE DISTRIBUTION BY AGES OF LIFE FOR THE BRITISH POPULATION

6. يشير تقرير إحصائي صادر عن الجهاز المركزي للإحصاء الفلسطيني بمناسبة اليوم العالمي للمسنين تحسن طرأ على أوضاع المسنين الفلسطينيين أدى الى ارتفاع معدلات البقاء على قيد الحياة إلى نحو 5-6 سنوات خلال العقد ونصف العقد الماضيين. يشير تقرير إحصائي صادر عن الجهاز المركزي للإحصاء الفلسطيني بمناسبة اليوم العالمي للمسنين تحسن طرأ على أوضاع المسنين الفلسطينيين أدى الى ارتفاع معدلات البقاء على قيد الحياة إلى نحو 5-6 سنوات خلال العقد ونصف العقد الماضيين. وارتفع عمر المسنين من نحو 67.0 سنة لكل من الذكور والإناث عام 1992 إلى 71.8 سنة للذكور و 73.3 سنة للإناث لعام 2006 ، وقد أدى ارتفاع معدل توقع البقاء على قيد الحياة عند الولادة إلى ارتفاع أعداد كبار السن في الأراضي الفلسطينية. وارتفع عمر المسنين من نحو 67.0 سنة لكل من الذكور والإناث عام 1992 إلى 71.8 سنة للذكور و 73.3 سنة للإناث لعام 2006 ، وقد أدى ارتفاع معدل توقع البقاء على قيد الحياة عند الولادة إلى ارتفاع أعداد كبار السن في الأراضي الفلسطينية.

7. ففي منتصف العام 2009 حسب الإحصاء الفلسطيني، بلغت نسبة كبار السن ( الأفراد 60 سنة فأكثر ) 4.4% من مجمل السكان في الأراضي الفلسطينية ( بواقع 4.9% في الضفة الغربية و 3.7% في قطاع غزة ) ، مع العلم أن نسبة كبار السن في الدول المتقدمة مجتمعة قد بلغت حوالي 16.0% من إجمالي سكان تلك الدول، في حين تبلغ نسبة كبار السن في الدول النامية مجتمعة حوالي 6.0% فقط من إجمالي سكان تلك الدول. ففي منتصف العام 2009 حسب الإحصاء الفلسطيني، بلغت نسبة كبار السن ( الأفراد 60 سنة فأكثر ) 4.4% من مجمل السكان في الأراضي الفلسطينية ( بواقع 4.9% في الضفة الغربية و 3.7% في قطاع غزة ) ، مع العلم أن نسبة كبار السن في الدول المتقدمة مجتمعة قد بلغت حوالي 16.0% من إجمالي سكان تلك الدول، في حين تبلغ نسبة كبار السن في الدول النامية مجتمعة حوالي 6.0% فقط من إجمالي سكان تلك الدول.

8. AGEING AND Health Added life to years not just more to life Added life to years not just more to life A growing body of evidence counter the stereotype that ageing is inevitable associated with sickness A growing body of evidence counter the stereotype that ageing is inevitable associated with sickness The optimistic some of studies factor such as diet,,marital stability, exercise,education,mental stimulation The optimistic some of studies factor such as diet,,marital stability, exercise,education,mental stimulation And social involvement are associated with longevity a And social involvement are associated with longevity a And quality of the life And quality of the life Some study in Sweden for people aged 85.more than three quarters were identified as having high levels of subjective well being measured by high and moderate levels on morale scale Some study in Sweden for people aged 85.more than three quarters were identified as having high levels of subjective well being measured by high and moderate levels on morale scale

9. The combination of this higher frequency of the physical ill health The combination of this higher frequency of the physical ill health And disability with other factor associated with ageing cognitive And disability with other factor associated with ageing cognitive Impairment,socio economic deprivation and social support deficit Impairment,socio economic deprivation and social support deficit This factor increase incidence of commonest metal health problem This factor increase incidence of commonest metal health problem Depression, anxiety disorder among oldest old Depression, anxiety disorder among oldest old Trends for increasing proportion of older people in population and having less disability and independent. Depend on continuing social Trends for increasing proportion of older people in population and having less disability and independent. Depend on continuing social,economic,and health care improvement,economic,and health care improvement Older people live alone without family support structure present a special challenge and need for innovation by health care providers Older people live alone without family support structure present a special challenge and need for innovation by health care providers

10. Older people mental health prevalence and impact of mental health problems Mental disorder are common in general population affecting more than a quarter of all people at some time in their life WHO 2001 Mental disorder are common in general population affecting more than a quarter of all people at some time in their life WHO 2001 Mental disorder accounted for four of 10 leading cause of the of disability Mental disorder accounted for four of 10 leading cause of the of disability Point prevalence rate for adult experiencing any mental disorder are 10 % Point prevalence rate for adult experiencing any mental disorder are 10 % To 15% To 15% The frequency of mental illness in elderly may be under-reported" make diagnosis in the presence of physical co-morbidity “ The frequency of mental illness in elderly may be under-reported" make diagnosis in the presence of physical co-morbidity “ Depressive and anxiety disorder affect between 1-7 people1-10 Depressive and anxiety disorder affect between 1-7 people1-10 Dementia and delirium of 11-17 and 1-25 {beekman1999,chew graham 2004} Dementia and delirium of 11-17 and 1-25 {beekman1999,chew graham 2004} SOME study in UK lower levels of common mental disorder in aged 60 SOME study in UK lower levels of common mental disorder in aged 60 And older these community studies are individual living in private house And older these community studies are individual living in private house Exclude people in situation,temporary hospitalized or homeless Exclude people in situation,temporary hospitalized or homeless UK 1996 33200 people living in hospital and 350000 older people having care in homes as mental disorder UK 1996 33200 people living in hospital and 350000 older people having care in homes as mental disorder

11. Prevalence 0f mental disorder 1n relation to demographic factors 1-gender 1-gender 1male to2 female 1male to2 female 2-MARITAL STATUS 2-MARITAL STATUS Marital disruption is consistently associated with higher rate of common mental disorder UK 7%MEN 12%FEMAL divorced status and separation associated mental disorder proportion divorce in Palestine 11.65 % Marital disruption is consistently associated with higher rate of common mental disorder UK 7%MEN 12%FEMAL divorced status and separation associated mental disorder proportion divorce in Palestine 11.65 % 3-socio-economic status 3-socio-economic status problem increase after 29 yrs that effects income,social class unemployment problem increase after 29 yrs that effects income,social class unemployment,,financial strain and education status impact by disorder prevalence,,financial strain and education status impact by disorder prevalence

12. Inter-relation between physical and mental disorder Inter-relations between physical and psychological health are evident with in all age however the frequency of negative association – co-morbidity rise with age Inter-relations between physical and psychological health are evident with in all age however the frequency of negative association – co-morbidity rise with age The frequency of interaction and severity of its effects are magnified in older The frequency of interaction and severity of its effects are magnified in older Much research has explored the relationship between depression and cardiac Much research has explored the relationship between depression and cardiac patient ’ compare with non depressed cardiac patient.the mortality rate patient ’ compare with non depressed cardiac patient.the mortality rate threefold increased in cardiac patient have major depression threefold increased in cardiac patient have major depression Epidemiological study has explored the dynamic of the interaction between Epidemiological study has explored the dynamic of the interaction between Physical illness and mental disorder Physical illness and mental disorder Physical illness appear to be an important risk factor for development of Physical illness appear to be an important risk factor for development of several mental agoraphobia in older people may be commonly precipitated several mental agoraphobia in older people may be commonly precipitated By stork and falls rather than associated with panic disorder. patient with By stork and falls rather than associated with panic disorder. patient with Chronic medical illness have increased risk of depressive illness Chronic medical illness have increased risk of depressive illness Older people have vascular disease prescribed medication may make mood disorder Older people have vascular disease prescribed medication may make mood disorder

13. Inter-relation between disability and mental disorder study appear disability resulting from physical illness are associated with common mental disorder especially depression study appear disability resulting from physical illness are associated with common mental disorder especially depression The disability arising from physical ill health has been estimated to be The disability arising from physical ill health has been estimated to be Cause of up 70%of new cases of depression in older people Cause of up 70%of new cases of depression in older people Depression cause disability features Depression cause disability features 1-reduce motivation 1-reduce motivation 2-psychomotorretardation 2-psychomotorretardation 3- poor sleep 3- poor sleep 4-lack of energy 4-lack of energy 5- avoidance and anhedonia 5- avoidance and anhedonia Are likely to limit activity and physical disability. They are mutual reinforcement process Are likely to limit activity and physical disability. They are mutual reinforcement process

14. Older hospital setting patient in general older people occupy tow – third of general hospital beds And exhibit a high prevalence of co-morbid mental disorder Predominantly delirium dementia and depression Predominantly delirium dementia and depression Level of patient with depression 50% {ames 1994} Co-exist with medical condition especially chronic illness sush as ischemic heart disease,stroke,cancer,chronic lung disease,Alzheimer's,and Parkinson disease likely to be prevalent At levels three time in the community

15. Problem affect mental disorder in hospital 1-length of stay 2- use of resource 3- cost of care 4- prognosis the complex range of physical and emotional and social problems are demand high level of skill from care staff and resource the recognition of mental problems in physical ill older people is made more difficult by the inter action of illness feature

16. Example depression symptom of anorexia.poor sleeping, and weight loss result from variety of physical condition physical feature such as aches pains fatigue may be aspect of mental disorder should be have screening measure in the hospital to identify mental health problem such as geriatric depression scale Example depression symptom of anorexia.poor sleeping, and weight loss result from variety of physical condition physical feature such as aches pains fatigue may be aspect of mental disorder should be have screening measure in the hospital to identify mental health problem such as geriatric depression scale

17. Older people in nursing and residential homes  Another setting is high prevalence of mental disorder among older people with absence optimal management  Is residential care   Care home are differentiated on the basis of whether they provide personal and social car   Research indicate that new admissions to all types of care homes in the UK increasingly old  Residents are more disabled than previously with higher level of cognitive impairment  Prevalence level of dementia 50%   Depression in USA PREVALENCE 20% TO 40% of  residents  residents

18. homes scored adequately in respect of non-restrictive care practice,standard homes scored adequately in respect of non-restrictive care practice,standard Of d é cor and cleanliness and facilities Of d é cor and cleanliness and facilities For activity and recreation For activity and recreation

19. Mental disorder are common when residential facilities is poor,limited social interaction and daily activity Challenges 1-staffing levels and skill mix match the type and complexity of client needs “ support ” 2- training of staff 3- absence of policy intervention 4-costs

20. mental health and older people specific disorder mental health and older people specific disorder 1- depression 1- depression 2- anxiety disorder 2- anxiety disorder 3- dementia 3- dementia 4- delirium 4- delirium

21. depression Prevelance major depression among older people 1% to 4% and in minor depression 4% to 12%. Increased over aged 80% Prevelance major depression among older people 1% to 4% and in minor depression 4% to 12%. Increased over aged 80% Older people with depression have longer duration of episodes and shorter time of relapse than younger persons Older people with depression have longer duration of episodes and shorter time of relapse than younger persons 30% remain chronicly depressed 30% remain chronicly depressed

22. The longer duration of episodes appear The longer duration of episodes appear To be co-existing physical illness To be co-existing physical illness To be poor self health status To be poor self health status To be depressed severity To be depressed severity Inadequacy social support Inadequacy social support Adverse life event Adverse life event

23. Depression,loneliness and social support The social environment plays crucial part in determining the quality of older people lives The social environment plays crucial part in determining the quality of older people lives Inters personal relationship have been found to act buffer between adverse event and depression Inters personal relationship have been found to act buffer between adverse event and depression Loneliness is associated with living alone and social isolation Loneliness is associated with living alone and social isolation

24. Vulnerability factor for loneliness Female Female Chronic health problem Chronic health problem Marital status Marital status Loneliness cause to increase depression and caused increased mortality rate Loneliness cause to increase depression and caused increased mortality rate

25. Suicide and depression Elderly people have the highest rate of completed suicide rate of any age group Elderly people have the highest rate of completed suicide rate of any age group

27. Assessment of depression and suicide risk in older people Depression in older people commonly complicates Depression in older people commonly complicates because co-morbid medical illness or dementia because co-morbid medical illness or dementia The clinical presentation may be typical and meet full criteria for depressive disorder The clinical presentation may be typical and meet full criteria for depressive disorder Stigma prevent seek help for emotional problem Stigma prevent seek help for emotional problem

28. Useful questions for uncovered depression Are you sad? Are you sad? Are you sleeping poorly? Are you sleeping poorly? Do you worry to much ? Do you worry to much ? What have you enjoyed doing later ? What have you enjoyed doing later ? Rating scale Rating scale during the past month,have you often been bother by feeling down,depressed or hopeless? Yes or no during the past month,have you often been bother by feeling down,depressed or hopeless? Yes or no During the past month have you often been bothered by little interest or pleasuer in doing things ?yes or no During the past month have you often been bothered by little interest or pleasuer in doing things ?yes or no

30. Depression management Ani depression treatment Ani depression treatment Psychological treatment Psychological treatment Cognitive treatment Cognitive treatment Problem solving therapy Problem solving therapy

31. Antidepressant treatment 50% to60% of older people improved 50% to60% of older people improved Studies have indicated that older patient treated with antidepressants should stay 12 month to two year's Studies have indicated that older patient treated with antidepressants should stay 12 month to two year's Older patient are have more side effect because of higher levels of multiple drug prescribing Older patient are have more side effect because of higher levels of multiple drug prescribing

32. Antidepressant drug 1- SSRI fluxetine, fluvoxamine 1- SSRI fluxetine, fluvoxamine 2- tricyclic imipramine, clomipramine 2- tricyclic imipramine, clomipramine 3-monoamone oxidase inhibition,phenelzine,selegiline 3-monoamone oxidase inhibition,phenelzine,selegiline 4- atypical bupropion,mitrazapine, nefazodone 4- atypical bupropion,mitrazapine, nefazodone 5- SNRI duloxetine,venlafaxine 5- SNRI duloxetine,venlafaxine

33. Other antidepressant substance Folk remedies Folk remedies Extract of st john wort Extract of st john wort 5-hydroxytryptophan and tryptophan 5-hydroxytryptophan and tryptophan Is amioacde available as dietary supplement and alternative treatment {conventional } difficult conclusion about efficacy Is amioacde available as dietary supplement and alternative treatment {conventional } difficult conclusion about efficacy

34. Psychological therapies Is important and enhancing the effect of medication and reducing relapse follow cessation of treatment and it is consistently found to be more acceptable than other treatment Is important and enhancing the effect of medication and reducing relapse follow cessation of treatment and it is consistently found to be more acceptable than other treatment

35. Cognitive behavior therapy Most establish treatment for depression and the aims to alter dysfunctional beliefs and negative thoughts that characterize depression by sessions Most establish treatment for depression and the aims to alter dysfunctional beliefs and negative thoughts that characterize depression by sessions CBT need some adaptation for work with older people because of different life experience and value related ego CBT need some adaptation for work with older people because of different life experience and value related ego

36. Problem solving therapy Defining the problem and goal selecting and Appling means of achieving the goal Defining the problem and goal selecting and Appling means of achieving the goal

37. Model of care :community mental health team for older people The involvement of community mental health teams for older people in depression management is associated with improved outcomes The involvement of community mental health teams for older people in depression management is associated with improved outcomes Co ordinate by a multi-disciplinary team compared with normal primary care delivered improvement for disable elderly receiving home care Co ordinate by a multi-disciplinary team compared with normal primary care delivered improvement for disable elderly receiving home care Regular monitoring physical health review, antidepressant prescribing and promotion of social involvment Regular monitoring physical health review, antidepressant prescribing and promotion of social involvment

38. Collaborative and case management approaches Primary care occupies a strategic potion in the management of late life depression and more feasible treatment setting for all except the sever and complex presentation Primary care occupies a strategic potion in the management of late life depression and more feasible treatment setting for all except the sever and complex presentation Approaches applies Approaches applies Chronic disease model to care, uses evidence based guideline, adherence program telephone support, with rapid direct access to specialist advice and support Chronic disease model to care, uses evidence based guideline, adherence program telephone support, with rapid direct access to specialist advice and support

39. Anxiety disorder Is co morbid with depression Is co morbid with depression Anxiety symptom and disorder among older people are associated with disability,reduce equality of life, increase use health services Anxiety symptom and disorder among older people are associated with disability,reduce equality of life, increase use health services Prevalence 10% making these mental disturbance in the late life Prevalence 10% making these mental disturbance in the late life The rate of anxiety disorder are around twice a high among women as men The rate of anxiety disorder are around twice a high among women as men

40. Vulnerability factor Lower level of education Lower level of education External locus of control External locus of control Resent loss of family Resent loss of family Physical illness Physical illness

41. Other factors induce anxiety Aspect of environment Aspect of environment Medication side effects {table 17.3} Medication side effects {table 17.3} Alcohol intoxication or withdrawal Alcohol intoxication or withdrawal *factors contribute to poor recognition *factors contribute to poor recognition 1-other common mental disorder 1-other common mental disorder 2- medical co-morbidity 2- medical co-morbidity 3- early age of onest and no treatment 3- early age of onest and no treatment

42. Treatment for anxiety disorder in later life Tricyclic antidepressant Tricyclic antidepressant 1-clomiparmine hydrochloride 1-clomiparmine hydrochloride 2- imipramin hydrochloride 2- imipramin hydrochloride General anxiety improved with anti depressants drug General anxiety improved with anti depressants drug

43. benzodiazepines Commonly used Commonly used Beneficial effect on symptoms of panic and general anxiety disorders Beneficial effect on symptoms of panic and general anxiety disorders Side effect drowsiness {driving accident risk} Side effect drowsiness {driving accident risk}

44. Psychological treatment CBT IS EFFECTIVE for older people CBT IS EFFECTIVE for older people Situational exposure, relaxation technique,self control desensitization and cognitive restructuring Situational exposure, relaxation technique,self control desensitization and cognitive restructuring

45. dementia Major health public problem Major health public problem It is neurodegenerative syndrome characterized by global,progressive impairment of cerebral function.it is primary disturbs higher brain function such as memory,thinking, orientation, comprehension, calculation learning, language and judgment It is neurodegenerative syndrome characterized by global,progressive impairment of cerebral function.it is primary disturbs higher brain function such as memory,thinking, orientation, comprehension, calculation learning, language and judgment Manifests in loss memory {resent event } and loss executive function such as ability to organise complex tasks or make decision Manifests in loss memory {resent event } and loss executive function such as ability to organise complex tasks or make decision Demintia affect about 7%of people aged over 65 years and 30% aged over 90 years Demintia affect about 7%of people aged over 65 years and 30% aged over 90 years

46. Subtype of dementia 1- Alzheimer disease 1- Alzheimer disease 2- vascular dementia 2- vascular dementia 3- lewy bodies and frontal lobe dementia 3- lewy bodies and frontal lobe dementia Alzheimer disease is the commonest 50% of cases slow onset slow deterioration Alzheimer disease is the commonest 50% of cases slow onset slow deterioration Vascular dementia abrupt onset step – wise deterioration,early gait,seizure, urinary disturbance and history of stroke Vascular dementia abrupt onset step – wise deterioration,early gait,seizure, urinary disturbance and history of stroke [greater prevalence of hypertension and stroke [greater prevalence of hypertension and stroke Important risk factor for dementia age and family history Important risk factor for dementia age and family history

47. Cerbrovaccular disease Risk factor Risk factor 1- raised blood pressure 1- raised blood pressure 2- DM 2- DM 3- HIGH CHOLESTROL 3- HIGH CHOLESTROL 4- High fat in take 4- High fat in take 5- obesity 6- smoking

48. assessment Patient need to link primary health care and secondary,social services voluntary organization …… Patient need to link primary health care and secondary,social services voluntary organization …… Stigma can effect on treatment so patient and family need education Stigma can effect on treatment so patient and family need education Clinical assessment memory impairment aphasia agnosia, apraxia function disturbance {instrumental activities of daily living} Clinical assessment memory impairment aphasia agnosia, apraxia function disturbance {instrumental activities of daily living} Physical examination is very important Physical examination is very important

49. Mini-mental state examination 25-30 normal 25-30 normal 18-24 mild to moderate impairment 18-24 mild to moderate impairment 17 or less impairment in daily activity 17 or less impairment in daily activity

50. treatment Prevention strategies and interventions to slow disease progress Prevention strategies and interventions to slow disease progress 1- blood pressure and vascular factor 1- blood pressure and vascular factor 2- nutrition,diet and dietary supplement 2- nutrition,diet and dietary supplement 1-omega 3 polyunsaturated fatty acid {oily fish 1-omega 3 polyunsaturated fatty acid {oily fish 3- limits vitamin C and E 3- limits vitamin C and E 4-limit green tea 4-limit green tea 5- ginkgo biloba {leaf decorative tree} 3- life style social involvement, physical exercise and cognitive activities

51. Drug treatment 1- Cholinesterase inhibitor 1- Cholinesterase inhibitor 1- donepezil 1- donepezil 2- rivastigmine 2- rivastigmine 3- galantamine 3- galantamine 2-atypical neuroleptic drug treat behavioral manifistation of demintia {lewy bodeis} 2-atypical neuroleptic drug treat behavioral manifistation of demintia {lewy bodeis}

52. Psychosocial intervention 1-enviromental modification aroma, music, reduce noisy, exercise 2-oriantation places time person 3-reminiscence therapy {talked about past } carer support 1-professional and organization practice 2-communty mental health old age services

53. delirium know as confusional state,is a common and serious of mortality and morbidity among older hospitalized patient, the core diagnostic criteria for delirium are acute generalized impairment of consciousness and attention, global disturbance of cognition and perceptual abnormalities know as confusional state,is a common and serious of mortality and morbidity among older hospitalized patient, the core diagnostic criteria for delirium are acute generalized impairment of consciousness and attention, global disturbance of cognition and perceptual abnormalities Key features rapid onset,fluctuating course, disturbance of the sleep walk disturbance Key features rapid onset,fluctuating course, disturbance of the sleep walk disturbance Delirium may be mistaken for avarity o other disorder including mood disorder,demintia,psychotic illness Delirium may be mistaken for avarity o other disorder including mood disorder,demintia,psychotic illness

54. Aeti0logy is multifactorial 1- head injury 2- renal, hepatic failar 3- hypoglycemia 4-heart failar,shock 5- electrolyte imbalance 6-substance intoxication 7- infection tow and six factor may present in single patient

55. Prevention and early intervention The prompt detection of delirium is important as it is potentially reversible The prompt detection of delirium is important as it is potentially reversible Patient risk factor need Patient risk factor need Good nurse practitioner,team work Good nurse practitioner,team work Encourage patient to exercise.walking,mental stimulation,discussing current event, reduce hypnotic drug,relaxation,treatment medical problem Encourage patient to exercise.walking,mental stimulation,discussing current event, reduce hypnotic drug,relaxation,treatment medical problem

56. management Environmental and supportive intervention are a crucial part of management of distress and disturbed behavior of the delirium Environmental and supportive intervention are a crucial part of management of distress and disturbed behavior of the delirium

58. Delirium rating scale item Temporal onset, perceptual disturbance, psychomotor behavior, cognition status, physical disease, sleep wake disturbance, mood and fluctuation of features Temporal onset, perceptual disturbance, psychomotor behavior, cognition status, physical disease, sleep wake disturbance, mood and fluctuation of features

59. Pharmacological approache Anti-psychotic drug especially that are less sedative,ant cholinergic Anti-psychotic drug especially that are less sedative,ant cholinergic Benzodiazepines related alcohol withdrawal Benzodiazepines related alcohol withdrawal

60. Thanks for Your Attention!!!