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In the name of God Geriatric Psychiatry
Mohamad Nadi . MD Psychiatrist
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Geriatric population increasing
2000, estimated that 13% of Americans were over 65 years of age By 2050, estimates are that 22% will be over the age of 65, and 5% over age 85. The population is aging rapidly ; it is a global phenomenon
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Geriatric population increasing
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Why is it a subspecialty?
Mental disorders may have different manifestations, pathogenesis, and pathophysiology from younger adults Coexisting chronic medical illness More medicines Cognitive impairments Increased risk for social stressors, including retirement and widowhood
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What Is Normal Aging? Some bodily functions decline with age, but health problems are not inevitable. “Normal” aging must be differentiated from disease. notion of chronological age (“how old are you?”) be abandoned, and instead that the stages of aging be considered. Age cut-offs are artificial and arbitrary.
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Prevalence of Mental Illnesses
Prevalence of psychiatric disorder (excluding dementia), was considerably lower in elderly compared younger adults. Nearly 20 percent of persons older than age 65 years have diagnosable psychopathological symptoms.
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The Aging Brain Structural Changes Neurochemical Changes
Changes in Cognitive and Motor Abilities
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Structural Changes Associated with Brain Aging
Decline of brain weight Neuron loss Neuronal atrophy Synaptic loss Pruning of dendritic trees White matter changes Gliosis
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Neurochemical Changes in Aging
marked changes in dopaminergic neurons decrease in the levels of markers of the cholinergic system
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Changes in Motor Abilities
Gait slowing Reaction time slowing Balance changes (vestibular, sensory, motor, and brain)
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Changes in Cognitive Abilities
Mental speed Executive function Retrieval Episodic memory vs procedural memory Free recall worse than recognition
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Changes in Cognitive Abilities
Cognition includes learning, memory, &. . . Learning is the ability to gain new skills and information. It may be slower in elderly, especially verbal learning.
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Changes in Cognitive Abilities
Memory : immediate, short- and long- term memory. Immediate and Short-term memory remain intact, however, there ar affected by concentration which may be less in older adults. Long-term memory is most affected by aging. Retrieval is less efficient; the elderly need more cues
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Prospects for Healthy Brain Aging
Control hypertension Treat diabetes and vascular risk factors Mental activity Cognitively demanding pastimes Social networks
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Prospects for Healthy Brain Aging
Regular physical activity Diet : Similar components to a heart-healthy diet Relatively low fat and cholesterol Anti-oxidant rich diet
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Mental Disorders of old age
Most common : cognitive disorders , depressive disorders, substances use. Risk factors include loss of social roles, loss of autonomy, deaths, declining health, increased isolation, financial constraints, and decreased cognitive functioning.
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Mental Disorders of old age
Most common : cognitive disorders depressive disorders substances use.
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Cognitive Disorders Include: Delirium Dementia Amnestic Disorders
Psychiatric disorders due to a Medical Condition Postconcussional Syndrome
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Delirium 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 Usually acute and fluctuating
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Features of delirium May be accompanied by hallucinations, illusions, emotional lability, alterations in the sleep-wake cycle, psychomotor slowing or hyperactivity
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Features of delirium Types:
Hyperactive , hyperalert delirium: almost always consultation Hypoactive, hypoalert delirium: no consultation
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Prevalence of delirium
The prevalence of delirium at hospital admission ranges from 10 to 35 percent Furthermore prevalence increases with multiple factors such as age, medication use, and comorbidities
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prevalence of delirium
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The mortality of Delirium
The mortality outcome at 6 months post discharge for delirious patients not identified was three times higher than the delirious patients who were identified and treated. 25 percent of delirius postoperative patient had a lethal outcome; control population 13%
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Burden of Delirium Increased mortality Increased nursing care
Increased length of stay Increased risk of cognitive decline Increased risk of functional decline
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Burden of Delirium Delay in postoperative mobilization
Prevention of early rehabilitation Increased need for home care services Increased distress to caregivers Barrier to psychosocial closure in terminally ill patient
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Etiologies of Delirium in Elderly Patients
Systemic illnesses Infections: Pneumonia, urinary tract infection, sepsis, influenza Cardiovascular conditions: Arrhythmia, congestive heart failure, myocardial infarction, severe hypertension
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Etiologies of Delirium in Elderly Patients
Medications Anticholinergics Benzodiazepines, other sedative-hypnotics (e.g., barbiturates) Antiarrhythmics, Digoxin Certain antibiotics (e.g., fluoroquinolones, clarithromycin) Interferons
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Etiologies of Delirium in Elderly Patients
Primary brain diseases Stroke or transient ischemic attack Trauma: Brain injury, subdural hematoma Infection/inflammation: Abscess, meningitis, encephalitis,
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Etiologies of Delirium in Elderly Patients
Metabolic derangements: Dehydration, hypoxia, hypoglycemia, hyperammonemia, uremia, hyponatremia, thiamine deficiency, hyperthyroidism
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Etiologies of Delirium in Elderly Patients
Surgery or trauma Hip fracture repair Open heart surgery (e.g., coronary artery bypass grafting) Withdrawal states Alcohol Benzodiazepines, other sedative-hypnotics
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Treatment of delirium Look for underlying cause
Close supervision, especially by family Reorient frequently Try not to use restraints, as it can worsen confusion.
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Treatment of delirium Medication Avoid polypharmacy
Low dose neuroleptic is treatment of choice, unless the delirium is due to withdrawal. If due to withdrawal, use a long-acting benzodiazepine.
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Dementing Disorders Only arthritis more common in geriatric population
5% have severe dementia, and 15% mild dementia in those over 65 Over 80, 20% have severe dementia
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Dementing Disorders Most common causes: Alzheimer’s disease, vascular dementia, alcoholism, and a combination of these 3 Risk factors are age, family history, and female sex
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Dementia Changes Cognition, memory, language
Personality, abstract thinking, aphasias However, level of awareness and alertness usually intact in early stages (differentiates dementia from delirium)
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Noncognitive symptoms accompanying dementia
Depressive disorder Pathological laughter and crying Irritability and explosiveness Delusions or hallucinations occur during the course of dementias in nearly 75%
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Behavior problems in dementia
Agitation, restlessness, wandering, violence, shouting Social and sexual disinhibition, impulsiveness Sleep disturbances
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Dementia and treatable conditions
10-15% from: heart disease, renal disease, and congestive heart failure endocrine disorder, vitamin deficiency, medication misuse primary mental disorders
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Alzheimer’s Disease 50-60% of patients with dementia
5% of those who reach 65 have Alzheimer’s Disease 15-25% of those 85 or older More common in women
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Alzheimer’s Disease General sequence is memory, language, then visuospatial functions On autopsy: neurofibrillary tangles and neuritic plaques Involves cholinergic system arising in basal forebrain Death occurs in about 7 yrs
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Vascular Dementia Second most common type
Can reduce known risk factors: hypertension, diabetes, cigarette smoking, and arrhythmias
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Other types of dementia
Multiple sclerosis is characterized by multifocal lesions in the white matter. May show early mood lability Vitamin B12 deficiency--neurologic changes may occur before megaloblastic changes Hypothyroidism Wilson’s disease
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Treatment of behavior problems
Consider the likelihood of depression and anxiety first Neuroleptics should not be first choice, and should be on a “prn” basis ,unless the patient is psychotic
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Medicines for behavioral problems
Valproic acid, trazodone, and buspirone may be of benefit BZDs may aggravate confusion
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Drug treatment for Alzheimer’s Disease
Most current ones affect acetylcholine Tacrine Donepezil (Aricept) Rivastigmine (Exelon) Galantamine (Reminyl) Early intervention may prevent or slow decline
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Depression 15% of all older adult community residences and nursing home patients Accounts for 50% of older adult admissions to a psychiatric facility Age is not a risk factor, but widowhood and chronic medical illness are
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Depression May have more somatic complaints such as decreased energy, sleep problems, pain, weakness, GI disturbances Increases use of primary care medical resources
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Depression For those with a medical condition, depressive symptoms significantly reduce survival Increases risk of suicide
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Depression in medical illness
Medicines or the medical illness may cause depression Rule out medical causes Use psychological symptoms such as hopelessness, worthlessness, guilt
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Depression in older adults
May have delusions which are usually persecutory or hypochondriacal in nature Need treatment with both an antidepressant and an antipsychotic ECT may be treatment of choice
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Bereavement Normal grief starts with shock, proceeds to preoccupation, then to resolution 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
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Bipolar Disorder Do organic workup if onset is over 65
Usually more irritable than euphoric, and paranoid rather than grandiose May have dysphoric mania, with pressured speech, flight of ideas, and hyperactivity, but thought content is morbid and pessimistic
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Schizophrenia Usually before 45, but there is a late onset type beginning after age 65 Paranoid type more common Residual type occurs in 30% of those affected: Emotional blunting, social withdrawal, eccentric behavior, and illogical thinking predominate
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Delusional Disorder Onset between 40 and 55
Persecutory or somatic delusions most common May be precipitated by stress, loss, social isolation , visual impairment, deafness, immigrant status
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Anxiety Disorders Very common in elderly
May occur first time after age 60, but not usually Most common are phobias, especially agoraphobia May be due to medical causes or depression
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Substances and Alcohol
Brain is more sensitive as ages Due to changes in metabolism, a given amount may produce a higher blood level May worsen normal changes in sleep and sexual functioning Sudden onset delirium in hospitalized patients usually from withdrawal
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Personality disorders
Borderline, narcissistic, and histrionic personality disorders may become less intense Before diagnosing a personality disorder, verify that it is not an improperly treated Axis I disorder Some personality traits may become more pronounced
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Sleep disorders Advanced age is associated with increased prevalence of sleep disorders REM sleep behavior disorder occurs among elderly men Advanced sleep phase Dementia associated with more arousals, increased stage I sleep; decreased stages 3/4
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