1. In the name of God Geriatric Psychiatry
Mohamad Nadi . MD
Psychiatrist

2. 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

3. Geriatric population increasing

4. 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

5. 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.

6. 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.

7. The Aging Brain Structural Changes Neurochemical Changes
Changes in Cognitive and Motor Abilities

8. Structural Changes Associated with Brain Aging
Decline of brain weight
Neuron loss
Neuronal atrophy
Synaptic loss
Pruning of dendritic trees
White matter changes
Gliosis

9. Neurochemical Changes in Aging
marked changes in dopaminergic neurons
decrease in the levels of markers of the cholinergic system

10. Changes in Motor Abilities
Gait slowing    
Reaction time slowing    
Balance changes (vestibular, sensory, motor, and brain)

11. Changes in Cognitive Abilities
 Mental speed    Executive function    Retrieval    Episodic memory vs procedural
memory    Free recall worse than recognition

12. 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.

13. 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

14. Prospects for Healthy Brain Aging
Control hypertension
Treat diabetes and vascular risk factors
Mental activity    Cognitively demanding pastimes    Social networks

15. 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

16. 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.

17. Mental Disorders of old age
Most common :
cognitive disorders
depressive disorders
substances use.

18. Cognitive Disorders Include: Delirium Dementia Amnestic Disorders
Psychiatric disorders due to a Medical Condition
Postconcussional Syndrome

19. 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

20. Features of delirium
May be accompanied by hallucinations, illusions, emotional lability, alterations in the sleep-wake cycle, psychomotor slowing or hyperactivity

21. Features of delirium Types:
Hyperactive , hyperalert delirium: almost always consultation
Hypoactive, hypoalert delirium: no consultation

22. 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

23. prevalence of delirium

24. 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%

25. Burden of Delirium Increased mortality Increased nursing care
Increased length of stay
Increased risk of cognitive decline
Increased risk of functional decline

26. 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

27. 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

28. Etiologies of Delirium in Elderly Patients
Medications
Anticholinergics
Benzodiazepines, other sedative-hypnotics (e.g., barbiturates)
Antiarrhythmics, Digoxin
Certain antibiotics (e.g., fluoroquinolones, clarithromycin)
Interferons

29. Etiologies of Delirium in Elderly Patients
Primary brain diseases
Stroke or transient ischemic attack
Trauma: Brain injury, subdural hematoma
Infection/inflammation: Abscess, meningitis, encephalitis,

30. Etiologies of Delirium in Elderly Patients
Metabolic derangements:
Dehydration, hypoxia, hypoglycemia, hyperammonemia, uremia, hyponatremia, thiamine deficiency, hyperthyroidism

31. 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

32. Treatment of delirium Look for underlying cause
Close supervision, especially by family
Reorient frequently
Try not to use restraints, as it can worsen confusion.

33. 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.

34. 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

35. 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

36. Dementia Changes Cognition, memory, language
Personality, abstract thinking, aphasias
However, level of awareness and alertness usually intact in early stages (differentiates dementia from delirium)

37. 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%

38. Behavior problems in dementia
Agitation, restlessness, wandering, violence, shouting
Social and sexual disinhibition, impulsiveness
Sleep disturbances

39. Dementia and treatable conditions
10-15% from:
heart disease, renal disease, and congestive heart failure
endocrine disorder, vitamin deficiency,
medication misuse
primary mental disorders

40. 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

41. 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

42. Vascular Dementia Second most common type
Can reduce known risk factors: hypertension, diabetes, cigarette smoking, and arrhythmias

43. 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

44. 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

45. Medicines for behavioral problems
Valproic acid, trazodone, and buspirone may be of benefit
BZDs may aggravate confusion

46. 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

47. 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

48. Depression
May have more somatic complaints such as decreased energy, sleep problems, pain, weakness, GI disturbances
Increases use of primary care medical resources

49. Depression
For those with a medical condition, depressive symptoms significantly reduce survival
Increases risk of suicide

50. Depression in medical illness
Medicines or the medical illness may cause depression
Rule out medical causes
Use psychological symptoms such as hopelessness, worthlessness, guilt

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. 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

58. 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

59. 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