General principles in geriatric psychiatry

transcript

GENERAL PRINCIPLES IN

GERIATRIC PSYCHIATRY PRESENTED BY :

Dr. Shubham Sadh (Dept of Manasa Roga)

SDMCAH HASSAN

EMAIL ID: (shubhamsadh@gmail.com)

CONTENTS• INTRODUCTION• DEMOGRAPHICS• DEFINITION• GERIATRIC PSYCHIATRY• COMMON CAUSES IN GERIATRIC PSYCHIATRY• GENERAL SIGNS AND SYMPTOMS OF GERIATRIC

PSYCHIATRY• PSYCHIATRY ASSESSMENT IN ELDERLY• MENTAL DISORDERS IN OLD AGE• GENERAL LINE OF MANAGEMENT• CONCLUSION

INTRODUCTION

• The term geriatric was coined in the USA by Dr. Ignatz Nascher in 1909.

“THE GOAL OF LIFE IS TO DIE YOUNG AS LATE AS POSSIBLE”

-Asle Montegue

DEMOGRAPHICS• The World population of the elderly is increasing

and by the year 2050, adults older than 65 years

will comprise 1/5th of the global population.

• In India 3.8% of the population are older than

65 years of age.

• According to an estimate the likely number of

elderly people in India by 2016 will be around

113 million.

Elderly Population in IndiaCensus Data & Projections

1901 1911 1921 1931 1941 1951 1961 1971 1981 1991 2001 2011 2016 2026 2051

millions

DEFINITIONS• GERIATRICS : A branch of Medicine dealing exclusively

with the problems of ageing and the diseases of the elderly. It is derived from the Greek root “ger –gero-geronto” meaning “old age” or “the aged”.

• GERANTOLOGY: The science dealing with old age.

• GERANTOLOGISTS : A person who treats problems related to ageing.

• OLD AGE: It is defined as the period beyond the retirement age, usually taken as starting around 65years of age

“The processes that occur during life which culminate in changes that decrease an individual's ability to cope with biological changes”.

Ageing

SYNONYMS OF AGEING:• Senescence

• Senility

• Senium.

• Geria

CLASSIFICATION OF AGEAGE

Chronological age - number of years lived

Biological age – age by body function

Psychological age – age how individuals feels it

CHRONOLOGICAL CATEGORIES •Young-Old - (ages 65 - 74) Set Old Age

•Middle-Old - (ages 75 - 84) Old Old Age

•Old-Old - (age 85 and older) Ripe Old Age

ACCORDING TO AYURVEDA• JARA – Derived from the root word

“eÉ×wÉç uÉrÉÉåWûÉlÉÉæ” explained as-

A) “uÉrÉ:M×üiÉzsÉjÉqÉÉÇxÉÉÌS AuÉxjÉÉpÉåS:”

B) In shabda koustubha, the word जरा has been defined as “zÉæÍjÉsrÉ AmÉÉSMüÉuÉxÉjÉÉ”

C) Acc to gurubalaprabhodika commentary on amar kosha “eÉÏUrÉÎliÉ AlÉÉrÉÉå AÇ…ÄÉÌlÉ CÌiÉ eÉUÉ:”

Types of Jara

Kalaja Jara:

Jara coming at the proper age is Kalaja Jara(after 60 yrs.). •It is ‘Parirakshana Krita’• chronological Ageing.• Dhatu kshaya janya jara.

Akalaja Jara – The Concept of Premature Ageing:

‘ Akalotpanna lakshana Akalaja’, ‘ Akale jata iti Akalaja’ means that thing which occurs Akalaja i.e. before its prescribed time.• This Akalaja Jara is of greater intensity, rapidly progressing one if neglected. • Biological Ageing. •Marga avarodha janya jara.

Ageing

Srotokharatwa(srotovahani)

Improper absorption &

assimilation of ahara rasa

Disequilibrium in upchaya &

apchaya

Rasadhatu kshaya

Uttarotara dhatu kshaya

Ojokshaya

Vata vriddhi

How Vata vriddhi occurs during ageing?

ACHARYA BALYAM MADHYAMAM VARDHIKYAM

CHARAKA Birth to 30years1. Aparipakvadhat

u birth to 16years

2. Vivardhamanadhatu 16 to 30 years

30 To 60 years 60 to 100 years

SUSHRUTA Birth to 16 years1. Ksheerapa birth

to 1yr.2. Kheerannada 1

to 2 yr.3. Annada 2 to 16

16 to 70 years1. Vriddhi 16 to 20

yr2. Yauvana 20 to

30 yr3. Sampurna 30 to

40 yr4. Hani 40 to 70 yr

70 onwards

VAGBHATA Birth to 34 years1. Kaumara birth

to 16yr2. Yauvana 16 to

34 yrs

34 to 70 yrs 70 onwards

MILESTONES OF AGEINGVAGBHATA VIEW

0 10 20 30 40 50 60 70 80 90 100BALYAMVRIDDHI

PRABHAMEDHA

TWAKSHUKRA

DRISHTISROTO

INDRIYA

SPARSHAINDRIYA

AGE INYEARS

SHARANGDHARA VIEW

0 10 20 30 40 50 60 70 80 90 100

BALYAM

VRIDDHI

DRISHTI

SHUKRAVIKRANA

BUDDHI

KARMENDRIYA

JEEVITA

AGE INYEARS

uÉÚ®: ÌlÉuÉïcÉlÉ • Acharya Charaka:

eÉÏhÉï- AiÉ: mÉUÇ WûÏrÉqÉÉlÉ kÉÉÎiuÉÎlSìrÉ oÉsÉuÉÏrÉïmÉÉæÂwÉmÉUÉ¢üqÉaÉëWûhÉkÉÉUhÉxqÉUhÉuÉcÉlÉÌuÉ¥ÉÉlÉÇ ´ÉqrÉqÉÉlÉkÉÉiÉÑaÉÑhÉÇ uÉÉrÉÑkÉÉiÉÑmÉëÉrÉ ¢üqÉãhÉ eÉÏhÉïqÉÑcrÉiÉã AÉuÉvÉiÉqÉç|

(cÉ.ÌuÉ. 8/122)

• The dhatus, indriyas, bala, virya, pourusha etc.. Gradually degenerates.

• The qualities of dhatus goes down

• Predominance of vayu

• Acharya sushruta: uÉ×®: - ¤ÉÏrÉqÉÉhÉ

kÉÉÎiuÉÎlSìrÉoÉsÉuÉÏrÉï EixÉÉWûqÉWûlrÉWûÌlÉ uÉsÉÏmÉÍsÉiÉZÉÉÍsÉirÉeÉÑ¹Ç MüÉxÉpuÉÉxÉmÉëpÉ×ÌiÉÍpÉÂmÉSìuÉæUÍpÉpÉÔrÉqÉÉlÉÇ xÉuÉï-Ì¢ürÉÉxuÉxÉqÉjÉïÇ eÉÏhÉÉïaÉÉUÍqÉuÉÉÍpÉuÉ×¹ qÉuÉxÉÏSliÉÇ uÉ×®qÉÉcÉ¤ÉiÉå|

(xÉÑ.xÉÔ.35/29)• Diminition of dhatus, indriya, bala, etc..day after

day.• Wrinkles on the skin• Inability to perform activities

GERIATRIC PSYCHIATRY

• Derived from the Greek word GEROS(old age) and IATROS (physician).

• Deals with preventing, diagnosing, and treating psychological disorders in older adults.

• Elderly phase of life cycle characterized by its own developmental issues.

Distribution of diseases in elderly • Cataract & visual impairment : 70 %

• Cardio-Vascular and hypertension : 48 %

• Psychiatric problems : 42 %

• Arthritis & locomotion disorder : 40 %

• Respiratory diseases : 36 %

• Neurological problems : 18 %

• G I T problems : 4.7 %

• Loss of Hearing : 8 %

NORMAL CHANGES IN OLD AGE• The major changes that occur in old age are:-

i. Physiological changes

ii. Sensory changes

iii. Changes in motor abilities

iv. Sexual changes

v. Changes in appearance

vi. Changes in mental abilities

FACTORS INFLUENCING ADJUSTMENT IN OLD AGE

• Preparation of old age

• Earlier experiences

• Satisfaction of needs

• Retention of old age

friendships

• Attitudes of family

• Personal attitudes

• Method of adjustment

• Health conditions

• Living conditions

• Economic conditions

COMMON STRESSORS TO ELDERLY

• Loss of partner

• Economic instability

• Poverty

• Insecurity

• Dependency

COMMON CAUSES OF GERIATRIC PSYCHIATRY

• Physical and Emotional stress

• Long term illness

• Change of environment

• Medication interaction

• Poor diet or malnutrition.

• Alcohol or substance abuse.

GENERAL SIGNS AND SYMPTOMS

• Sad or depressed mood.

• Social withdrawal.

• Unexplained fatigue, energy loss, or sleep changes

• Confusion, disorientation, problems with

concentration or decision-making

• Increase or decrease in appetite.

• Memory loss.

• Feelings of worthlessness, helplessness;

thoughts of suicide.

• Physical problems like aches, constipation, etc.

• Changes in appearance.

• Trouble handling finances.

PSYCHIATRIC ASSESSMENT OF THE ELDERLY

• The initial steps in psychiatric assessment of elderly includes:

A. Initial assessment a) Assessment the context b) Seeing the patient c) History from the patient (and reliable informant)

B. Further process of Assessment

After an accurate detailed history, the further

assessment includes:

a) Physical examination

b) Routine laboratory examination

c) Special tests and scales for geriatric psychiatry.

d) Specialized investigations

GERIATRIC RATING SCALES• Geriatric depression scale

• Brief assessment schedule Depression cards

• Cornell scale for Depression in Dementia

• Hamilton rating scale for Depression

• Montgomery-Asberg Depression rating

scale(MADRS)

• Mini-Mental state examination

• Clock drawing test

• Seven-minute neurocognitive screening battery

• Alzheimer’s disease assessment scale (ADAS)

• Clinical Dementia rating

• Brief psychiatry rating scale (BPRS)

MENTAL DISORDERS OF OLD AGE

1) Dementing Disorder

2) Depressive Disorder

3) Schizophrenia

4) Delusional Disorder

5) Anxiety Disorder

6) Somatoform Disorders

7) Alcohol and Other Substance Use Disorder

8) Sleep Disorders

Dementing Disorder

• A generally progressive and irreversible impairment of the intellect, the prevalence of which increases with age.

• Dementias associated with advanced age typically are caused by primary degenerative central nervous system (CNS) disease and vascular disease, many factors contribute to cognitive impairment; in older persons, mixed causes of dementia are common.

Depending on the site of the cerebral lesion, dementias are classified as

subcortical cortical

occurs in Huntington's disease occur in dementias of the Alzheimer's type,,

Parkinson's disease, Creutzfeldt-Jakob disease (CJD)

vascular dementia Pick's disease,

Wilson's disease Sporadic CJD accounts for 85 percent of the human prion diseases

associated with movement disorders, gait apraxia, psychomotor retardation, apathy.

frequently manifest aphasia, agnosia, and apraxia.

Depressive disorder

• symptoms are present in about 15 percent of all older adult .

• Age itself is not a risk factor for the development of depression.

• Late-onset depression is characterized by high rates of recurrence.

The common signs and symptoms of depressive disorders

• Reduced energy and concentration

• sleep problems (especially early morning awakening and multiple awakenings)

• decreased appetite, weight loss, and somatic complaints.

• The presenting symptoms may be different in older depressed patients from those seen in younger adults.

• Older persons are particularly vulnerable to major depressive episodes

Dementia syndrome of Depression (pseudodementia)

• Cognitive impairment in depressed geriatric patients is

referred to as the dementia syndrome of depression

(pseudodementia), which can be confused easily with

true dementia.

• Pseudodementia occurs in about 15 percent of

depressed older patients, and 25 to 50 percent of

patients with dementia are depressed.

Schizophrenia• Women are more likely to have a late onset of

schizophrenia than men.

• Difference between early-onset and late-onset schizophrenia is the greater prevalence of paranoid schizophrenia in the late-onset type.

• Older persons with schizophrenic symptoms respond well to antipsychotic drugs.

Delusional Disorder

• Somatic delusions, in which persons believe they have a fatal illness, also can occur in older persons.

• Delusions also can accompany other disorders such as dementia of the Alzheimer's type, alcohol use disorders, schizophrenia, depressive disorders, and bipolar disorder which need to be ruled out.

• The prognosis is fair to good in most cases; best results are achieved through a combination of psychotherapy and pharmacotherapy.

Anxiety Disorder

The anxiety disorders include-

• Panic disorder

• Phobias

• Obsessive-compulsive disorder (OCD)

• Generalized anxiety disorder

• Acute stress disorder

• Posttraumatic stress disorder (PTSD).

• Obsessions and compulsions may appear for the first time in older adults, although older adults with OCD usually had demonstrated evidence of the disorder (e.g., being orderly, perfectionistic, punctual, and parsimonious) when they were younger.

• When symptomatic, patients become excessive in their desire for orderliness, rituals, and sameness. They may become generally inflexible and rigid and have compulsions to check things again and again.

Somatoform Disorders

• Somatoform disorders, characterized by physical

symptoms resembling medical diseases, are relevant

to geriatric psychiatry because somatic complaints are

common among older adults.

• Repeated physical examinations help reassure patients

that they do not have a fatal illness.

• Hypochondriasis is common in persons over 60

years of age, although the peak incidence is in

those 40 to 50 years of age. The disorder

usually is chronic, and the prognosis guarded.

Alcohol Use Disorder In Geriatrics

• Usually are medically ill, primarily with liver disease, and

are either divorced, widowed.

• A large number have chronic dementing illness, such as

Wernicke's encephalopathy and Korsakoff's syndrome.

• Substance-seeking behaviour characterized by crime,

manipulativeness, and antisocial behaviour is rarer in

older than in younger adults.

• Older patients may abuse anxiolytics to allay chronic

anxiety or to ensure sleep.

Other Substance Use Disorder• Older persons may misuse over-the-counter substances,

including nicotine and caffeine.

• Over-the-counter analgesics are used by 35 percent of

older persons and 30 percent use laxatives.

• Unexplained gastrointestinal, psychological, and metabolic

problems should alert clinicians to over-the-counter

substance abuse.

Sleep DisordersPrimary sleep problems Secondary sleep problems

Breathing related SD Depression & Psychosis

Narcolepsy/hypersomnia Arthritis & Parkinson’s

Circadian rhythm disorder Substance induced disorders

Parasomnias Fragmented Circadian rhythm disorder, sleep in AD.

RETIREMENT SYNDROME• It is the termination of a pattern of life or a transition to a new

pattern of life.

• Attitude towards retirement

1. Transformer

2. Maintainers

• Problems seen after retirement may be due to

1. Fall in physical and mental abilities

2. Retirement

MANAGEMENT

GENERAL ASPECTS OFMANAGEMENT

• Early, correct and full diagnosis• Keep patients at home as long as possible

TREATMENT• Drugs • Psychotherapy• Hospitalization(special geriatric unit)

• Beware of over and under medication.

• Assess physical conditions before administering any drug.

• Treat with lowest effective dose.

• Introduce medication carefully to avoid side effects.

• Eg.- Antidepressants, Antipsychotic, Anxiolytic.

Psychotherapy for Geriatric Patients

The standard psychotherapeutic interventions such as

• Insight-oriented psychotherapy

• Supportive psychotherapy

• Cognitive therapy

• Group therapy

• Family therapy

• Psychotherapy helps older persons to deal with issues and the emotional problems surrounding them and to understand their behavior and the effects of their behavior on others.

• In addition to improving interpersonal relationships, psychotherapy increases self-esteem and self-confidence, decreases feelings of helplessness and anger, and improves the quality of life.

• As described by Alvin Goldfarb, geriatric psychotherapy has the general aim of assisting older adults to have minimal complaints, to help them make and keep friends.

• Therapists must be more active, supportive, and flexible in conducting therapy with older than with younger adults.

Goldfarb has described a brief, supportive therapy technique for cognitively impaired patients. • The therapist promotes

patients' foundering self-esteem,

• sense of control, • and safety by permitting

them to develop an apparent special relationship with the therapist.

Reminiscence Therapy• Reminiscence is characterized

by the progressive return of memories of past experiences, especially those that were meaningful and conflictual.

• To varying degrees, elderly patients in therapy, reminisce about the past, search for meaning in their lives, and strive for some resolution of past interpersonal and intrapsychic conflicts.

Life Review Therapy

• Life review therapy systematically enhances this reminiscing process and makes it more conscious and deliberate.

• The therapist may guide the process by encouraging the patient to write or tape a biography with review of special events and turning points.

• Techniques include reunions with family and good friends and looking through memorabilia, such as scrapbooks or picture albums.

• This technique has been reported to resolve old problems, increase tolerance of conflict, relieve guilt and fears, and enhance self-esteem, creativity, generosity, and acceptance of the present.

•The Therapy, which gives the benefit of good Rasa, is Rasayana. Hence, it is the therapy by which one gets the Rasa, Raktadi Dhatus of optimum quality.

RASAYANA

•Rasayana Tantra is one which deals with delaying of ageing process, increasing of intellect and strength, prolongation of life and curing of disorders.

Definition sÉÉpÉÉåmÉÉrÉÉå ÌWû zÉxiÉÉlÉÉÇ

UxÉÉSÏlÉÉÇ UxÉÉrÉlÉqÉç | (cÉ.ÍcÉ.1/1)• The therapy which produces the best quality of ras, rakta

dhatu & other dhatus, is rasayan.

• Which decreases the ageing process, increases the longevity & increases the mental as well as physical strength & which destroys the disease process, is rasayan

Rasayana Benefits

• As per "CHARAKA" Benefits of regular usages of Rasayanas are Longevity, good memory power, Health, youthfulness, complexion, luster, good sensory function and resistance against diseases etc.

Medhya Rasayana

qÉhQÕûMümÉhrÉÉï: xuÉUxÉ: mÉërÉÉåerÉ: ¤ÉÏUåhÉ rÉ¹ÏqÉkÉÑMüxrÉ cÉÔhÉïqÉç|

UxÉÉå aÉÑQÕûcrÉÉxiÉÑ xÉqÉÔsÉmÉÑwmrÉÉ: MüsMü: mÉërÉÉåerÉ:ZÉsÉ ÑzÉÇZÉmÉÑwmrÉÉ:||

(cÉ.ÍcÉ. 1(3)/30)

Other medhya rasayana –• AµÉaÉlkÉÉ• uÉcÉÉ• eÉOûÉqÉÉÇxÉÏ• erÉÉåÌiÉwqÉÌiÉ• oÉëÉ¼Ï

Achara Rasayana• xÉirÉuÉÉÌSlÉqÉ¢üÉåkÉÇ• ÌlÉuÉ×iÉÇ qÉ±qÉæjÉÑlÉÉiÉç• AÌWÇûxÉMüqÉlÉÉrÉÉxÉÇ• mÉëzÉÉliÉÇ ÌmÉërÉuÉÉÌSlÉqÉç

Benefits –• Enhances satwa guna.• Person can be free from emotional conflicts.• Stress free life.

• eÉmÉzÉÉæcÉmÉUÇ kÉÏUÇ SÉlÉÌlÉirÉÇ iÉmÉÎxuÉlÉqÉç|

Action –• Normalizes the important neurotransmitters like-

serotonin, nor epinephrine,GABA and regulates a wide variety of neuro psychological processes like mood disturbances,sleep induction.

Ajasrika Rasayana • Food supplements like milk, ghee and other nutritious

elements of diet is the practice of Ajasrika rasayana.

Some rasayana formulations-• Chyavanprasha(medha, smriti, ayu prakarshan)• Haritaki rasayana (best vayasthapak)• Amalaki rasayana (inhibits ageing)• Pippali vardhaman rasayana (medhya vayasthapana)• Triphala rasayana (medha, smriti, inhibits jara vyadhi)

PANCHKARMA IN GERIATRIC PSYCHIATRY

Shiro Vasti –• Procedure of retaining medicated oil on the

head in flexible container brimmed over head. • This procedure calms the mind and enhances

the intellect .• commonly prescribed in psychological / psycho

somatic disorders .• Loss of Buddhi (cognition) • Loss of Smriti (memory)

• Shiro Dhara – • It is procedure of pouring medicated oil / milk /

butter milk on the fore head from a container.

• It induces soothening effect to regulate the stress and there by the stress induced disorders in old age.

CONCLUSION• Geriatric psychiatric is the study of the causes

and medical treatment of mental illness associated with old age.

• Proper assessment and diagnosis is necessary.

• Extra care and support should be provided.

• Anti ageing management of Ayurveda should be adopted for the healthy old age.

Thank u….

General principles in geriatric psychiatry

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