1

GERIATRIC PSYCHIATRY

M. Surya Husada – Vita CamelliaPsychiatry Department Medical Faculty - USU

2

DefinitionGeriatric Psychiatry is concerned

with preventing, diagnosing, and treating psychological disorders in older adults

Geriatric Psychiatry also promoting longevity

Persons with a healthy mental adaptation to life have been found to live longer than those stressed with emotional problem

3

EpidemiologyLate aduthood/old age : begin at age 65In Indonesia : begin at age 60Divided into young old (ages 65-74),

old-old (ages 75-84), and oldest old (age 85 and beyond)

Also divided into well-old (those who are healthy) and sick-old (persons with an infirmity that interferes with daily functioning and that requires medical or psychiatric care)

4

The life expectancy in USA : approaching 80 % (an average of 74 for men and 81 for women)

People at least 85 years old now constitute 10 % of those 65 and older and is the most rapidly growing segment of the older population

5

Biology Of AgingThe aging process (senescence) is

characterized by a gradual decline in the functioning of all the body’s system (cardiovascular, respiratory, endocrine, immune, etc)

Cognition : mild memory loss common, it called benign senescent forgetfulness

New material can be learned, however it requires more repetition and practice than in younger patient

6

IQ doesnt decreasePersons of low socioeconomic

status are at a higher risk for cognitive decline than persons in higher groups

Cognitive decline slowed in persons who are involved in continual learning and stimulation

7

Change in cellular DNA and RNA structures : intracellular organelle degeneration

Change in immune system : impaired T-cell response to antigen

Change in musculoskeletal : reduction in lean muscle mass and muscle strength

Change in integumen : graying of hair results from decreased melanin production

Change in genitourinary and reproduction : decreased glomerular filtration rate and renal blood flow

Change in special senses : Inability to accommodate (presbyopia)

Change in cardiovascular : increase in size and weight of heart

Change in GIT : decreased blood flow to gut and liver

8

Change in endocrine : adrenal androgen decreases

Change in respiratory : decreased vital capacity

Change in neurotransmitter : norepinephrine decrease in CNS

Change in brain : decrease in gross brain weight, ventricle enlarge, widened sulci, gyral atrophy, decreased cerebral blood flow and oxygenation

9

Medical IllnessThe leading five causes of death in the

elderly are :- Heart disease- Cancer- Stroke- Alzheimer’s disease- PneumoniaBenign prostatic hyperplasia : 75% of

men over age 75Urinary incontinence : 20% of the

elderly

10

These common disorders result in behavior modification

Arthritis : restrict activity and alter lifestyleThey will hide or deny their disability to

maintain self-esteem.Hypertension : result in CNS effects ranging

from headaches to stroke, pharmacotherapy for this condition can result in mood and cognitive disorders

Difficulties with convergence, accommodation, and macular degeneration are sources of visual disability

These sensory changes frequently interact with psychopathological disabilities, serving to magnify psychopathological deficit

11

Psychiatric Illness The most common disorders of old age are

depressive disorder, cognitive disorders (dementia), phobic disorders, and alcohol use disorders

Older adults (over age 75) have one of the highest risks for suicide

Many mental disorders of old age can be prevented, ameliorated, or even reversed

Special importance are the reversible causes of delirium and dementia, if not diagnosed accuaretly and treated in timely fashion, these conditions can progress to an irreversible state requiring a patient’s institutionalization

12

Dementia of the Alzheimer’s typeMost common type of dementiaWomen > menCharacterized : gradual onset and

progressive decline of cognitive functioning

Impaired of memory, aphasia, apraxia, agnosia, and disturbances in executive functioning

Neurologic defect (gait disturbances) eventually appear

About 50% of patients with Alzheimer’s disease experience psychotic symptoms

13

Etiology : selective loss of cholinergic neurons, reduced gyral volume in the frontal and temporal lobes, microscopic alteration include senile plaques and neurofibrillary tangles

Treatment : There is no known prevention or cure

Treatment is palliativeSome patients show improvement in

cognitive and functional measures when treated with donepezil or memantine

Psychosis of Alzheimer’s type is treated pharmacologically

14

Vascular DementiaThe second most common type of

dementiaIt has focal neurologic signs and

symptomsAlso has an abrupt onset and a

stepwise, deteriorating courseOther Dementias : Dementias due to

Huntington’s disease, dementia due to normal pressure hydrocephalus, parkinson disease, and other cause

15

Depressive disordersAbout 15% of all older adult community

residents and nursing home patientsCommon signs and symptoms : reduced

energy and concentration, sleep problems (especially early morning awakening and multiple awakening), decreased appetite, weight loss, and somatic complaints

Cognitive impairment in depressed geriatric patients is referred to as the dementia syndrome of depression (pseudodementia), which can be confused with easily with true dementia

Pseudodementia : 15% of depressed older patients

25 – 50% patients with dementia are depressed

16

Bipolar I disorderUsually begins in middle adulthoodA vulnerability to recurrence remains, so

patients with a history of bipolar I disorder may display a manic episode late in life

Signs and symptoms in older are similar to those in younger persons : elevated/expansive/irritable mood, decrease need to sleep, distractibility, impulsivity, and often excessive alcohol intake

Hostile and paranoid behavior is usually present

17

Treatment : lithium remains the treatment choice for mania, but its use by older patients must be monitored carefully because its reduced renal clearance makes lithium toxicity a significant risk

Neurotoxic effects are also more common in older persons than in younger adults

Other drugs : carbamazepine, valproic acid and divalproex

18

SchizophreniaSigns and symptoms : emotional blunting,

social withdrawal, eccentric behavior, and illogical thinking

Delusions and hallucinations are uncommon

Usually begins in late adolescence or young adulthood and persists throughout life

Women > men (late onset schizophrenia) About 20% patients show no active

symptoms by age 65

19

Treatment : Older persons with schizophrenic symptoms respond well to antipsychotic drugs

Medication must be administered judiciously, and lower-than-usual dosages are often effective for older adults

Antipsychotic : clozapine, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, haloperidol, chlorpromazine

20

Delusional disorderCan occur under physical or

psychological stress and maybe precipitated by the death of a spouse, loss of job, retirement, social isolation, debilitating medical illness or surgery, visual impairment, and deafness

Usually occurs between ages 40 and 55The most common are persecutory typeMay results from medication or be early

signs of a brain tumor

21

Anxiety disorderSigns and symptoms of phobia in older

adults are less severe than in those that occur in younger persons, but the effects are more debilitating for older patients

Obsessions and compulsions may appear for the first time in older adults, although older adult with obsessive-compulsive disorder usually had demonstrated evidence of the disorder when they were younger

When symptomatic, patients become excessive in their desire for orderlines and rituals

Other anxiety disorder : panic disorder, generalized anxiety disorder, acute stress disorder, and posttraumatic stress disorder

22

Anxiety disorders begin in early or middle adulthood, but some appear for the first time after age 60

The most common disorder are phobia (4-8%)

Treatment : must take into account the biopsychosocial interplay producing the disorder

Both pharmacotherapy and psychotherapy are required

23

Alcohol and other substance use disorders Older adults with alcohol dependence usually

give history of excessive drinking that began in young or middle adulthood

They usually are medically ill, divorced, or never married

The clinical presentation are varies and includes confusion, poor personal hygiene, depression, malnutrition, and the effects of falls

Unexplained gastrointestinal, psychological, and metabolic problems should alert clinicians to over-the-counter substance abuse

24

Alcohol and other substance use disorder account for 10% of all emotional problems in older persons

Dependence on hypnotics, anxiolytics, and narcotics is more common in old age than in generally recognized

35 % use over-the-counter analgesics

30% use laxatives

25

Sleep disordersAs a results of the decreased length of

their daily sleep-wake cycle, older persons without daily routines may experience an advanced sleep phase in which they go to sleep early and awaken during the nigth

Changes in sleep structure involve both REM and non REM sleep

The REM changes : redistribution of REM sleep throughout the night, more REM episodes, shorter REM episodes, and less total REM sleep

26

The nonREM changes : decreased amplitude of delta waves, lower percentage of stage III and IV sleep, and a higher percentage of stages I and II sleep

Among the primary sleep disorders, dyssomnias are the most frequent, especially primary insomnia, nocturnal myoclonus, restless legs syndrome, and sleep apnea

Alcohol usage can also interfere with the quality of sleep and can cause sleep fragmentation and early morning awakening

27

THANKYOU