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