Old Age Psychiatry:
Principles and Assessment
George Tadros
Clinical Director of Urgent Care pathway, BSMHFT
Professor of Liaison Psychiatry and Dementia, Aston
Medical School
Professor of Dementia Care in Acute Hospitals, University
of Chester
What is different about the
elderly? Age related health problems
• Diseases
• Medications
Culture
Brain degeneration
Bereavement
Transference & Counter-transference
Treatment • Slower metabolism, slower circulation.
• Frail body, reduced BMI
• Drug interactions
Measuring Intellectual Changes in
Old Age Psychometrics
– Designed for you people
– Do not show individual variations
Crystallized Vs Fluid intelligence
– Crystallized intelligence (e.g. knowledge)
• Not affected by age, could get better
– Fluid intelligence (native wit)
• Tested by IQ test.
• General decline after the age of 60
Bridge and chess
Old typists
Causes of aging decline
Cohort effect
Physical effect
– Slower body & slower brain
– Sensory impairment
• Strong correlation; sensory abilities & intellectual skills
• Visual & auditory acuity account for 49% of the recorded variance of the difference in intelligence in the elderly.
– Impaired metabolic and cardiovascular systems.
– Decline in CNS transmission speed, cell loss & increased neural noise.
Psychological effect
Cross Sectional Studies
Comparing two different age groups
– What are the possible problematic confounders?
• Different generations
• Materialistic differences
• Effect of education
• How to control??!!
The peak of intellectual performance is around 25 years of age, and gradually decline thereafter.
Longitudinal Studies
Problems
– Very expensive
– Only a few
– Very long time to conclude (50 years or so)
– Drop out effect (less well more likely to drop out)
– Still cohort study.
Intellectual functions remain static till about the age of 53, then start to decline.
60-80 years; great individual variations, 60-80% remain stable or improving.
80-100 decline in all subtests
Ageing and cognitive decline
Age related cognitive can occur in the healthiest elderly person.
The normal elderly less frequently experience impairment in cognitive areas other than memory.
Not universal but variable
Slowing of intellectual and physical performance but maintain reasonable level of functioning.
Other factors associated with age: • Illness
• Medications
• Sensory deprivation
• Social isolation
Features of normal ageing Decreased sensory processing and under-arousal
Slowed neuronal processing
Decreased complex and sustained attention
Accentuation of personality traits • Decreased flexibility and tolerance to change
• Decreased excitability & impulsivity; more cautious
Ageing and intelligence: • Preserved crystalized intelligence
• Decreased fluid intelligence
• Stable verbal IQ but decline in performance IQ
Decrease in naming ability
Decrease in primary and working memory
Decreased retrieval of stored memory
Language relatively well spared
Sleep; fragmented, increased daytime somnolence
What is Cognition?
Cognition is the ability to use and integrate
basic capacities such as perception,
language, behaviour, actions, memory and
thoughts in order to interact appropriately
with the world.
Assessment of Cognition
History
Memory
Orientation into time/ place / person
Attention and Concentration
Language/ speech
Thinking/ judgment
Object & person Identification
Frontal Lobe Functions
Stages of memory
LIBRARY ANALOGY
1. ENCODING - catalogue and label books
2. STORAGE - shelve systematically, store safely
3. RETRIEVAL - locate and retrieve on request
Forgetting – Loss and decay
Where is memory based?
Explicit memory is based in the limbic
system (Hippocampus, Parahippocampal
gyrus, Amygdala, Mammilary body,
Fornix, Thalamus and Dentate gyrus) and
temporal neocortex.
Implicit memory is based in the basal
ganglia and different parts of the cerebral
cortex.
Memory
Episodic Semantic
Long Term
Spatial Verbal
Short Term
Explicit
Conditioning Motor Skills
Implicit
Memory
Dementias
0.01% before the age of 40.
5-8% of all individuals over 65.
15-20% of all individuals over 75.
25-50% of all individuals over 85.
60-80% of all individuals over 95.
90% of all individuals over 100
100% of all individuals over ??
50% of all individuals in nursing homes.
820,000 persons in the UK.
People with/without dementia
Census 2001 : 20% above the age of 65. • How many in Birmingham?
750,000 in UK today with dementia.
More with cognitive impairment …!!
37% in institutional care
50% live with a carer
13% live alone, usually supported by a carer.
Size and cost of Dementia It is estimated that 35.6 million people living with
dementia worldwide in 2010, – increasing to 65.7 million by 2030 and 115.4 million by
2050.
– The total estimated worldwide costs of dementia are US$604 billion in 2010.
– The United Dementia Republic • What if dementia was a republic in terms of population economy? • It would have ranked 18th Largest economy in the world
About 70% of the costs occur in Western Europe and North America.
Approximately 30% of the total annual cost of AD is invested in the direct management of BPSD.
820,000 people with dementia in the UK – The cost of dementia care exceeds that of cancer, heart
disease and stroke combined. – £17 billions/ year – Triple to £50 billions/ year over the next 30 years
Definition of dementia
It is an acquired, persistent impairment in
multiple areas of intellectual function, not
due to delirium.
Operationally, there is a compromise in
three or more of the following nine
spheres of mental activities:
– Memory, language, perception, praxis,
calculation, conceptual or semantic
knowledge, executive functions, personality,
emotional expression.
What is dementia
Progressive and global cognitive impairment
– Memory (STM & LTM)
– Orientation into time, place, person.
– Visiuo-special awareness.
– Speech.
– Activity of Daily Living.
– Personality & judgment.
– Behaviour.
– Associated features
PATHOLOGY
CORTICAL ATROPHY
Generalized, more in
frontotemporal
NEURONAL LOSS
50% in early and 25% in late onset.
In mid-frontal area, superior temporal area, parietal area and hippocampus.
Limbic system is primarily affected.
cell loss in nucleus basalis of Meynert reduce acetyl-transferase reduce acetyl choline. NFT
Intracellular structures.
More numerous in type II > type I.
Occur diffusely in the grey matter and
particularly in hippocampus.
Tau protein is a major component
of the tangles.
Amyloid materials found in the
tangles.
OTHER HISTOLOGICAL
FINDINGS
SENILE PLAQUES
Amyloid plaques
Temporal cortex, Hippocampus
Amygdala,
Subcortical grey matter less affected.
Plaques not seen in white matter
No. of plaques = impairment of
cognitive functions.
Types of Dementia
AD VaD
DLB
FTD Infe-
ction
NPH
Psych
Mov
Dis
Toxi
c
Causes and types of dementia
Not just due to aging but increased risk with age. – Alzheimer’s disease
– Vascular dementia (multiple infarctions)
– Dementia of Lewy Body
– Fronto-temporal dementia (FTD)
– Alcohol related dementia.
– Parkinson's Disease
– Head Injury
– CJD
– Others
Some Characteristic Features
Alzheimer’s Dementia
– Dementia
– Global cognitive impairment
– No clear neurological signs
Vascular Dementia
– Dementia
– Vascular risk factors
– Neurological signs
Some Characteristic Features Dementia of Lewy Body
1. Parkinsonian signs
2. Fall
3. Fluctuation
4. Visual hallucinations
5. Hypersensitivity to antipsychotics
FDT (Fronto-temporal dementia) 1. Behavioural problems.
2. Speech impairment
3. Cognitive impairment
Behavioural and Psychological
Symptoms of Dementia (BPSD) Behavioural Symptoms
• Agitation, pacing,
• Aggression (verbal or physical)
• Trailing, shadowing
• Wandering
Psychological Symptoms • Anxiety, insecurity
• Depression
• Delusions
• Hallucinations
Issues to consider with carers
Daily burden
Loss of key relationship
Role change within
family
Role conflict
Age of carer
Cognitive function of
carer
Guilt
Nature of premorbid
relationship
Impact on other
relationships.
Role engulfment
Support by professionals
and voluntary sector
Beliefs and attributions
Anti-dementia Drugs !!!
Acetyl Cholinesterase Inhibitors
How do they work?
Do they work?
What do they do?
What are they?
Nice guidelines.
Reversible Causes of Dementia
Physical Causes Psychological
Causes
Normal pressure hydrocephalus
Subdural haematoma
Anaemia
B1, B6, B12 deficiency
Endocrine disorders e.g. hypothyroidism,
Cushing’s syndrome, Addison’s disease.
Infections e.g. AIDS, Syphilis.
Alcohol related dementias (early stage).
Wilson’s disease.
Electrolytes imbalance
Pseudodementia
Dissociative amnesia
Transient global amnesia
Dementia Vs Delirium
Delirium Dementia
1.
2.
3.
4.
Dementia Vs Pseudo-dementia
Dementia Pseudo-dementia
1.
2.
3.
4.
MMSE
Orientation to time (5)
Orientation to place (5)
Memory registration (3)
Concentration (5)
Memory recall (3)
Object identification (2)
Sentence (1)
3 stages task (3)
R, W, C (1X3)
Cut off point 26/30
What does it mean?
Advantages
Limitations
CAMCOG
CANTAB
Depression in the Elderly.
What is different from younger people?
I. Causes Psychological
Bereavement, insecurity,
loss of role,
End of life issues ... etc.
Biological Disease (vascular pathology, Parkinson, Degeneration)
Medication (Hypotensives, antibiotics .... Etc)
Social Social isolation
Poverty
Depression in the elderly
What is different from younger
people?
II. Presentation Less emotional/mood symptoms
Older people tend not to complain about depression
More somatic symptoms
Behavioural problems
Agitation
Loss of appetite and weight loss
Psychomotor retardation
Memory impairment
Poor concentration
Lack of interest
Depression in the elderly: What
is different from younger
people? III. Assessment
Open questions
Stigma
Consider sensory deprivation
Good history
Assessment of mood
Any thought disorders
Perceptual abnormalities
Suicidal ideations
Depression in the elderly: What
is different from younger
people? IV. Management
Antidepressants Lower doses
Consider side effects and drug interactions
Takes longer time to show effect.
Psychological symptoms CBT
Difficulty with accessibility
ECT Severe depression
Consider memory side effects
Risk of GA
Late Onset Psychosis
Psychosis • Delusions
• Hallucinations
Different terminology • Late Schizophrenia
• Late Paraphrenia
• Paranoid states of late life
• Late onset Psychosis
Late Onset Psychosis
Causes: Organic
Brain pathology Tumours (SOL)
Dementia
Strokes
Others
Sensory deprivation Deafness more than blindness
?? Charles Bonnett Syndrome
Systemic cause
Medication Steroids .... etc
Psychological Loss of role
Social Social isolation
Late Onset Psychosis
Treatment
Treat cause
Support
Antipsychotics
Smaller doses
Consider side effects
Consider interactions
Anxiety
Generalised anxiety disorder Somatic symptoms
Physical symptoms
Phobias Specific phobias
Space and falls
Agoraphobia
Anxiety
Management
Psychological
CBT
Social managment
Medication
Avoid benzodiazepines
B-blockers (SE)
Antidepressants
Pregabalin
