?????? Geriatric Psychiatry

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??????Geriatric Psychiatry
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Points of Geriatric Psychiatry

• Epidemiology
• Prevalence of mental disorder
• Barriers to mental health service utilization
• Normal aging
• Psychiatry disorders or problems commonly seen
• Dementia, depression, delirium, sleep problems,
  anxiety, suicide
• Treatment
• Pharmacotherapy, Psychotherapy
• Treatment models

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Mental disorders among older adults--ECA
community inpatients
Cognitive impairment 4.9 30.2
Affective disorders 2.5 18.5
Anxiety disorders 5.5 5.2
Alcoholism 0.9 2.6
Schizophrenia 0.1 0
Somatization 0.1 0
Personality disorders 0 8.3
Others 0 7.9
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Normal aging -- neuropsychiatry

• Brain structure
• Decrease in gross brain weight
• Widened sulci, gyral atrophy, Ventricles enlarge
• Increased transport across BBB
• Prefrontal lobes are disproportionately affected
  by aging changes
• Subcortical monoaminergic cell populations are
  subject to prominent decline in aging

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Normal aging -- neuropsychiatry

• Cognition
• Takes longer to learn new materials
• IQ remains stable until age 80
• Verbal ability maintained with age
• Psychomotor speed declines
• Encoding ability diminishes
• Simple recall declines

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Normal aging -- Sleep

• Latency to sleep onset ?
• Frequency of awakening ?
• Total stage-3, -4 sleep ?
• Total stage-1, -2 sleep ?
• Redistribution of REM sleep

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??????? -- TOADS

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Features of Mental Problems among the elderly

• Highly comorbid with
• Medical illness
• Disabilities
• Complication of psychopathology
• Cognitive dysfunction
• Distinct clinical courses
• Barrier to assess mental health resources

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Long-term care (LTC) facilities- USA data

• 4.13 elders in LTC facilities in 1995
• 8 of nations total health care costs
• Mean age increased in LTC facilities
• Very disabled
• Options and setting becoming diverse

Jones A Vital Health Stat 13 20021-116 Gabrel C
and Jones A Vital Health Stat 13 20001-83
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?? 65 0.38
?? 781 0.96
???? 25 0.04
Total 871 1.38
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Barriers to geriatric mental health care

• Poorly served by the mental health system
• Fewer visits for mental health care
• Rely more heavily on primary care physicians
• Low rate of depressive elders taking
  antidepressant
• Possible reasons
• Stigma
• Low rate of case identification by primary
  physicians
• Multiple medical illnesses divert physicians
  attention
• Depression and anxiety may be viewed as normal
• Neglect by family

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Life events

• Death of significant others
• Medical ill of oneself or partner
• Disability
• Financial issues
• Relationship with family
• Retirement

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Somatic Symptoms
Physical Illness
Depressive Disorder
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Cognitive deterioration
Dementia
Depression (pseudodementia)
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Delirium??
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Causes of delirium

• Drugs and alcohol
• Intracranial causes
• Metabolic and endocrine disorders
• Systemic infections
• Postoperative states

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Late life depression

• Late-onset vs. early onset
• Vascular depression
• Subsyndromal depression
• Depression-executive dysfunction syndrome

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Suicide

• Increases with
• age
• bereavement
• isolation
• deteriorating health
• pain
• Actual attempted are closely linked

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Vascular depression hypotheiss

• Subtype
• Vascular risk factors, neuroimaging findings
• More cognitively impaired, more disabled, more
  psychomotor retardation, less insight
• Disruption by vascular lesions of
  striato-pallodo-thalamo-cortical pathways

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Medications associated with depression

• Antihypertensions
• Reserpine
• Methyldopa
• ßblockers
• Oral contraceptives
• Steroids
• BZD
• H2 antagonists
• Cimetidine
• Ranitidine

• Chemotherapy
• ..
• Interferon
• Psychoactive substances
• Alcohol
• Opiates
• Amphetamine withdrawal

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Treatment

• Treating underlying medical conditions reducing
  disability
• Psychopharmacology selection depends on
• Side effect profiles
• Concurrent conditions and medications
• Target symptoms
• Previous treatment responses
• ECT
• Psychotherapy

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Sleep disorders

• Lack of social or vocational activity
• Disturbed circadian rhythm
• living in nursing home, without daily routines
• degenerative brain
• Breath related sleep disorders
• Alcohol or drugs induced sleep disorders
• Sleep related accidents

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Neuropsychiatric syndrome

• Post Stroke syndrome
• Depression, anxiety, apathy, psychosis, mania,
  emotional lability
• Parkinsons disease and Parkinsonism
• Depression, anxiety, mania, psychosis, drug
  induced psychosis

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Principles of pharmacological treatment

• Pretreatment medical evaluation
• Given in equally divided dose
• Reduced dose to 1/41/2 as the young need
• Simplified medicine
• Slow titration from low dose
• Know the interaction between medicine

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Mini-Mental Status Examination (MMSE)

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• 5-8-2 3-9
• 6-9-4 6-2
• 6-4-3-9 3-7-2
• 4-1-7-9-3-8-6 1-4-9-3-7-4

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• Activities of daily living (ADL)
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• Instrumental activities of daily living (IADL)
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???? ???? Email sheng_at_kmu.edu.tw