Common Psychiatric Disorder

in
Elderly

..

5


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Common Psychiatric Disorder in Elderly

 Pretest

1.

A. Elder abuse
B. Psychotic disorder
C. Factitious disorder
D. Neurocognitive disorder
 Pretest

1. Characteristic of geriatric patients

A. Socially rejected
B. Attention seeking
C. Physical infirmity
D. Need more financial support
 Pretest

3.
A.
B.
C.
D.
Pretest

1. Functional assessment

A.
B. Occupational assessment
C. Assessment of living situation
D. Assessment of financial status
 Pretest

5.
A.
B.
C.
D.
Outline
1. Aging population
2. Assessment
3. Epidemiology of psychiatric disorder
4. Individual disorders and management
5. Elder abuse
6. Principle of treatment in elderly
 United Nation : Aging Society definition

Society 60 yrs. of total 65 yrs. of total

pop. pop.
(Aging 10% 7%
Society)

(Aged 20% 14%

Society)
(Super- 20%
aged Society)
Aging population :
Aging population :Demography


 Aging population :

-
-
-
-

-
( /

-

//

 /

1. .

2.

3.
4.

5.

6.
 The geriatric patient (aged- elders)
Old
Multi- morbidity
At risk : somatic disorder, social
stressors (retirement), widowhood,
physical infirmity
Need for rehabilitation
Need for psychosocial services
Assessment for elders : WHY?

Take longer time

Requiring more than one interview
Greater reliance on informants
Strictly understanding : medical and its treatment,
psychosocial situation.
PE AND lab. : greater role
Psychiatric assessment : HOW?

Referral : referrer hope to gain, different expectations and

needs (possibly conflicting)
Informants : need complete and reliable information, previous
personality, coping skills
Where to assess : own home, in patient ward, memory clinic.
What to assess: full hx.(+ medical history, past/present
medication , PE and neuro exam., cognitive ax. lab, risk and
needs of carer(s),
Functional assessment
Evaluation

Illness in elderly: atypical present, vague complaints, cognitive

deicits, functional losses, behavioral changes.
Beginning : observation the pt., interaction with fam./carer,
approach to the physician.
Psychiatric assessment: evaluation of the affect, behavior,
cognition.
Addressed symptoms of mood and affect, sleep, interests,
appetite,
MSE: concentration, psychomotor agitation, guilt.


congestive heart failure chronic obstructive

lung disease

- (forgetfulness)

(age associated memory

impairment)

anticholinergic

Spar JE, Rue AL. Clinical manual of geriatric

psychiatry.1st ed. Arlington, VA: American Psychiatric Publishing,

Inc.; 2006. p. 83.

 Cognitive assessment

MMSE (Mini-Mental State Examination)

MMSE Thai 2000 (Mini-Mental State Examination)
MoCA (Montreal Cognitive Assessment test)
Functional assessment

1. (Activity
of Daily Livings: ADLs)
-
-
-
-

2. (Instrumental
Activity of Daily Livings: IADLs)
-
-
-
Functional assessment

ADLs
IADLs
Summarize the history of the pts function (over the past several years)
Assessment of living situation.
Financial status : dependent/ benefits.
Psychiatric disorder in elderly

Common
Frequent: undetected, untreated
Induced functional disability
Disturb rehabilitation
Burden health system
Impair life-quality ( elders , relatives and carers)
Multidisciplinary approach

( Biological treatment)
( Psychological treatment)
(Psychosocial treatment)

( )



Cognition 4.9 30.2
(Affective disorders) 2.5 18.5
(Anxiety disorders ) 5.5 5.2
(Alcohol abuse or 0.9 2.6
dependence)
( Personality 0 8.3
disorder)
0 7.9

: Spar JE, Rue AL. Clinical manual of geriatric psychiatry. 1st ed.
Arlington, VA: American Psychiatric Publishing, Inc.; 2006. p 9.
Changing prevalence of psychiatric disorder with age
among the elderly

Age n Dementia* Depression Anxiety Psychotic

(years) disorders disorders

70 393 2 6 6 1

75 3033 5 6 4 2

79 206 11 11 3 3

85 494 31 13 10 5

Moderate or severe
Figures are percentage values.
Adapted from Skoog 2004
Neurocognitive disorder: NCD

Most common = Alzheimers disease (AD ) 50-60%

(NCD due to AD)

15-20% vascular disease multi-infarct dementia

MNCD 5%
20% 65
30% 80
90
50% 95
Neurocognitive disorder: NCD
Alzheimers disease :

(amnesia)

(lack of initiation)
(slow psychomotor speed)

(disorientation to time and place)
(impaired decision making, poor judgment)
(oversensitive to rejection) (irritability)
(change in personality and behavior)
AD: Behavioral and psychological symptoms of dementia:( BPSD)

neurofibrillary tangles (prefrontal

lobes)
Psychosis, depression, anxiety
Agitation and aggression, irritability, apathy
(aberrant motor behavior)
(disinhibition)
(sleep problem)
(delusion of misidentification Capgras
syndrome)
Hallucinations 10% : auditory hallucination, visual hallucinations,
(olfactory hallucinations) (tactile hallucinations)
20%25%
major depressive episode persistent depressive disorder
 MNCD due to AD 3- 20 8-10

1 ( )
2 ( )

3 ( )




4 ( )


5 (

)

6 ( )


7 ( )


: What Are the 7 Stages of Alzheimers Disease? 18 2559
http://www.alzheimers.net/stages-of-alzheimers-disease/
 MNCD due to AD

1. (general well-being)
2.
3.
 MNCD due to AD
1. (general well-being)

(mobility)

1. IADLs / ADLs
2.
3.


Non-pharmacological therapy Pharmacological therapy

(cognition-oriented) 1.
Emotional oriented - Donepezil
(stimulation - Rivastigmine
oriented) - Galantamine
(behavior oriented) - Memantine
2. BPSD
(caregivers - oriented)
ATD
ADLs
ATP
Anxiolytic
Antiepileptic


1.
2.
3.
Delirium
(generalized dysfunction)

14-70%
Medicine :15-40%
Surgery ( CVT,Ortho. )post op. 35-70%
(predisposing factors) :
- 65
- sensory impairment
- neurocognitive impairment
Delirium: (precipitating factors)
metabolic electrolyte disturbance
Infection ( urinary tract infection pneumonia )



-
12 ICU



Distinction between dementia and delirium

Dementia Delirium

Onset Insidious Acute

Decline Relatively slow Rapid
Level of Alert Clouding of consciousness
consciousness
Sensory No hypersensitivity Hypersensitivity (eg. perception
hyperacusis)
Visual hallucination Less common More common
Stability of mental Fairy stable state fluctuating
 delirium




-
haloperidol 0.25-0.5 . 1-2
5-10 .
- + second generation antipsychotic (SGA) quetiapine, risperidone, olanzapine aripiprazole
-
:

Common drugs causing depression in elderly

Analgesics (narcotics,NSAIDs)
Antihypertensive
Antipsychotics
Anxiolytics( BZDs, alcohol)
Chemotherapeutics agents( anti-neoplastics)
Diuretics( thiazides)
H2 blockers
Sedative-hypnotics
Steroids
 MNCD depression with cognitive impairment
Depression with cognitive impairment MNCD


- -

MNCD





"
"
(recent memory)
(remote memory)

(cue)
(recall)
(reteival) (false memory)
: Spar JE, Rue AL. Clinical manual of geriatric psychiatry.1st ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2006. p. 89.
 Depression

- Geriatric Depression Scale (GDS)
- Beck Depression Inventory (BDI and BDI-II)
- Cornell Scale for Depression in Dementia
- Hamilton Rating Scale for Depression (Ham-D)
- Depression items from the Patient Health Questionnaire (PHQ-9)
 Treatment recommended for depression in elderly
Drug Dose range Comment
(mg/day)
Tricyclic antidepressants
- Nortriptyline 10-150 Reliable blood levels, minimal orthostasis, mildly
-Amitriptyline 10-150 anticholinergics
Stimulants
-Dextroamphetamine 2.5-40 Agitation and mild tachycardia
-Methylphenidate 2.5-60
Selective Serotonin Re-uptake Inhibitors (SSRIs)
-Fluoxetine 5-60 Akathisia, headache,agitation, GI complaint,
diarrhes/constipations
-Sertraline 25-200
-Paroxetine 5-40
-Fluvoxamine 25-300
-Escitalopram 5-40
Serotonin/Norepinephrine Re-uptake Inhibitors (SNRIs)
- Venlafaxine 37.5-300 Increase in systolic BP, confusion
Alpha2Antagonist/Selective Serotonin
- Mirtazapine 15-30 Sedation, weight gain
Serotonin Antagonist and Re-uptake Inhibitors
-Trazodone 25-250 Sedation, orthostasis, iincontinence, hallucination
-Nefazodone 50-600 ,priaprism
Norepinephrine Dopamine Re-uptake Inhibitors
- Bupropion 75-450 Seizures, less mania/cycling, headache, nausea
 (Anxiety disorders)

-
-
-
-
- 19%
- Most com. : GAD phobic disorders prevalence 7 - 14%
- Panic disorder 1%
- 40% GAD
- 50%
- NCD 22%
- 2 1


(first-line treatment) (secondt-line treatment)
Panic disorder with/without SSRIs, SNRIs, / CBT TCAs
agoraphobia
Generalized anxiety disorder SNRIs, SSRIs, Buspirone / TCAs
CBT
Social Phobia
- Generalized SSRIs CBT Benzodiazepines
- Specific Buspirone / CBT Benzodiazepines

Simple (specific ) phobia CBT Benzodiazepines

SSRI = selective serotonin reuptake inhibitor; SNRI = serotonin norepinephrine reuptake inhibitor; CBT=
cognitive behavioral therapy
Agronin ME, Maletta GJ. Principle and Practice of Geriatric Psychiatry. Philadelphia, PA: Lippincott Williams &
Wilkins; 2006. p.440.


1.

2. rapid eye movement (REM)
REM
3. delta wave 3 4
spindle wave
REM (intellectual
function impairment)
4. -

5. Growth hormone growth hormone
3 4
6. melatonin (pineal)


1.:
(sleep hygiene)

stimulus control therapy, sleep restriction therapy bright light therapy

2. :
-





Elder abuse

VULNERABILITY

-
-
-
-


 Elder abuse:
:
-
- (cognitive impairmen)
- :


 Elder abuse:

1.
2.
3. (depressive disorders)
4.
5.
6.
 Elder abuse:

1.
2.
3.
Elder abuse:

(physical abuse):

(sexual abuse):

(psychological/emotional abuse)


(financial abuse)



(neglect)



(physical abuse) 0.2-4.9
(sexual abuse) 0.04-0.81
(psychological abuse) 0.7-6.3
(financial abuse) 1.0-9.2
(neglect) 0.2-5.5
:World report on aging and health. World Health
Organization. Fact sheet No 357 Updated October 2015.
Elder abuse:

- (awareness)

-
Principles and practice

Organization of services
Assessment
Treatment
Legal issues
 Organization of services

Primary health care team

Specialist old age psychiatric team
Inpatient unit
Rehabilitation
Day care, respite care, residential care facilities
Family and social support
Liaison with geriatric medicine
Education of healthcare providers about the need of elderly with psych. And
med. Problems.
Common Psychiatric Disorder in Elderly
Question and answer
 References and suggested reading

1. Sadock BJ, Sadock VA. Geriatric Psychiatry . In: Sadock BJ, Sadock VA.Editors.
Kaplan & Sadock's Synopsis of psychiatry: behavioral sciences/clinical
psychiatry, 11th Ed. Philadelphia: Lippincott Williams & Wilkins; 2015. p. 1334-
51.
2.
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3. Johnston B, Reuben BD. Geriatric Assessment. In: Williams BA, Chang A, Ahalt
C, Chen H, Conant R, Landefeld CS, et al. Current Diagnosis and Treatment
Geriatrics.2th Ed.Singapore:M Graw Hill Education;2014.p.24-8.