GERIATRIC PSYCHIATRY

Introduction
 Geriatric : geros = old age
(from the Greek) iatros =physical
 Geriatric psychiatry is concerned with
preventing, diagnosing and treating
psychological disorders in older adults. It is
also concerned with promoting longevity:
persons with a healthy mental adaptation to
life are likely to live longer than those
stressed with emotional problems.
 Mental disorders in the elderly often differ
in clinical manifestations, pathogenesis and
pathophysiology from disorders of younger
adults.
 Diagnosing and treating older adults can
present more difficulties than treating
younger persons because older persons may
have coexisting chronic medical diseases
and disabilities, may take many medications
and may show cognitive impairments.
Mental Disorders of Old Age
 The National Institute ofmental Health’s
Epidemiologic Catchment Area ( ECA)
program has found that the most common
mental disorders of old age are :
– depressive disorders
– cognitive disorders
– phobias
– alcohol use disorders
 Older adults also have a high risk for suicide
and drug-induced psychiatric symptoms
 Several psychosocial risk factors also
predispose older persons to mental disorders:
– 1. Loss of social roles
– 2. Loss of autonomy
– 3. The deaths of friends and relatives
– 4. Declining health
– 5. Increased isolation
– 6. Financial constraints
– 7. Decreased cognitive functioning
 Many drugs can cause psychiatric symptoms
in older adults. These symptoms can result
from :
– 1. Age-related alterations in drug absorption
– 2. A prescribed dosage that is too large
– 3. Not following instructions
– 4. Taking too large a dose
– 5. Sensitivity to the medication
– 6. Conflicting regimens presented by several
physician.
Depressive Disorders
 Are present in + 15 % of all older adult
community residents and nursing home
patients.
 Common sign & symptoms : reduced
energy & concentration,sleep problems
( especially early morning awakening &
multiple awakenings), decreased appetite,
weight loss & somatic complaints.
 Particularly vulnerable to major depressive
episodes with melancholic features
:depression, hypochondriasis, low self-
esteem, feeling of worthlessness and self-
accusatory trends ( especially about sex and
sinfulness) with paranoid and suicidal
ideation
Dementia
 Definition
– Dementia is a condition which shows clinical
syndrome and the manifestations are the
impairment in memory, orientation, cognition
and the changes in behavior
Classification
 According to the etiology :
– I. Dementia of the Alzheimer’s type
– II.Vascular dementia
– III.Dementia in other disease
– IV.Unspecified dementia
Risk factors
 Dementia of the Alzheimer’s type is more
common in women ; history of Alzheimer’s
disease in family; history of brain damage;
Down’s syndrome
 Vascular dementia is more common in men;
age 60-70 years old; history of hypertension
Etiology
 1. Alzheimer’s disease
 2. Vascular disorders
 3. Other diseases, such as :
– - Parkinson disease
- HIV
- trauma capitis
etc
Clinical manifestations
 Dementia is characterized by the decline of
intellectual function and disturb the daily
activities such as take a bath, get dressed,
eat, personal hygiene,urination and
defecation
 Deficit in memory, judgement, abstract
thinking and other cortical function such as
aphasia
 Personality changes
 Sensitive to physical and psychological
stressor
Differential Diagnosis
 Normal process in old age
 Delirium
 Schizophrenia
 Major depressive episode
Therapy
 Medical care
 Emotional support to the patient and the
family
 Medication : anxiolytic, antidepressant,
antipsychotic, tetra hydroamino acridine,
donepezil
Bipolar Disorder
 The signs and symptoms of mania in older
persons are similar to those in younger
adults and include an elevated, expansive or
irritable mood, a decreased need to sleep,
distractibility, impulsivity, often excessive
alcohol intake, hostile or paranoid behavior.
 Therapy : Lithium
Schizophrenia
 Schizophrenia in old age usually begins in
late adolescence or young adulthood and
persist throughout life.
 The most common type is : residual type of
schizophrenia
Delusional Disorder
 Delusions can take many forms: the most
common are persecutory( patients believe
that they are being spied on, followed,
poisoned or harassed in some way)
 Persons with delusional disorder may
become violent toward their supposed
persecutors.
 Among those who are vulnerable, delusional
disorder can occur under physical or
psychological stress.
 May be precipitated by the death of a spouse,
loss of a job, retirement, social isolation,
adverse financial circumstances, debilitating
medical illness or surgery , visual
impairment and deafness.
Anxiety Disorders
 Include : panic disorder, phobias, obsessive
compulsive disorder and posttraumatic
stress disorder
 The most common disorders : phobias
(4-8 %) and panic disorder (1 %)
 Predisposition: the fragility of the ANS in
older persons may account for the
development of anxiety after a major
stressor.
Somatoform Disorders
 Characterized by physical symptoms
resembling medical diseases
 Somatic complaints are common among
older adults
 More than 80 % of persons over 65 years of
age have at least one chronic disease-
usually arthritis or cardiovascular problems
Alcohol and Other Substance Use
Disorder
 Usually began in young or middle
adulthood
 Usually are medically ill, primarily with
liver disease
 Clinical presentations varies, includes
confusion, , poor personal hygiene,
depression, malnutrition, etc
Sleep Disorders
 Sleep-related phenomena are : sleeping
problems, daytime sleepiness, daytime
napping and the use of hypnotic drugs.
 The most common form : awake too early
Sleep disorder in old age caused
by :
 Respiratory disturbances
 Gastrointestinal disturbance induced by
drugs
 Primary insomnia
 Sleep apnoe
 pain
 Nocturia
 Heartburn
 Lack of a daily structure and of social or
vocational responsibilities contributes to
poor sleep
 Other mental disorders
Psychopharmacological Treatment
of Geriatric Disorders
 Principles: the major goals of the
pharmacological treatment of older persons
are to :
– 1. improve the quality of life
– 2. maintain persons in the community
– 3. delay or avoid their placement in nursing
homes
 Individualization of dosage is the basic
tenet of geriatric psychopharmacology.
 Alterations in drug dosages are required
because of the physiological changes that
occur as persons age.
A. Antidepressants
 Nortriptline and desipramine are the most
frequently used tricyclic antidepressant
drugs in geriatric depression.
 Because they have lower anticholinergic
and sedative effects.
 Be careful in prescribing MAO-I to elderly,
because the decrease of MAO in old age.
 Severe side effects of antidepressants:
– Trazodone : sedation, orthostatic hypotension
– Amoxapine : EPS
– Maprotiline : convulsion
 Selective Serotonin Reuptake Inhibitor
(SSRI) is safe in old age.
B. Psychostimulant
 Include : amphetamine, methylphenidate,
pemoline
 In selected patients, they can improve the
mood, apathy and anhedonia of depressed
older persons,especially when these
symptoms are caused by an associated
chronic medical illness such as rheumatoid
arthritis or multiple sclerosis
 C. Lithium
– The use of lithium in elderlypatients is more
hazardous than its use in young patients
because of the common occurrence of age-
related morbidity and physiological changes of
the heart, the thyroid and the kidneys
 D. Antipsychotics
– start in low dosage
– older adults are much more sensitive to many
of the adverse effects of antipsychotics
medications than young patients
E. Anxiolytics
 Geriatric patients with mild or moderate
anxiety can benefit from anxiolytics,
benzodiazepine are the most widely used.
 Benzodiazepine with short or intermediate
half-lives are preferable for use as
hypnotics.
 Elderly patients accumulate the long acting
benzodiazepine in adipose tissue & this ...
 …process increases such adverse effects as
ataxia, insomnia & confusion, these can be
avoided by prescribing the lowest possible
dosage.
 Anxiolytic which is rather safe for old age :
buspirone, because :
– without sedative properties
– longer onset of action
– doesn’t cause cognitive impairment
– doesn’t have any potential for abuse
F. Pharmacological Management of
Agitation and Agression in Dementia

 The use of antipsychotics and

benzodiazeine may produce side effects, so
can be changed with :
– beta adrenergic antagonist: buspirone
– 5-HT-2 antagonist : trazodone
Other Therapy for Geriatric Patients

 1. Insight -oriented psychotherapy

 2. Supportive psychotherapy
 3. Cognitive- behavioral therapy
 4. Family therapy
 5. Group therapy