Mental Disorders in Elderly

Indah Sandy Febryanti

030.05.113
 who are they?
 WHO (1989)
>60 years old

 Indonesian Health Ministry

60 – 69 years old

 Greater improvement on health care

elder population >>
Greater life expectancy

 Indonesia Today : 24 millions elder (9,77%)

 World Estimation : 2030 - 70 millions

2050 - 82 millions
 aging process
old age is not a disease.
Lifestyle
Diet & Nutrition
degrading/degenerating
Environment
physiological organ functions
etc.

sociological psychological Integrity

versus
new role
Despair
in society
(Erik Erikson)
 psychiatric examination
of the older patient
●
Physical Examination
●
Laboratory Examination

●
Psychiatric History

●
Mental State Examination

●
Neuropsychological Evaluation
 physical & laboratory
Complete physical examination
Supportive laboratory exams
(kidney function, liver function, ct-scan, etc)

 Due to aging process

 Diagnostics
 Exclude overlying diseases
 Psychiatry manifestation as side effect of general condition or
medication
 Precaution before giving prescription
 psychiatric history
 Minor memory impairments
benign senescent of forgetfulness

 Childhood and adolescent history

personality, defense mechanism, coping strategies

 Occupational history (pension)

 Plans for future?

 Current social situation

children, financial, caregiver

 Marital history
spouse, widow, grief
 Mental State
 General Description Examination
 Functional Assessment -- Activity Daily Living

 Mood, Feelings and Affect

mood disturbances : early sign of dementia

 Perceptual Disturbances (Hallucinations, Illusions)

 Language Output (Aphasia)

 Visuospatial Functioning Decline in this function is normal w/ aging

 Thought (Loss ability of abstract thinking – early sign of dementia)

 Sensorium and Cognition

 Judgment
 Neuropsychological
Evaluation
Mini Mental State Examination (MMSE)

Cognitive functions : orientation, attention, calculation, recall, etc

Wechsler Adult Intelligence Scale-Revised (WAIS –R)

Assessment of intellectual abilities. Verbal, performance, IQ scores

Bender Gestalt Test / Halstead Reitan Battery

Visuospatial functions.

Geriatric Depression Scale

To assess depression
 epidemiology
 Estimation on mid 20th century
Psychiatric Disorders : 20 millions.

 Indonesian National Prevalence

Mental disorder at age > 15 yrs old 11,6%
Psychotic disorder 4,6 %

Highest prevalence : DKI Jakarta (20,3‰)

Nangroe Aceh Darussalam (18,5‰),
West Sumatera (16,7‰),

 Mental disorder prevalence increases as the age.

>75 yrs old : 33,7 %

Other risk factors : Female, low education level, unemployed, and poverty.
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 Dementia
 A generally progressive and irreversible impairment of the
intellect.

 Develops over time. Gradually.

 Characteristic Changes
cognition, memory, language, visuospatial functions

behavioral disturbances :
agitation, restlessness, wandering, rage, violence, shouting, social
disinhibiton, sleep disturbances, delusions.
 Causes of Cognitive Impairment
Brain injuries, cerebral tumors, AIDS, alcohol, medications, infections,
chronic pulmonary disease, inflammatory.

 10-15% have potentially treatable Conditions.

systemic disorder (heart disease, renal disease, endocrine, etc)
primary mental disorders (mostly depressive)
ALZHEIMER DEMENTIA
50 -60 %
female > male

 Memory impairment with at least one of the following : aphasia, apraksia, agnosia, executive
function impairment.

 Etiology unknown.
Hypothetically : loss of selective colinergic neurons.
Loss of volume in frontal and temporal lobe.

 Prevention, not useful

 Palliative Care
 To decrease agitation and agression : propanolol, pindolol, buspirone, valproate.
Haloperidol for acute behavioral disorder.

VASCULAR DEMENTIA
Cognitive deficit (as Alzheimer)
but associated with focal neurological signs

Sudden onset.

Prevention useful.
 Diagnostic MRI  Decreased cerebral blood flow causes dementia.
 Depressive Disorders
 15 %

 Symptoms and Signs

Reduced energy and concentration
Sleep problems
Decreased appetite, weight loss
Somatic complaints.

 Age itself is not a risk factor

But : widowed, chronic medical illness, etc

 Suicidal Ideation

 Pseudodementia
The dementia syndrome of depression
 Bipolar Disorder
 1 % prevalence (all age category)

 Recurrence

 Symptoms and Signs

expansive mood, irritability, decreased sleeping hours,
impulsive, distracted easily.

 Deficit in consciousness, disorentation and cognitive

impairment  organic cause.

 Individualized dose of Lithium.

Neurotoxicity in Elderly >>
 Schizophrenia
 First episode after age 65 : RARE
 20 % : no active symptoms by age 65
80 % : varying degrees of impairment

 Greater prevalence of paranoid schizophrenia in the late-

onset-type

 30 % Residual Type
emotional blunting, social withdrawal, eccentric behavior,
illogical thinking, delusions, hallucinations
 Delusional Disorders
 Age of onset : 40 – 55 yrs old

 Delusions
Persecutory >>
Somatic

 Paraphrenia
late onset of delusional disorder
persecutory delusions
not associated with dementia

 Physical or Psychological stress.

death of spouse, medical illnesses, surgery, visual impairment, deafness
 Anxiety Disorders
 Panic disorder, phobia, OCD, generalized anxiety disorder,
acute stress disorder, PTSD.

 The thought of death with a sense of despair may cause

anxiety

 Previous personality organization

 Somatoform Disorder
 Somatic complaints in older age is very COMMON.

 Hypochondriasis
common in >60 yrs
peak incidence : 40 – 50 yrs

 Repeated physical examinations

Avoid invasive and high risk examinations.

Clinicians should acknowledge that the complaint is real.

 Sleep Disorder
 Altered regulatory and physiological systems in aging.

 Causes
Primary sleep disorder
dysomnia >> (primary insomnia, restless legs syndrome, sleep apnea)
Mental disorder
General medical disorder
Social and environmental factors

 Interfering Conditions
Pain, nocturia, dyspnea, heartburn
Lack of daily structure and of social or vocational responsibilites

 REM Sleep : more and shorter REM episode, less total REM Sleep
NREM Sleep
 Management
Psychopharmacological
 A pretreatment medical evaluation
 Bring all currently used medications
 GOALS
to improve quality of life
maintain persons in the community
delay or avoid placement in nursing home
 Psychotropic drugs
given in equally divided doses (3-4 times) over a 24-hour period.

 Response monitoring

 Individualization of Dosage
Drug metabolism (liver)
Drug clearance (kidney and liver)
Drug absorption (GI)
Drug distribution (fat body mass)

 The lowest possible dose should be used to achieve the desired

therapeutic response.

 Multiple drug interactions.

Psychotherapy
 Insight-oriented psychotherapy
supportive psychotherapy
cognitive therapy
group therapy
family therapy

 Adapting to common age-related issues

- recurrent and diverse losses (death of friends,etc)
- the need to assume new roles
- the need to accept mortality/death

 Psychotherapy
- increases self-esteem and self-confidence
- decreases feelings of helplessness and anger
- improves the quality of life
 References
  
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Jakarta : Bina Rupa Aksara. 2010. Hal 867-891.
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Press. 1997. Hal 155-263.
 Sadock BJ, Sadock VA. Concise Textbook of Clinical Psychiatry. Edisi kedua. Philadelphia : The William-Wilkins.
2004. Hal 599-602.
 Sadock BJ, Sadock VA. Synopsis of Psychiatry. Edisi kesepuluh. Philadelphia : The William-Wilkins. 2007. Hal
1348-1358.
 Kaplan HI, Sadock BJ and Grebb JA. Kaplan-Sadock Sinopsis Psikiatri jilid 1. Alih bahasa : Wijaya Kusuma.
Jakarta : Bina Rupa Aksara. 2010. Hal 116-134.
 WebMD. Alzheimer's Disease and Other Forms of Dementia. Diunduh dari :
http://www.webmd.com/alzheimers/guide/alzheimers-dementia. Diakses tanggal 10 Desember 2010.
 Alzheimer's Society. What is vascular dementia? Diunduh dari :
http://alzheimers.org.uk/site/scripts/documents_info.php?categoryID=200137&documentID=161&pageNumber=1.
Diakses tanggal 10 Desember 2010.
 Helpguide.org. Depression in Older Adults and Elderly. Diunduh dari :
http://helpguide.org/mental/depression_elderly. Diakses tanggal 12 Desember 2010.
 Laporan Riset Kesehatan Dasar Tahun 2007. Departemen Kesehatan RI.
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Diakses tanggal 12 Desember 2010.
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