This presentation is about geriatric Psychiatry awareness. it contains basic information about what is geriatric psychiatry, which are the main psychiatry disorder found in elderly and how to manage them?. it contains some detailed information about late life depression, delirium and dementia in geriatric population.
2. Dr. Ravi Soni
DM Geriatric Psychiatry
Introduction
Consultant Geriatric Psychiatrist
GIPS Psychiatry Clinic
[Memory clinic and Geriatric Psychiatry Clinic]
Mobile No: 7379076870, 9601555370
Area of Work:
o Elderly Psychiatric Illnesses including
Depression, Psychosis, bipolar disorder,
Anxiety disorder etc.
o Management of all types of Dementia
o Expert in Management of Delirium
o Counselling and Psychotherapy
Achievements:
o MD Psychiatry from BJMC Ahmedabad
o DM Geriatric Psychiatry From KGMC, Lucknow
o First and Only Geriatric Psychiatrist of Gujarat
o Faculty and Speaker in Various national and regional
conferences
o Conducted many workshops for “Awareness about
Geriatric Psychiatric illnesses and Dementia”
o Published 4 articles in national and International
Journals
3. What is on the plate today?
Why this specialty is needed?
Aging and Disease?
Life events in Elderly
Fears of Elderly
Triple Ds of elderly
Late life Depression
Delirium
Dementia- Ultra Brief
4. Why this Specialty required?
Psychiatric illnesses may have different
manifestations, pathogenesis, and
pathophysiology from younger adults
Coexisting chronic medical illness
More medicines-Interactions
Cognitive impairment
Effects of aging physiology on drug therapy
Increased risk for social stressors, including
retirement and widowhood
5. Ageing: Demographic Scenario
Advancing Age : Birth of Elderly
o Steady rise in the
population of elderly
globally
o In India - increasing
longevity
o Improvement in Health
Care Services
o Consequently increasing life expectancy
Males Females
1951 32.45 31.66
2001 62.80 63.80
2011 68.90 69.50
o Census 2011 population:
o India- 1220 m; Elderly - 92 m
o Gujarat- 61 m Elderly- 5.25 m
6. Ageing is a progressive
deterioration of physiological
function, an intrinsic age-
related process of loss of
viability and increase in
vulnerability.
(Magalhaes JP de, Integrative Genomics of
Ageing group, 2001, 2004, 2005, 2008)
Ageing
7. Ageing and Diseases
Diseases due to the Ageing Process
The “biological age” of a person is not identical with his “chronological age”.
Years may wrinkle the skin, but worry, doubt, fear, anxiety, tension, and self-distrust
wrinkle the soul.
With the passage of time, certain changes take place in an organism.
The following disabilities are considered as incident to it:
o Senile cataract
o Glaucoma
o Nerve deafness
o Osteoporosis affecting mobility
o Failure of special senses
o Bronchitis
o Alzheimer’s disease
o Rheumatism
o Dental problems
8. Ageing and Diseases (contd.)
Major Mental Health Disorders
Impaired memory, rigid outlook and resistance
to change are some of the mental changes in
the elderly.
Major mental health problems of older adults
are:
Organic Disorders
Late Life Functional Diseases:
Mood (Affective) Disorders
Neurotic, Stress Related and Somatoform Disorders
Schizophrenia, Schizotypal and Delusional
Disorders (Functional Psychoses)
Psychoactive Substance Use Disorders
Suicidal Behaviors in the Elderly
Loneliness
10. Indicators Healthy Ageing
No physical disability over the age of 75 as rated
by a physician;
Good subjective health assessment (i.e. good
self-ratings of one's health);
Length of un-disabled life;
Good mental health;
Objective social support;
Self-rated life satisfaction in different domains;
Marriage; income-related work; children;
friendship and social contacts; hobbies;
community service activities; religion and
recreation/sports.
11. Some useful Suggestions for
Healthy Ageing
o Eat a balanced diet, including fruits and
vegetables daily.
o Maintain sleep-wake cycle.
o Exercise regularly (check with a doctor before
starting an exercise program).
o Do meditation.
o Get regular health check-ups.
o Quit smoking (it's never too late to quit).
o Practice safety habits at home to prevent falls
and fractures.
o Always wear your seatbelt in a car.
o Stay in contact with family and friends.
12. Some useful Suggestions for
Healthy Ageing
Stay active through work, play, and
community.
Active sexual life.
Avoid overexposure to the sun and the cold.
If you drink, moderation is the key.
When you drink, let someone else drive.
Keep personal and financial records in order
to simplify budgeting and investing.
Plan long-term housing and money needs.
Keep a positive attitude towards life.
Do things that make you happy.
13. Aging and the Life Cycle (Erickson)
Young adulthood--intimacy versus
isolation
Middle-aged--generativity versus self-
absorption
Elderly--Integrity versus despair
(Acceptance of mortality,
satisfaction with one’s meaning in
the world)
Fear of death is usually a mid-life
issue
14. Concerns/Life Events of Elderly
Retirement Lowered Self Esteem
Economic Insecurity Loss of Control
Decreasing Health Abuse/Neglect and Isolation
Dependency Loss and Loneliness
Chronic illnesses So many Medications
Lack of caregiver Boredom
Reminiscence is normative
On-time normative incidents do not usually result in crisis
20. Risk factors include
Loss of social roles
Loss of autonomy
Deaths
Declining health
Increased isolation
Financial constraints
Decreased cognitive functioning
21. Persistent depression in older adults ---- enormous individual and
family burden.
Increases mortality both from suicide and concurrent medical
illness.
Under-recognized in primary care settings, general hospitals and
nursing homes.
Different presentation---- Happily sad, suffering with
smile
Late life Depression Common but
Different
presentation
22. Late life Depression
Late onset
Depression- First time
after age 50
Vascular
Depression
Post Stroke
Depression
Psychotic
Depression
23. Phenomenology
“Depression without sadness”
Lack of feeling or emotion
Prominent cognitive complaints
Prominent somatic complaints (eg:
preoccupation with bowel function)
24. Phenomenology (contd..)
Unexplained health worries,
unknown fear
Heightened pain
experience/complaints
Multiple Physician/Hospital visits
without resolution of the problem
Irritability
25. Phenomenology (contd..)
Problems in initiative, self care, household maintenance,
transportation and communication.
Social withdrawal, avoidance of social interaction
Prominent loss of interest and pleasure in activities
Signs of functional impairment or otherwise unexplained
functional decline
26. Epidemiology
Classical major depression is less
frequent in older adults (prevalence
of 1%)
15 to 25 % experience depressive
symptoms that do not meet criteria
for a specific depressive syndrome
but cause distress and significant
dysfunctioning.
Confused
Clinician
27. Theories behind low prevalence of
major depression in elderly
“Resilience” – capacity to adjust and
recover from stressors without loss of
equanimity.
Shared experience or “generational
temperament” give rise to variation in
prevalence across generations
Flaws in the diagnostic approaches and
interview techniques.
28. Risk factors
Medical illness- parkinson’s disease,
stroke, Alzheimer’s disease,
hypothyroidism, malignancies.
Past history, spousal death, separation,
lack of social contact, death of loved
ones and bereavement.
Staying in nursing homes, cognitive
decline, pain problems, under-
nutrition.
29. Suicide
Rates are high
First episode of major depression which was
not diagnosed or untreated
Psychotic depression, alcohol, recent loss or
bereavement, loss of spouse, abuse of
sedatives and hypnotics.
30. Major depression in elderly
Same criteria as for young population
Disturbances in sleep, appetite and sexual
functioning are not always reliable indicator.
Use of HAM-D, MMSE and GDS are useful in elderly
in primary care settings for screening.
31. Age of onset : early vs late
Early onset depression :
childhood, adolescence
or earlier adulthood.
Late onset depression is
with first onset in the
second half of life at age
of 50.
32. Contd...
Early onset depression have more first degree
relatives with depression (genetic loading)
Late onset depression have
More chronic physical illness,
Less complete response to treatment, and
Chronic course,
Poorer prognosis,
Increased mortality and
Frontal and temporal atrophy on scans.
33. Depression with reversible dementia
Depression in elderly is associated with cognitive
impairments
“Pseudodementia of depression” or “depression with
reversible dementia” is now considered obsolete.
Brain dysfunction is “unmasked” by depression or its
just beginning of dementing process
34. Vascular depression
Cerebrovascular diseases both cortical and sub
cortical (chronic microvascular).
Frontostriatal disconnection : executive
dysfunction, reduced interest in activities,
psychomotor retardation, cognitive impairment
and impaired insight.
Impairment in instrumental activities of daily
living and poor prognosis.
35. Post stroke depression
Depression developing a year or more after a
stroke is strongly influenced by impairment in
social and physical functioning.
Depression after a 3 to 6 months period of stroke
have more vegetative features and larger lesion
volumes.
36. Depression with psychosis
Respond not at all to placebos, poorly to
antidepressants used alone, and more
often to combinations of antidepressant
and antipsychotic medications
Hospitalization is typically indicated and
electroconvulsive therapy (ECT) is the
treatment of first choice when agitation,
starvation, dehydration, or suicidality
threaten survival.
37. Delusions in psychotic depression involve guilt, jealousy,
paranoia, or somatic symptoms (e.g., beliefs in suffering a
serious or a fatal medical illness).
Patients frequently complain bitterly of somatic symptoms
without medical explanation, and can express profound
nihilistic beliefs and hopelessness, but hallucinations are
relatively infrequent.
Some patients are unable to urinate or defecate and require
urgent, separate intervention for these problems.
Depression with psychosis
38. Post-bereavement and depression
Many elderly people experience a great deal of
loss, not only in the form of death (e.g., spouse,
friends, relatives, loved pets), but also in other
spheres of life such as loss of
Physical ability,
Financial income,
Social status,
Mobility,
Life ambitions, and
Independence
39. Symptoms favoring major
depression
Guilt about things other than actions taken
or not taken by the survivor around the time
of the death
Thoughts of death other than the survivor
feeling that he or she would be better off
dead or should have died with the deceased
person
Morbid preoccupation with worthlessness
40. contd...
Marked psychomotor retardation
Prolonged and marked functional impairment
Hallucinatory experiences other than thinking
that he or she hears the voice or footsteps, or
transiently sees the image, of the deceased
person
41. Chronic medical illness
Increased medical burden increases
depressive symptoms, and long-term
depressive symptoms increase medical
burden and mortality
Depression lowers self-rated health and
intensifies physical symptoms including
amplifying the perception of pain, and
chronic pain worsens depression.
42. Cerebral abnormalities
Structural brain abnormalities are more frequent in
patients with LOD than EOD.
Depression is especially common with higher grades of
WMHs in the frontal lobes, even after controlling for
vascular risk factors such as hypertension, diabetes,
and ischemic heart disease
43. Pharmacotherapy
SSRI - drug of choice.
Common adverse effects are GI
distrtess, agitation, akathisia,
insomnia, sexual dysfunction and
occasionally parkinson like motor
side effects
Risk of serotonin syndrome
Hyponatremia – inappropriate ADH,
urinary retention
44. TCA- anticholinergic side effects
Nortriptyline and desipramine have less SE.
TCA better for chronic pain management
45. Venlafaxine, desvenlafaxine, mirtazapine,
bupropion, duloxetine and MAOIs can be used as
only agents or as part of augmentation.
Psychostimulants, such as methylphenidate and
amphetamine have inconclusive evidence for
efficacy.
46. Psychotherapy
Evidence is insufficient to recommend
psychotherapy as a first-line treatment
for depression in older adults, but
clinical judgment is the preferred
decision tool in individual cases.
Cognitive-behavioral therapy (CBT) and
problem-solving therapy (PST), and
antide-pressant medication combined
with interpersonal therapy (IPT) has
role.
47. A few studies document the promise of various
forms of psychotherapy (CBT, PST, IPT, , and
dialectical behavior therapy [DBT] group skills’
training) in geriatric depression in outpatients.
Various obstacles to use psychotherapy in elderly.
48. Treatment resistance
Delayed onset of therapeutic activity
because of need to “start low and go
slow”
Lack of full remission frequently
experienced by depressed elderly, even
after having an adequate medication
trial.
50. Treatment resistance (contd..)
Although approximately 50% to 60% of elderly
patients improve clinically with
antidepressant therapy
The efficacy of these agents may be lower
mainly in those with vascular or
neurodegenerative brain disease.
51. ECT
ECT is the most important of the non-
pharmacological somatic treatments
It is the treatment of choice in certain older
patients with severe depression due to poor
tolerance of psychotropic medications, psychotic
features, significant comorbid medical conditions,
or marked disability or urgent risk to life.
52. COURSE AND PROGNOSIS
Left untreated, late-life major depression
tends to remit spontaneously after 12–48
months, but patients with first-episode
depression with onset after age 60 have a
70% chance of recurrence within 2 years.
53. Data from naturalistic studies have identified several
predictors of relapse and recurrence:
Frequent prior episodes,
High pretreatment severity of depression and anxiety,
Supervening medical illness,
History of myocardial infarction or vascular disease,
and
Cognitive impairment.
COURSE AND PROGNOSIS
54. Delirium
Usually acute and fluctuating
Altered state of consciousness (reduced
awareness of and ability to respond to the
environment)
Cognitive deficits in attention,
concentration, thinking, memory, and
goal-directed behavior are almost always
present
56. That is what delirium is …..
Agitation Confusion Sedation Compulsive
Searching
OR
Combination
HallucinationsDistractions
57. Features of delirium
May be accompanied by
Inattention
Hallucinations,
Illusions,
Emotional lability,
Alterations in the sleep-wake cycle,
Evening worsening of symptoms
Fluctuations in Symptoms
Psychomotor slowing or hyperactivity,
Searching and picking behavior
Removing clothes, life support equipments (like IV line, Catheter, Nasogastric
tube, Ventilator support)
Usually abrupt and resolution is also rapid when underlying cause
is corrected.
58. Types of delirium
Types:
Hyperactive , hyperalert
delirium: almost always consultation
Hypoactive, hypoalert delirium: no
consultation
Mixed: Fluctuation between
hyperactive and hypoactive
59. Causes of Delirium: I WATCH DEATH
Infectious Deficiencies
Withdrawal Endocrinopathies
Acute metabolic Acute vascular
Trauma Toxins/drugs
CNS Pathology Heavy Metals
Hypoxia
Note that prescribed medicines may
cause delirium
60. The Mortality of Delirium
The mortality outcome at 6 months post
discharge for delirious patients not identified
was three times higher than the delirious
patients who were identified and treated.
25 percent of delirious postoperative patient
had a lethal outcome; control population 13%
61. Burden of Delirium
Increased mortality
Increased nursing care
Increased length of stay
Increased risk of cognitive decline
Increased risk of functional decline
62. Treatment of delirium
Look for underlying cause “always be
suspicious”
Close supervision, especially by family
Reorient frequently
Adequate lighting
63. Treatment of delirium (continued)
Use consistent personnel
Try not to use restraints, as it can worsen confusion.
Medication only if behavioral attempts fail
Avoid polypharmacy
Low dose neuroleptic is treatment of choice, unless the
delirium is due to withdrawal.
If due to Alcohol withdrawal, use a short-acting
benzodiazepine. (Lorazepam)
64. Treatment
Dose Route Reps
Haloperidol 0.25 -1 mg POIM bid/tid Every 30-60 min
Risperidone 0.25 - 0.5 mg PO bid/tid Every 30-60 min
Olanzapine 2.5 – 5 mg PO/IM Every 30-60 min
Quetiapine 25 – 50 mg PO Every 30-60 min
For excessive agitation
65.
66. Dementia is a syndrome due to disease of the brain, usually
of a chronic or progressive nature.
There is disturbance of multiple higher cortical functions,
including memory, thinking, orientation, comprehension,
calculation, learning capacity, language, and judgement.
Dementia produces an appreciable decline in intellectual
functioning, and usually some interference with personal
activities of daily living, such as washing, dressing, eating,
personal hygiene, excretory and toilet activities.
What is dementia?
67. AD is the most common cause of dementia amongst
people aged 65 and older
Prevalence among people over 60 years–5% to 8 %
Starting with 0.5% prevalence at 55 yrs., it goes on
doubling every five years (60yrs-1%; 65yrs. – 2%; 70 yrs. -
4%; 75yrs.-8% and so on)
Risk at the age of 80 years is around 15 to 20%
At present nearly 35.6 million people worldwide with
dementia. Expected to double by 2030 and triple by 2050.
About 7.7 million new cases of dementia each year.
A new case detected in every 4 seconds somewhere in
world. (WHO)
Epidemiology
68. Common Types of Dementias
Type of Dementia % in total Cases
Alzheimer’s Dementia 50-55
Vascular Dementia 30-35
Lewy body Dementia 5-7
Pick’s Dementia 3-5
Other Dementias 10-15
69. Age: 60-70 years
Gender: female
Prior stroke
Atherosclerosis
Heart disease
High blood pressure
Diabetes
Diet
Risk Factors for Dementia
• Cholesterol problems
• Atrial fibrillation
• Smoking
• Low Education
• Family history
71. Structural Disease or Trauma
Normal pressure hydrocephalus
Neoplasms
Dementia pugilistica
Vascular Disease
Vascular dementia
Vasculitis
Heredo-metabolic Disease
Wilson’s disease
Other late-onset lysosomal storage diseases
Etiological classification of dementia
72. Demyelinating or Demyelinating Disease
Multiple sclerosis
Infectious Disease
Human immunodeficiency virus, type 1
Tertiary syphilis
Creutzfeldt-Jakob disease
Progressive multifocal leukoencephalopathy
Whipple’s disease
Chronic meningitis – e.g. Cryptococcal
Etiological classification of dementia
73. Nutritional deficiency:
Vitamin B12 deficiency, Folate deficiency, thiamine
deficiency.
Organ failure:
Uremic and hepatic encephalopathy
Endocrine disease:
Diabetes mellitus, hyper/ hypothyroidism, Cushing's
syndrome etc.
Etiological classification of dementia
74. D = Drugs, Delirium
E =Emotions (depression) &
Endocrine Disease
M=Metabolic Disturbances
E =Eye & Ear Impairments
N =Nutritional Disorders
T =Tumors, Toxicity, Trauma to
Head
I = Infectious Disorders
A= Alcohol, Arteriosclerosis
Irreversible / Reversible dementias
• Alzheimer’s Dementia
• Lewy Body Dementia
• Pick’s Disease
(Frontotemporal
Dementia)
• Parkinson’s
• Heady Injury
• Huntington’s Disease
• Creutzfeldt- Jacob
Disease
75. Early symptoms
o ભૂલી જવું
o એકની એક વાત વારુંવાર કરવી
o ઘરના વ્યક્તતના નામ ભૂલી જવા
o જૂની વાતો યાદ કરવી
o શક-શુંકા કરવી
o કોઈ ચોરી કરી ગયું એવી વાતો
કરવી
o ખાવાનું ખાઈને વારુંવાર ભૂલી
જવું
o નાવા-ધોવામાું વધ સમય લેવો
o પોતાની કાળજી ના રાખી શકવી
o રસ્તા ભૂલી જવા
o પેશાબ ગમે તયાું કરી દેવો
o રાતભર ભટક્યા કરવું
o અચાનક હસવા-રડવા લાગવું
o ગમસમ બેસી રહેવું
76. Complete Blood Count, ESR
Serum Urea, Creatinine, Electrolytes
Thyroid function tests
Serum B 12 & Folate
Electrocardiogram
Chest X-ray
CT Scan of head/ MRI head
Lumber Puncture (if suspicion of infectious etiology)
Tests for syphilis, HIV
Drug screen if appropriate
Brain biopsy (for confirmatory diagnosis)
Lab and other tests for dementia
77. Diffuse brain atrophy
Enlargement of ventricles
Widening of sulci and gyri
Atrophy more prominent in hippocampus
There can also be evidences of strokes,
lacunar infarcts, and white matter hyper
intensities. These complicate the picture.
Neuroimaging
78. Characteristics Alzheimer’s Disease Vascular Dementia
Sex Women Men
Age Generally over age 75 years Generally over age 60 years
Onset & progression Gradually progressive Stuttering or episodic, with
stepwise deterioration
History of hypertension Less common Common
History of
stroke(s),transient
ischemic attack(s),or
other focal neurological
symptoms
Less common Common
Hypertension Less common Common
Focal neurological signs Uncommon Common
Emotional lability Less common More common
Cognitive deficits Uniform patchy
Alzheimer’s Disease Vs Vascular Dementia
79. a
BPSDActivities of daily
living
Behavioural and Psychological Symptoms
of Dementia:
A heterogeneous range of psychological
reactions, psychiatric symptoms and
behaviours resulting from the presence of
dementia
Cognitive
deficits
80. Dementia is associate with progressive cognitive disability, a
high prevalence of Behavior and Psychological symptoms of
Dementia (BPSD) such as agitation, depression and psychosis.
BPSD are an integral part of the disease process and present
severe problems to patients, their families and caregivers and
society at large.
It increases stress in caregivers.
BPSD are treatable and generally respond better to therapy
than other symptoms of dementia.
Behavioral and psychological
symptoms of dementia (BPSD)
81. They result in:
Excess disability
Increased hospitalization
Premature institutionalization
Suffering for patient and caregiver
Substantial increase in financial costs
Associated with greater functional impairment
Elder abuse
Associated with increased mortality
Why is BPSD important?
82. Seen in:
≈40% of mild cognitive impairment
≈ 60% of patients in early stage of dementia
Affects 90-100% of patients with dementia at
some point in the course of their illness
(Mega et al. 1996).
Gets more frequent and troublesome with
advancing dementia
BPSD
83. BPSD- behavioural symptoms
Most common Common Less common
•Apathy
•Aggression
•Wandering
•Restlessness
•Eating
problems
•Agitation
•Disinhibition
•Pacing
•Screaming
•Sundowning
•Crying
•Mannerisms
84. BPSD- psychological symptoms
Most common Common Less common
•Depression
•Anxiety
•Insomnia
•Delusions
•Hallucinations
•Misidentification
86. Agitation up to 75%
Wandering up to 60%
Depression up to 50%
Psychosis up to 30%
Screaming up to 25%
Aggression up to 20%
Sexual Disinhibition up to 10%
(Mega, Cumming et al. 1996)
Estimated frequency of common
BPSD
87. 50 – 90% of caregivers considered physical
aggression as the most serious problem they
encountered and a factor leading to
institutionalization (Rabins et al. 1982)
BPSD
Treatment of
Dementia
Very Lengthy Topic to cover: So not
covered
88.
89. Integrity vs despair
Psychosocial
Conflict: Integrity
versus despair
Major Question: "Did I
live a meaningful life?“
Basic Virtue: Wisdom
Important
Event(s): Reflecting
back on life
Integrity: the state of being
whole and undivided
Despair: the complete loss or
absence of hope
This stage occurs during late
adulthood from age 65 through
the end of life.
During this period of time,
people reflect back on the life
they have lived and come away
with either a sense of
fulfillment from a life well
lived or a sense of regret and
despair over a life misspent.
90. THE END
“healthy children will
not fear life if their elders have
integrity enough not to fear
death.”
91. Dr. Ravi Soni
DM Geriatric Psychiatry
Introduction
Consultant Geriatric Psychiatrist
GIPS Psychiatry Clinic
[Memory clinic and Geriatric Psychiatry Clinic]
Mobile No: 7379076870, 9601555370
Area of Work:
o Elderly Psychiatric Illnesses including
Depression, Psychosis, bipolar disorder,
Anxiety disorder etc.
o Management of all types of Dementia
o Expert in Management of Delirium
o Counselling and Psychotherapy
Achievements:
o MD Psychiatry from BJMC Ahmedabad
o DM Geriatric Psychiatry From KGMC, Lucknow
o First and Only Geriatric Psychiatrist of Gujarat
o Faculty and Speaker in Various national and regional
conferences
o Conducted many workshops for “Awareness about
Geriatric Psychiatric illnesses and Dementia”
o Published 4 articles in national and International
Journals