general principles in geriatric psychiatry.....

1. GENERAL PRINCIPLES IN GERIATRIC
PSYCHIATRY
PRESENTED BY :
Dr. Shubham Sadh
(Dept of Manasa Roga)
SDMCAH HASSAN
EMAIL ID:
(shubhamsadh@gmail.com)
1

2. CONTENTS
• INTRODUCTION
• DEMOGRAPHICS
• DEFINITION
• GERIATRIC PSYCHIATRY
• COMMON CAUSES IN GERIATRIC
PSYCHIATRY
• GENERAL SIGNS AND SYMPTOMS OF
GERIATRIC PSYCHIATRY
• PSYCHIATRY ASSESSMENT IN ELDERLY
• MENTAL DISORDERS IN OLD AGE
• GENERAL LINE OF MANAGEMENT
• CONCLUSION
2

3. INTRODUCTION
• The term geriatric was coined in the USA by Dr.
Ignatz Nascher in 1909.
3
“THE GOAL OF LIFE IS TO DIE YOUNG
AS LATE AS POSSIBLE”
-Asle Montegue

4. DEMOGRAPHICS
• The World population of the elderly is increasing
and by the year 2050, adults older than 65 years
will comprise 1/5th of the global population.
• In India 3.8% of the population are older than
65 years of age.
• According to an estimate the likely number of
elderly people in India by 2016 will be around
113 million. 4

5. Elderly Population in India
Census Data & Projections
0
50
100
150
200
250
300
1901 1911 1921 1931 1941 1951 1961 1971 1981 1991 2001 2011 2016 2026 2051
5
millions

6. DEFINITIONS
• GERIATRICS : A branch of Medicine dealing exclusively
with the problems of ageing and the diseases of the
elderly. It is derived from the Greek root “ger –gero-
geronto” meaning “old age” or “the aged”.
• GERANTOLOGY: The science dealing with old age.
• GERANTOLOGISTS : A person who treats problems
related to ageing.
• OLD AGE: It is defined as the period beyond the
retirement age, usually taken as starting around 65years
of age 6

7. “The processes that occur during life which culminate in changes that
decrease an individual's ability to cope with biological changes”.
Ageing
SYNONYMS OF AGEING:
• Senescence
• Senility
• Senium.
• Geria

8. CLASSIFICATION OF AGE
AGE
Chronological age
- number of years
lived
Biological age –
age by body
function
Psychological age
– age how
individuals feels it
CHRONOLOGICAL CATEGORIES
•Young-Old - (ages 65 - 74) Set Old Age
•Middle-Old - (ages 75 - 84) Old Old Age
•Old-Old - (age 85 and older) Ripe Old Age

9. ACCORDING TO AYURVEDA
• JARA – Derived from the root
word “eÉ×wÉç uÉrÉÉåWûÉlÉÉæ”
explained as-
A) “uÉrÉ:M×üiÉzsÉjÉqÉÉÇxÉÉÌS AuÉxjÉÉpÉåS:”
B) In shabda koustubha, the word
जरा has been defined as “zÉæÍjÉsrÉ
AmÉÉSMüÉuÉxÉjÉÉ”
C) Acc to gurubalaprabhodika
commentary on amar kosha
“eÉÏUrÉÎliÉ AlÉÉrÉÉå AÇ…ÄÉÌlÉ CÌiÉ eÉUÉ:”
9

10. Types of Jara
Kalaja Jara:
Jara coming at the proper age is Kalaja Jara(after 60 yrs.).
•It is ‘Parirakshana Krita’
• chronological Ageing.
• Dhatu kshaya janya jara.
Akalaja Jara – The Concept of Premature Ageing:
‘ Akalotpanna lakshana Akalaja’,
‘ Akale jata iti Akalaja’
means that thing which occurs Akalaja i.e. before its prescribed time.
• This Akalaja Jara is of greater intensity, rapidly progressing one if neglected.
• Biological Ageing.
•Marga avarodha janya jara.

11. Ageing
Srotokhar
atwa
(srotovah
ani)
Improper
absorption
&
assimilation
of ahara
rasa
Disequilibr
ium in
upchaya &
apchaya
Rasa
dhatu
kshaya
Uttarota
ra dhatu
kshaya
Ojo
kshaya
Vata
vriddhi
How Vata
vriddhi occurs
during ageing?

12. ACHARYA BALYAM MADHYAMAM VARDHIKYAM
CHARAKA Birth to 30years
1. Aparipakvadhat
u birth to
16years
2. Vivardhamanad
hatu 16 to 30
years
30 To 60 years 60 to 100 years
SUSHRUTA Birth to 16 years
1. Ksheerapa birth
to 1yr.
2. Kheerannada 1
to 2 yr.
3. Annada 2 to 16
years
16 to 70 years
1. Vriddhi 16 to 20
yr
2. Yauvana 20 to
30 yr
3. Sampurna 30 to
40 yr
4. Hani 40 to 70 yr
70 onwards
VAGBHATA Birth to 34 years
1. Kaumara birth
to 16yr
2. Yauvana 16 to
34 yrs
34 to 70 yrs 70 onwards
12

13. MILESTONES OF AGEING
VAGBHATA VIEW
0 10 20 30 40 50 60 70 80 90 100
LOSS
AGE IN
YEARS
13

14. SHARANGDHARA VIEW
0 10 20 30 40 50 60 70 80 90 100
BALYAM
VRIDDHI
CHAVI
MEDHA
TWAK
DRISHTI
SHUKRA
VIKRANA
BUDDHI
KARME
NDRIYA
JEEVITA
LOSS
AGE IN
YEARS
14

15. uÉÚ®:ÌlÉuÉïcÉlÉ
• Acharya Charaka:
eÉÏhÉï-AiÉ:mÉUÇ WûÏrÉqÉÉlÉ kÉÉÎiuÉÎlSìrÉ
oÉsÉuÉÏrÉïmÉÉæÂwÉmÉUÉ¢üqÉaÉëWûhÉkÉÉUhÉxqÉUhÉuÉcÉlÉÌuÉ¥
ÉÉlÉÇ ´ÉqrÉqÉÉlÉkÉÉiÉÑaÉÑhÉÇuÉÉrÉÑkÉÉiÉÑmÉëÉrÉ¢üqÉãhÉ
eÉÏhÉïqÉÑcrÉiÉãAÉuÉvÉiÉqÉç|
(cÉ.ÌuÉ.8/122)
• The dhatus, indriyas, bala, virya, pourusha etc..
Gradually degenerates.
• The qualities of dhatus goes down
• Predominance of vayu 15

16. • Acharya sushruta:
uÉ×®:- ¤ÉÏrÉqÉÉhÉ kÉÉÎiuÉÎlSìrÉoÉsÉuÉÏrÉï EixÉÉWûqÉWûlrÉWûÌlÉ
uÉsÉÏmÉÍsÉiÉZÉÉÍsÉirÉeÉѹÇ
MüÉxÉpuÉÉxÉmÉëpÉ×ÌiÉÍpÉÂmÉSìuÉæUÍpÉpÉÔrÉqÉÉlÉÇxÉuÉï-
Ì¢ürÉÉxuÉxÉqÉjÉïÇeÉÏhÉÉïaÉÉUÍqÉuÉÉÍpÉuÉ×¹qÉuÉxÉÏSliÉÇ
uÉ×®qÉÉcɤÉiÉå|
(xÉÑ.xÉÔ.35/29)
• Diminition of dhatus, indriya, bala, etc..day after
day.
• Wrinkles on the skin
• Inability to perform activities
16

17. GERIATRIC PSYCHIATRY
• Derived from the Greek word GEROS(old age)
and IATROS (physician).
• Deals with preventing, diagnosing, and treating
psychological disorders in older adults.
• Elderly phase of life cycle characterized by its
own developmental issues.
17

18. Distribution of diseases in elderly
• Cataract & visual impairment : 70 %
• Cardio-Vascular and hypertension : 48 %
• Psychiatric problems : 42 %
• Arthritis & locomotion disorder : 40 %
• Respiratory diseases : 36 %
• Neurological problems : 18 %
• G I T problems : 4.7 %
• Loss of Hearing : 8 %
18

19. NORMAL CHANGES IN OLD AGE
• The major changes that occur in old age are:-
i. Physiological changes
ii. Sensory changes
iii. Changes in motor abilities
iv. Sexual changes
v. Changes in appearance
vi. Changes in mental abilities
19

20. FACTORS INFLUENCING
ADJUSTMENT IN OLD AGE
• Preparation of old age
• Earlier experiences
• Satisfaction of needs
• Retention of old age
friendships
• Attitudes of family
• Personal attitudes
• Method of adjustment
• Health conditions
• Living conditions
• Economic conditions
20

21. COMMON STRESSORS TO
ELDERLY
• Loss of partner
• Economic instability
• Poverty
• Insecurity
• Dependency
21

22. COMMON CAUSES OF
GERIATRIC PSYCHIATRY
• Physical and Emotional stress
• Long term illness
• Change of environment
• Medication interaction
• Poor diet or malnutrition.
• Alcohol or substance abuse.
22

23. GENERAL SIGNS AND
SYMPTOMS
• Sad or depressed mood.
• Social withdrawal.
• Unexplained fatigue, energy loss, or sleep
changes
• Confusion, disorientation, problems with
concentration or decision-making
• Increase or decrease in appetite. 23

24. • Memory loss.
• Feelings of worthlessness, helplessness;
thoughts of suicide.
• Physical problems like aches, constipation, etc.
• Changes in appearance.
• Trouble handling finances.
24

25. PSYCHIATRIC ASSESSMENT OF
THE ELDERLY
• The initial steps in psychiatric assessment of
elderly includes:
A. Initial assessment
a) Assessment the context
b) Seeing the patient
c) History from the patient (and reliable
informant)
25

26. B. Further process of Assessment
After an accurate detailed history, the further
assessment includes:
a) Physical examination
b) Routine laboratory examination
c) Special tests and scales for geriatric psychiatry.
d) Specialized investigations
26

27. GERIATRIC RATING SCALES
• Geriatric depression scale
• Brief assessment schedule Depression cards
• Cornell scale for Depression in Dementia
• Hamilton rating scale for Depression
• Montgomery-Asberg Depression rating
scale(MADRS)
• Mini-Mental state examination
• Clock drawing test
27

28. • Seven-minute neurocognitive screening battery
• Alzheimer’s disease assessment scale (ADAS)
• Clinical Dementia rating
• Brief psychiatry rating scale (BPRS)
28

29. MENTAL DISORDERS OF
OLD AGE
1) Dementing Disorder
2) Depressive Disorder
3) Schizophrenia
4) Delusional Disorder
5) Anxiety Disorder
6) Somatoform Disorders
7) Alcohol and Other Substance Use Disorder
8) Sleep Disorders
29

30. Dementing Disorder
• A generally progressive and irreversible
impairment of the intellect, the prevalence of
which increases with age.
• Dementias associated with advanced age
typically are caused by primary degenerative
central nervous system (CNS) disease and
vascular disease, many factors contribute to
cognitive impairment; in older persons, mixed
causes of dementia are common.
30

31. Depending on the site of the cerebral
lesion, dementias are classified as
subcortical cortical
occurs in Huntington's disease occur in dementias of the Alzheimer's
type,,
Parkinson's disease, Creutzfeldt-Jakob disease (CJD)
vascular dementia Pick's disease,
Wilson's disease Sporadic CJD accounts for 85 percent of
the human prion diseases
associated with movement disorders,
gait apraxia, psychomotor retardation,
apathy.
frequently manifest aphasia, agnosia,
and apraxia.
31

32. 32

33. Depressive disorder
• symptoms are present in about 15 percent of
all older adult .
• Age itself is not a risk factor for the
development of depression.
• Late-onset depression is characterized by
high rates of recurrence.
33

34. The common signs and symptoms of
depressive disorders
• Reduced energy and concentration
• sleep problems (especially early morning awakening
and multiple awakenings)
• decreased appetite, weight loss, and somatic
complaints.
• The presenting symptoms may be different in older
depressed patients from those seen in younger adults.
• Older persons are particularly vulnerable to major
depressive episodes 34

35. Dementia syndrome of
Depression (pseudodementia)
• Cognitive impairment in depressed geriatric patients is
referred to as the dementia syndrome of depression
(pseudodementia), which can be confused easily with
true dementia.
• Pseudodementia occurs in about 15 percent of
depressed older patients, and 25 to 50 percent of
patients with dementia are depressed.
35

36. Schizophrenia
• Women are more likely to have a late onset of
schizophrenia than men.
• Difference between early-onset and late-onset
schizophrenia is the greater prevalence of paranoid
schizophrenia in the late-onset type.
• Older persons with schizophrenic symptoms respond
well to antipsychotic drugs.
36

37. Delusional Disorder
• Somatic delusions, in which persons believe they have a
fatal illness, also can occur in older persons.
• Delusions also can accompany other disorders such as
dementia of the Alzheimer's type, alcohol use disorders,
schizophrenia, depressive disorders, and bipolar
disorder which need to be ruled out.
• The prognosis is fair to good in most cases; best results
are achieved through a combination of psychotherapy
and pharmacotherapy.
37

38. Anxiety Disorder
 The anxiety disorders include-
• Panic disorder
• Phobias
• Obsessive-compulsive disorder (OCD)
• Generalized anxiety disorder
• Acute stress disorder
• Posttraumatic stress disorder (PTSD).
38

39. • Obsessions and compulsions may appear for the first
time in older adults, although older adults with OCD
usually had demonstrated evidence of the disorder (e.g.,
being orderly, perfectionistic, punctual, and
parsimonious) when they were younger.
• When symptomatic, patients become excessive in their
desire for orderliness, rituals, and sameness. They may
become generally inflexible and rigid and have
compulsions to check things again and again.
39

40. Somatoform Disorders
• Somatoform disorders, characterized by physical
symptoms resembling medical diseases, are relevant
to geriatric psychiatry because somatic complaints are
common among older adults.
• Repeated physical examinations help reassure
patients that they do not have a fatal illness.
40

41. • Hypochondriasis is common in persons over 60
years of age, although the peak incidence is in
those 40 to 50 years of age. The disorder
usually is chronic, and the prognosis guarded.
41

42. Alcohol Use Disorder In
Geriatrics
• Usually are medically ill, primarily with liver disease, and
are either divorced, widowed.
• A large number have chronic dementing illness, such as
Wernicke's encephalopathy and Korsakoff's syndrome.
42

43. • Substance-seeking behaviour characterized by crime,
manipulativeness, and antisocial behaviour is rarer in
older than in younger adults.
• Older patients may abuse anxiolytics to allay chronic
anxiety or to ensure sleep.
43

44. Other Substance Use Disorder
• Older persons may misuse over-the-counter
substances, including nicotine and caffeine.
• Over-the-counter analgesics are used by 35 percent of
older persons and 30 percent use laxatives.
• Unexplained gastrointestinal, psychological, and
metabolic problems should alert clinicians to over-the-
counter substance abuse.
44

45. Sleep Disorders
Primary sleep problems Secondary sleep problems
Breathing related SD Depression & Psychosis
Narcolepsy/hypersomnia Arthritis & Parkinson’s
Circadian rhythm disorder Substance induced disorders
Parasomnias Fragmented Circadian rhythm
disorder, sleep in AD.
45

46. RETIREMENT SYNDROME
• It is the termination of a pattern of life or a transition to a
new pattern of life.
• Attitude towards retirement
1. Transformer
2. Maintainers
• Problems seen after retirement may be due to
1. Fall in physical and mental abilities
2. Retirement
 MANAGEMENT
46

47. GENERAL ASPECTS OF
MANAGEMENT
• Early, correct and full diagnosis
• Keep patients at home as long as possible
TREATMENT
• Drugs
• Psychotherapy
• Hospitalization(special geriatric unit)
47

48. Drugs
• Beware of over and under medication.
• Assess physical conditions before administering any
drug.
• Treat with lowest effective dose.
• Introduce medication carefully to avoid side effects.
• Eg.- Antidepressants,
Antipsychotic,
Anxiolytic.
48

49. Psychotherapy for Geriatric
Patients
 The standard psychotherapeutic interventions such as
• Insight-oriented psychotherapy
• Supportive psychotherapy
• Cognitive therapy
• Group therapy
• Family therapy
49

50. • Psychotherapy helps older persons to deal
with issues and the emotional problems
surrounding them and to understand their
behavior and the effects of their behavior
on others.
• In addition to improving interpersonal
relationships, psychotherapy increases
self-esteem and self-confidence,
decreases feelings of helplessness and
anger, and improves the quality of life.

51. • As described by Alvin Goldfarb, geriatric
psychotherapy has the general aim of
assisting older adults to have minimal
complaints, to help them make and keep
friends.
• Therapists must be more active, supportive,
and flexible in conducting therapy with older
than with younger adults.

52. Goldfarb has
described a brief,
supportive therapy
technique for
cognitively impaired
patients.
• The therapist promotes
patients' foundering self-
esteem,
• sense of control,
• and safety by permitting
them to develop an
apparent special
relationship with the
therapist.

53. Reminiscence Therapy
• Reminiscence is characterized
by the progressive return of
memories of past experiences,
especially those that were
meaningful and conflictual.
• To varying degrees, elderly
patients in therapy, reminisce
about the past, search for
meaning in their lives, and
strive for some resolution of
past interpersonal and
intrapsychic conflicts.

54. Life Review Therapy
• Life review therapy systematically enhances this
reminiscing process and makes it more
conscious and deliberate.
• The therapist may guide the process by
encouraging the patient to write or tape a
biography with review of special events and
turning points.

55. • Techniques include
reunions with family
and good friends and
looking through
memorabilia, such as
scrapbooks or picture
albums.
• This technique has
been reported to
resolve old problems,
increase tolerance of
conflict, relieve guilt
and fears, and
enhance self-esteem,
creativity, generosity,
and acceptance of the
present.

56. •The Therapy, which gives the benefit of good Rasa,
is Rasayana. Hence, it is the therapy by which one
gets the Rasa, Raktadi Dhatus of optimum quality.
RASAYANA
•Rasayana Tantra is one which deals with delaying
of ageing process, increasing of intellect and
strength, prolongation of life and curing of disorders.

57. Definition
sÉÉpÉÉåmÉÉrÉÉå ÌWûzÉxiÉÉlÉÉÇUxÉÉSÏlÉÉÇ UxÉÉrÉlÉqÉç |
(cÉ.ÍcÉ.1/1)
• The therapy which produces the best quality of ras, rakta
dhatu & other dhatus, is rasayan.
• Which decreases the ageing process, increases the
longevity & increases the mental as well as physical
strength & which destroys the disease process, is rasayan

58. Rasayana Benefits
• As per "CHARAKA" Benefits of regular usages of
Rasayanas are Longevity, good memory power,
Health, youthfulness, complexion, luster, good
sensory function and resistance against diseases
etc.

59. Medhya Rasayana
qÉhQÕûMümÉhrÉÉï:xuÉUxÉ:mÉërÉÉåerÉ:¤ÉÏUåhÉrɹÏqÉkÉÑMüxrÉ cÉÔhÉïqÉç|
UxÉÉåaÉÑQÕûcrÉÉxiÉÑxÉqÉÔsÉmÉÑwmrÉÉ:MüsMü:mÉërÉÉåerÉ:ZÉsÉ
ÑzÉÇZÉmÉÑwmrÉÉ:||
(cÉ.ÍcÉ. 1(3)/30)
Other medhya rasayana –
• AµÉaÉlkÉÉ
• uÉcÉÉ
• eÉOûÉqÉÉÇxÉÏ
• erÉÉåÌiÉwqÉÌiÉ
• oÉëɼÏ
59

60. Achara Rasayana
• xÉirÉuÉÉÌSlÉqÉ¢üÉåkÉÇ
• ÌlÉuÉ×iÉÇqɱqÉæjÉÑlÉÉiÉç
• AÌWÇûxÉMüqÉlÉÉrÉÉxÉÇ
• mÉëzÉÉliÉÇÌmÉërÉuÉÉÌSlÉqÉç
Benefits –
• Enhances satwa guna.
• Person can be free from emotional conflicts.
• Stress free life.
60

61. • eÉmÉzÉÉæcÉmÉUÇkÉÏUÇ SÉlÉÌlÉirÉÇ iÉmÉÎxuÉlÉqÉç|
Action –
• Normalizes the important neurotransmitters like-
serotonin, nor epinephrine,GABA and regulates a wide
variety of neuro psychological processes like mood
disturbances,sleep induction.
61

62. Ajasrika Rasayana
• Food supplements like milk, ghee and other nutritious
elements of diet is the practice of Ajasrika rasayana.
Some rasayana formulations-
• Chyavanprasha(medha, smriti, ayu prakarshan)
• Haritaki rasayana (best vayasthapak)
• Amalaki rasayana (inhibits ageing)
• Pippali vardhaman rasayana (medhya vayasthapana)
• Triphala rasayana (medha, smriti, inhibits jara vyadhi)
62

63. PANCHKARMA IN GERIATRIC
PSYCHIATRY
Shiro Vasti –
• Procedure of retaining medicated oil on the
head in flexible container brimmed over head.
• This procedure calms the mind and enhances
the intellect .
• commonly prescribed in psychological / psycho
somatic disorders .
• Loss of Buddhi (cognition)
• Loss of Smriti (memory)
63

64. • Shiro Dhara –
• It is procedure of pouring medicated oil / milk /
butter milk on the fore head from a container.
• It induces soothening effect to regulate the
stress and there by the stress induced disorders
in old age.
64

65. CONCLUSION
• Geriatric psychiatric is the study of the causes
and medical treatment of mental illness
associated with old age.
• Proper assessment and diagnosis is necessary.
• Extra care and support should be provided.
• Anti ageing management of Ayurveda should be
adopted for the healthy old age.
65

66. Thank u….