4. The Young Old, the Old Old, and the Oldest
Old
Developmentalists distinguish between
subperiods in this stage, although definite age
boundaries are not yet agreed upon.
The young old are 65-74 years of age.
The old old are 75 years and older.
Some distinguish the oldest old as 85 years and
older.
4
5. The Young Old, the Old Old, and the Oldest
Old
Many experts prefer to make the distinction
based on functioning, rather than age.
Functional age: A person's actual ability to
function -> the young old = those who regardless
of their actual age are vital and active.
5
8. Retirement is
detrimental to an
individual's health; six
months ago he retired
and now he's dead,
retirement killed him
8
9. Longevity: Life Expectancy and Life
Span
Life span - the upper boundary of life, the
maximum number of years an individual
can live.
The maximum life span of human beings
is approximately 120 years of age.
Life expectancy - the number of years
that will probably be lived by the
average individual born in a particular
year.
The life expectancy of individuals born
today in Canada is 78.6 years.
9
10. Sex Differences in Longevity
Today, life expectancy for females is 82, males 76.
Beginning at age 25, females outnumber males,
and the gap continues to grow.
By the time adults are 75 years of age, more than
61% of the population is female.
These differences are due to health attitudes,
habits, lifestyles, and occupation.
Biological factors play a role, too, as females
outlive males in virtually all species.
10
11. Variations in Life Span: Factors
Quality of the health care system
Quality of food
Genetic predispositions
Health habits
Geographic location
Psychological variables: Optimism. Self-esteem.
Concept: Active life expectancy
11
17. 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
17
18. Challenges of Late Life
Co-morbid medical illness /
cognitive disorders
Sensory loss
Financial worries
Retirement
Dependency
Dying and death
Bereavement
18
19. What Is Normal Aging?
Some bodily functions decline with
age, but health problems are not
inevitable.
“Normal” aging must be differentiated
from disease.
notion of chronological age (“how old
are you?”) be abandoned, and
instead that the stages of aging be
considered.
Age cut-offs are artificial and arbitrary.
19
20. Physical Changes of Aging
Heart
Muscles
Brain
Skin
Kidney
Vision
Hearing
Bones
Taste
~ Pumping effectiveness decreases
~ Muscle mass decreases
~ Some loss of cell structure and function
~ Dryness, slower healing
~ Less efficient
~ Decreases in depth perception, color
perception, and peripheral vision
~ Decreased acuity, esp. higher pitch
~ Mineral loss faster than replacement
~ Decreased taste buds, saliva
production
20
21. Getting older v. living
longer Mental changes
Personality
amplification of character traits
Cognition, memory
mental slowing
transformed memory structure
summerised experiences
Emotional changes
Emotional maturity
21
22. Getting older v. living
longer Social changes
Retirement (financial difficulties)
Decrease in social status
Facing somatic and mental
disfunctioning
Somatic diseases
Grief (loss of spouse, brothers or
sisters, friends)
Social isolation
Moving to nursing/residential home
22
24. Structural Changes
Associated with Brain
AgingDecline of brain weight
Neuron loss
Neuronal atrophy
Synaptic loss
Pruning of dendritic trees
White matter changes
Gliosis
24
26. Age related changes in the Central
Nervous System
Gross brain atrophy
Ventricular enlargement
Selective regional neuronal loss
Remodeling of dendrite, axons &
synapses
Appearance of intraneuronal
lipofuschin
Selective regional decrease in
neurotransmitter & neuropeptides.
26
27. Contd...........
Selective modification of
neurotransmitter metabolism
Possible dysregulation of gaseous
neurotransmitter metabolism
Glucocorticoid neurotoxicity
Changes in receptors
Changes in neurotrophins
Changes in signal transduction
27
28. …contd.
Impairment of calcium homeostasis
Possible changes in cell cycle regulations
(eg, cyclins)
Possible changes in extra cellular matrix
proteins (eg. Laminin, proteoglycans)
Possible regional decline in cerebral blood
flow
Possible regional decline in metabolic rate
Appearance of senile plaque &
neurofibrillary tangle
28
29. Changes in Motor Abilities
Gait slowing
Reaction time slowing
Balance changes
(vestibular, sensory, motor,
and brain)
29
31. Changes in Cognitive
Abilities
Cognition includes learning,
memory, &. . .
Learning is the ability to
gain new skills and
information. It may be
slower in elderly, especially
verbal learning.
31
32. Changes in Cognitive
Abilities
Memory : immediate, short- and
long- term memory.
Immediate and Short-term memory
remain intact, however, there ar
affected by concentration which
may be less in older adults.
Long-term memory is most affected
by aging. Retrieval is less efficient;
the elderly need more cues
32
33. Prospects for Healthy Brain
Aging
Control hypertension
Treat diabetes and
vascular risk factors
Mental activity
Cognitively demanding
pastimes
Social networks
33
34. Prospects for Healthy Brain
Aging
Regular physical activity
Diet : Similar components
to a heart-healthy diet
Relatively low fat and
cholesterol
Anti-oxidant rich diet
34
36. PHARMACODYNAMICS AND AGING
Neurotransmitter Pharmacodynamic changes
with aging
Dopaminergic system
↓ Dopamine D2 receptor in the striatum
Cholinergic system
↓ Choline acetyl transferase
↓ Cholinergic cell numbers
Contd...........
36
37. Adrenargic system
↓ cAMP production in response to beta-agonists
↓ Beta – adrenoceptor number
↓ Beta – receptor affinity
↓ Alpha 2 – adrenoceptor responsiveness
Gabaminergic system
↓ Psychomotor performance in response to
benzodiazepines
? ↑ Post – synaptic receptor response to GABA.
Contd...........
37
43. Psychotic agitation in the elderly with mania
Initial treatment
Haloperidol 0.25 to 0.5 mg IM or PO
After one hour, administer lorazepam 0.5mg IM or PO
Stabilization
Repeat alternating doses every hour until calm
Monitor carefully to avoid over sedation
Alternative regimen if extra pyramidal symptoms develop
Atypical antipsychitic riseperidone (0.5mg), or olanzapine (2.5
- 5 mg)
Avoid chlorpromazine and thioridazine due to their
anticholinergic and hypotensive side effects.
Chronic medication
Daily dose of medication is determined by adding the total
dose of each medication required to calm the patient and
dividing it equally throughout the day.
43
44. Adjunctive antipsychotic medication
Risperidone
Daily divided doses of .5 to 3mg
Monitor patient carefully for orthostatic hypotension
and EPS as dose is increased
Olanzapine
Daily doses of 2.5 to 10 mg /day’
Transient elevation in liver enzyme have been
reported
Risepeidone plus olanzapine
Observe for increased agitation or other manic
symptom because of breakthrough mania with
risperidone.
Clozapine
Reserved for patients who are intolerant of
44
45. ATYPICAL ANTIPSYCHOTICS IN THE
ELDERLY
Drug Metabolite t½ (h) CLR and T½
changes in
elderly
CYP enzyme involved in
metabolism (potential
drug interactions)
Geriatric
doses mg
per day
Clozapine Norclozapine, clozapine
N- oxide (very limited
activity)
4-12 CLR
decreased
CYP1A2, CYP2D6,
CYP3A4 (theophylline,
digoxin, warfarin)
50
Risperidone 9 hydroxy risperidone
(active)
20 CLR
decreased
t½ prolonged
CYP2D6 (inhibitor drugs
such as quinidine) 2
Olanzapine 10-N-glucoranide, N-
demethyl-olanzapine
(inactive)
30 CLR
decreased
t½ prolonged
CYP2D6 (inhibitor drugs
such as quinidine) 10
Quetiapine Multiple (main
metabolite is a
sulphoxide, usually
inactive)
6' CLR
decreased
t½ prolonged
CYP3A4 (phenytoin,
Thioridazine)
200
45
46. COMMON ANTIPSYCHOTIC DRUG
INTERACTION IN THE ELDERLY
Combination Effect
TCAs and conventional
antipsychotics
Raises blood antidepressant
concentrations
SSRIs and clozapine Raises blood clozapine concentrations
Risperidone and clozapine Raises blood clozapine concentration
Smoking Lower blood antipsychotic concentration
Cimetidine Lower blood antipsychotic concentration
Anticholinergic drugs Additive memory and delirious effects
Anticonvulsant, antihypertensive
and sedative drugs
Additive sedative and delirious effects
46
47. Psychiatric disorder in old
age
OVERVIEWDementia - BPSD
Late Onset Psychosis
Depression in late life
Anxiety in late life
Delirium
Other types of dementia (Lewy Body, FTD)
47
48. Mental Disorders of old
age
Most common : cognitive
disorders , depressive disorders,
substances use.
Risk factors include loss of social
roles, loss of autonomy, deaths,
declining health, increased
isolation, financial constraints, and
decreased cognitive functioning.
48
49. Mental Disorders of old
age
Most common :
cognitive disorders
depressive disorders
substances use.
49
51. Delirium
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
Usually acute and fluctuating
51
52. Treatment of delirium
Look for underlying cause
Close supervision, especially by
family
Reorient frequently
Try not to use restraints, as it can
worsen confusion.
52
53. Treatment of delirium
Medication
Avoid polypharmacy
Low dose neuroleptic is treatment
of choice, unless the delirium is
due to withdrawal.
If due to withdrawal, use a long-
acting benzodiazepine.
53
54. Dementing Disorders
Only arthritis more common in
geriatric population
5% have severe dementia, and
15% mild dementia in those over
65
Over 80, 20% have severe
54
55. Dementing Disorders
Most common causes:
Alzheimer’s disease, vascular
dementia, alcoholism, and a
combination of these 3
Risk factors are age, family
history, and female sex
55
60. Alzheimer’s Disease
50-60% of patients with
dementia
5% of those who reach 65
have Alzheimer’s Disease
15-25% of those 85 or older
More common in women
60
61. Alzheimer’s Disease
General sequence is memory,
language, then visuospatial
functions
On autopsy: neurofibrillary tangles
and neuritic plaques
Involves cholinergic system arising
in basal forebrain
Death occurs in about 7 yrs
61
62. Vascular Dementia
Second most common
type
Can reduce known risk
factors: hypertension,
diabetes, cigarette
smoking, and arrhythmias
62
63. Other types of dementia
Multiple sclerosis is
characterized by multifocal
lesions in the white matter.
May show early mood lability
Vitamin B12 deficiency--
neurologic changes may
occur before megaloblastic
changes
Hypothyroidism
Wilson’s disease
63
64. Treatment of behavior
problems
Consider the likelihood of
depression and anxiety first
Neuroleptics should not be
first choice, and should be
on a “prn” basis ,unless the
patient is psychotic
64
66. Drug treatment for
Alzheimer’s Disease
Most current ones affect
acetylcholine
Tacrine
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Reminyl)
Early intervention may prevent or
slow decline
66
67. Depression
15% of all older adult
community residences and
nursing home patients
Accounts for 50% of older
adult admissions to a
psychiatric facility
Age is not a risk factor, but
widowhood and chronic
medical illness are
67
68. Depression
May have more somatic
complaints such as
decreased energy, sleep
problems, pain, weakness,
GI disturbances
Increases use of primary
care medical resources
68
69. Depression
For those with a medical
condition, depressive
symptoms significantly
reduce survival
Increases risk of suicide
69
70. Depression in medical
illness
Medicines or the medical
illness may cause
depression
Rule out medical causes
Use psychological
symptoms such as
hopelessness, worthlessness,
guilt
70
71. Depression in older adults
May have delusions which are
usually persecutory or
hypochondriacal in nature
Need treatment with both an
antidepressant and an
antipsychotic
ECT may be treatment of
choice
71
72. Bereavement
Normal grief starts with shock,
proceeds to preoccupation,
then to resolution
May be prolonged in elderly,
but consider major depression
if there is marked
psychomotor retardation, lasts
over 2 months, marked
impairment, or if suicidal
ideation
72
73. Bipolar Disorder
Do organic workup if onset is
over 65
Usually more irritable than
euphoric, and paranoid rather
than grandiose
May have dysphoric mania,
with pressured speech, flight of
ideas, and hyperactivity, but
thought content is morbid and
pessimistic
73
74. Schizophrenia
Usually before 45, but there is
a late onset type beginning
after age 65
Paranoid type more common
Residual type occurs in 30% of
those affected: Emotional
blunting, social withdrawal,
eccentric behavior, and
illogical thinking predominate
74
75. Delusional Disorder
Onset between 40 and 55
Persecutory or somatic delusions
most common
May be precipitated by stress, loss,
social isolation , visual impairment,
deafness, immigrant status
75
76. Anxiety Disorders
Very common in elderly
May occur first time after
age 60, but not usually
Most common are phobias,
especially agoraphobia
May be due to medical
causes or depression
76
77. Substances and Alcohol
Brain is more sensitive as ages
Due to changes in
metabolism, a given amount
may produce a higher blood
level
May worsen normal changes
in sleep and sexual
functioning
Sudden onset delirium in
hospitalized patients usually
from withdrawal
77
78. Personality disorders
Borderline, narcissistic, and
histrionic personality disorders
may become less intense
Before diagnosing a
personality disorder, verify that
it is not an improperly treated
Axis I disorder
Some personality traits may
become more pronounced
78
79. Sleep disorders
Advanced age is associated with
increased prevalence of sleep
disorders
REM sleep behavior disorder occurs
among elderly men
Advanced sleep phase
Dementia associated with more
arousals, increased stage I sleep;
79
