Problems &

Management of PsychoGeriatrics
Oleh

Prof. dr. Andi Jayalangkara Tanra,

Ph.D, Sp.KJ(K)
Dr. Kristian Liaury, Ph.D, Sp.KJ
Bagian Psikiatri
Fakultas kedokteran
Universitas Hasanuddin
Makassar

INTRODUCTION
Old age is not a disease
A phase of the life cycle characterized by
its own developmental issues, many of
which are concerned with loss of physical
ability, and mental acuity, friends and
loved ones, and status and power
At the same time, old age is associated:
Wisdom
Opportunity to pass that on to future
generations
A time of integrity and not a time of despair
(Erik Erikson)

 Geriatric psychiatry deals with

preventing, diagnosing, and treating
psychological disorders in older
adults (the sick-old)
One of the fastest growing fields in
psychiatry
35 million > 65 years (2005), + 70
million (2030), 85 million (2050)
25 % psychiatric symptoms (9
million in 2005, 20 million in 2050)

Normal Changes with Aging:

Nervous & mental change:
Increased motor response time
Slower psychomotor performance
Slowing intellectual performance
Decreased complex learning
Decreased hours of sleep

Common versus Normal

Just because a finding is common in the
elderly doesnt mean its normal
Hypertension, osteoarthritis, and dementia are
common in the elderly but not normal

Patients only discuss things with you that

they feel are abnormal
If your patient considers incontinence a
normal part of aging, he/she wont bring it up
during a clinic visit.

Patient expectations are often wrong

Disability and Disease

Geriatric disorders are usually disabilities
rather than discretely defined diseases
ADL (Activities of Daily Living) and IADL
(Instrumental Activities of Daily Living)
difficulties increase with age
Less than 10 percent of those 65-69 need help
with IADL/ADL
60% of females over 85 living in the
community needed help with IADLs, and 40%
required help with ADLs

Activities of Daily Living

(ADL)
Activities of Daily Living (ADL) include

Dressing
Eating
Walking
Going to the bathroom
Bathing

These are severe functional disabilities

and define dependency

Instrument Activities
of Daily Living (IADL)
IADL include:

Shopping
Housekeeping
Accounting/bill paying
Food/meal preparation
Travel/driving

These are less severe than ADL, but

clearly cause dysfunction and lead to
dependency

 Stressor:

Acute and chronic medical illnesses

Concomitant use of therapeutic drugs
Complication of drug and drug-disease interactions
Income/poverty
The loss of one's job (voluntary and involuntary retirement)
loss of financial resources
The loss of contemporaries through death, illness, and migration
Forming new relationships that result in marriage is difficult in
old age.
Physical limitations and the loss of friends social isolation
Moved to residential extended-care facility for the elderly lost
of privacy

**Internet keep older persons an opportunity to

remain socially connected to family and friends

Top 10 Chronic Conditions for Persons > 65

Years
1.Arthritis
2.Hypertension
3.Hearing impairment
4.Heart disease
5.Cataracts
6.Deformity or orthopedic impairment
7.Chronic sinusitis
8.Diabetes
9.Tinnitus
10.Visual impairment

What are the differences between older

and younger persons with mental
illness?
Assessment is different: e.g., cognitive
assessment needed, recognize sensory
impairments, allow more time

Symptoms of disorders may be different:

e.g., different symptoms in depression
Treatment is different: e.g., different doses
of meds, different psychotherapeutic
approaches
Outcome may be different:
e.g., psychopathology in
schizophrenia may improve with age

PSYCHIATRIC EXAMINATION

History-taking (independent history should be obtained

from a family member or caretaker)
Mental status examination
Be careful with suicidal thoughts or paranoid ideation
Examine for cognitive disorders
Chief complaint
History of the present illness, previous illnesses, personal
and family history (Alzheimer's disease is transmitted as an
autosomal-dominant)
Review of medications
Personality organization, coping strategies and defense
mechanisms used under stress
The marital history
Patient's sexual history: sexual activity, orientation, libido,
masturbation, extramarital affairs, and sexual symptoms

MENTAL STATUS
EXAMINATION

General Description

Appearance, psychomotor activity, attitude toward the

examiner, and speech activity

Functional Assessment
Capacity to maintain independence and to perform the
activities of daily life (ADL): toileting, preparing meals,
dressing, grooming, and eating

Mood, Feelings, and Affect

Suicide is a leading cause of death of older persons
(Loneliness) look for signs of depression (loneliness,
worthlessness, helplessness, and hopelessness)
Depression and anxiety can interfere with memory
functioning
Expansive or euphoric mood manic episode or may
signal a dementing disorder

 Perceptual Disturbances
Hallucinations and illusions decreased sensory acuity
(Transient)
Confusion organic condition

Language Output
Aphasias

Visuospatial Functioning
Copy figures or a drawing

Thought
Neologisms, word salad, circumstantiality, tangentiality,
loosening of associations, flight of ideas, clang associations, and
blocking
The loss of the ability to appreciate nuances of meaning
(abstract thinking) early sign of dementia
Phobias, obsessions, somatic preoccupations, and compulsions
Ideas about suicide or homicide
Delusions

 Consciousness
Orientation
Impairment in orientation to time, place, and person
cognitive disorders

Memory
Immediate, recent, and remote memory

Early Detection and Prevention

Strategies

Age-related illnesses develop insidiously and gradually

progress over the years
most common cause of late-life cognitive impairment
Alzheimer's disease
AD characterized neuropathologically by a gradual
accumulation of neuritic plaques and neurofibrillary tangles
in the brain
AD Clinically, a progression of cognitive decline, which
begins with mild memory loss and ends with severe
cognitive and behavioral deterioration
Brain Imaging: PET & fMRI
R/: cholinesterase inhibitor drugs, anticholesterol drugs,
anti-inflammatory drugs, and others (e.g., vitamin E)
Scientists may not be able to cure Alzheimer's disease in its
advanced stages, but they may be able to delay its onset
effectively

Mental Disorders of Old Age

DEMENTIA
Features
Key feature is gradual impairment of
multiple cognitive abilities including
memory, language, and judgment

With impaired social/occupational functioning

Often see global cognitive impairment

ability to solve novel problems goes first,
then overlearned abilities (e.g., vocabulary)
First signs: personality change and memory
loss
Chronic progressive
GCS intact

10 15% of all patients who exhibit symptoms of

dementia have potentially treatable conditions
(heart disease, renal disease, and congestive
heart failure; endocrine disorders, such as
hypothyroidism; vitamin deficiency; medication
misuse; and primary mental disorders, most
notably depressive disorders)
Depending on the site of the cerebral lesion,
dementias are classified as cortical (Alzheimer's
type, Creutzfeldt-Jakob disease (CJD), and Pick's
disease) and subcortical (Huntington's disease,
Parkinson's disease, normal pressure
hydrocephalus, vascular dementia, and Wilson's
disease)

Alzheimers Disease
Development of multiple cognitive deficits
manifested by both:
1) Memory impairment
2) One (or more) of the following:
a) Aphasia
b) Apraxia
c) Agnosia
d) Disturbance in executive functioning
3)Significant impairment and decline
4)Gradual onset and continuing decline
5)Rule out other dementias and mental
disorders

6) Onset usually in 60s or 70s

Early signs in 40s and 50s (presenile
dementia)

7) Definitive diagnosis can only be

made on autopsy where
histopathology confirmed:
1. Gross atrophy of the brain
2. Neurofibrillary tangles
3. Senile plaques

Alzheimer Warning Signs

Top Ten
Alzheimer Association

1. Recent memory loss affecting job

2. Difficulty performing familiar tasks
3. Problems with language
4. Disorientation to time or place
5. Poor or decreased judgment
6. Problems with abstract thinking
7. Misplacing things
8. Changes in mood or behavior
9. Changes in personality
10. Loss of initiative

Clock Drawing Test (CDT)

The Progress of Alzheimers Disease

30

Early diagnosis

Mild-moderate

Severe

Cognitive symptoms
25

M M S E s c o re

20

Loss of ADL

15
10
5

Behavioral problems
Nursing home placement
Death

0
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9

Years
Feldman H, Gracon S. In: Clinical Diagnosis and Management of Alzheimers Disease. 1996:239-253.

Treatment of dementia
alzheimer
Limited some drugs can improve cognitive
functioning, but only temporary
Pharmacologic interventions include:
Acetylcholinesterase inhibitors [e.g., tacrine
(Cognex), donepezil (Aricept), rivastigmine
(Exelon), and galantamine (Reminyl)j to
temporarily slow progression of the disease.
These agents cannot restore function already lost.
Memantine (Namenda), an NMDA antagonist, was
recently approved to slow deterioration in
patients with moderate to severe disease.
Psychotropic agents are used to treat associated
symptoms of anxiety, depression, or psychosis.

 Psychological treatments

Memory wallet
Memory skills training
Teach to use navigational cues to avoid
getting lost

Demensia Vaskuler
Dulu disebut Demensia Arteriosklerosis
atau Demensia Multi-infark
Khas: riwayat serangan iskemi, ggn
kesadaran, paresis atau hilangnya
penglihatan sepintas
Dpt terjadi akibat ggn serebro-vaskuler &
jarang o/ st serangan stroke yg besar
Hendaya daya ingat & pikir
Onset dpt akut a/ lambat, biasanya pd usia
lanjut setelah st episode iskemi
Daya tilik diri & daya nilai relatif baik
Kadang: labilitas emosi, jarang perubahan
kepribadian

 Ped. Diagnostik
Memenuhi Ped. Diag. Umum
Hendaya kognitif tdk merata
Tilikan & daya nilai relatif baik
Onset akut a/ deteriorasi bertahap.
Adanya gejala neurologis fokal
meningkatkan kemungkinan D/. Kadang
hanya dpt ditetapkan dgn CT-Scan

Jenis:
a. Demensia Vaskuler Onset Akut
Terjadi cepat setelah serangkaian stroke
akibat trombosis/emboli atau perdarahan,
jarang oleh st infark besar
b. Demensia Multi-Infark
Onset > lambat
Setelah serangan iskemi minor akumulasi
infark parenkim otak
c. Demensia Vaskuler Subcortikal
Fokus pd substansia alba hemisfer (CT-Scan)
Korteks serebral biasanya tetap baik
Klinis mirip Demensia Peny. Alzhaimer
d. Demensia Vaskuler Campuran Kortikal &
Subkortikal
Dpt diduga dari gamb. klinis/otopsi

Demensia Pada Peny. Lain

Demensia pada
Demensia pada
Jacob
Demensia pada
Demensia pada
Demensia pada

Peny. Pick
Peny. CreutzfeldtPeny. Huntington
Peny. Parkinson
Peny. HIV

DELIRIUM
Dulu disebut:
Sindrom Otak Akut
Psikosis Infektif Akut
Reaksi Organik Akut
Sindrom Psiko-Organik Akut

Onset biasanya cepat, perjalanan

hilang timbul, seringkali cepat
sembuh, ada juga yg berlarut
Penyebab: riwayat peny.
otak/sistemik a/ penggunaan zat

Pedoman Diagnostik
Ggn Kesadaran & perhatian
Taraf berkabut s/d koma
Kemampuan memusatkan, mempertahankan &
mengalihkan perhatian menurun

Ggn kognitif sec umum

Distorsi persepsi: ilusi & halusinasi visual
Hendaya daya pikir & abstrak, dgn/tanpa
waham bersifat sementara & selalu ada
inkoherensi ringan
Hendaya daya ingat segera & jangka pendek,
jangka panjang relatif utuh
Disorientasi waktu, kalau berat juga tempat &
orang

 Ggn psikomotor

Hipo/hiperaktivitas
Waktu bereaksi lebih panjang
Arus pembicaraan bertambah atau berkurang
Reaksi terperanjat meningkat

Ggn siklus tidur-bangun

Insomnia atau waktu tidur terbalik
Gejala memburuk pd malam hari
Mimpi buruk, berlanjut halusinasi

Ggn emosional
Depresi, cemas, cepat marah, euforia, apatis, kehilangan
akal

Onsetnya cepat, fluktuasi sepanjang hari, bisa

membaik atau berlanjut tetapi < 6 bln

Distinguishing Delirium from Dementia

Onset/
etiology

Duration/
course

Attention
span;
Sensorium;
cognition

Psychomotor
activity

Mood

Psychotic
features

delirium

Sudden
(hrs/
days;
Usually
immediate
cause

Usually
short
(days/
wks);
fluctuating

Decreased
attention;
impaired
sensorium;
Often
several
cognitive
deficits

Increased
(1/3) or
decreased
(2/3)

Normal
to
anxious

Visual/
tactile;misinterpretations
of visual
stimuli

dementia

Insidious
(mos to yrs);
usually no
immediate
cause

Usually
slowly
progressive over
yrs;
steady

Normal
attention;
sensorium
intact early
stages;
short-term
memory
early

Usually
normal to
decreased

Normal
but
apathy
common

Paranoid
ideations,
sometimes
visual
hallucinations

Depression
Onset: rapid
Precipitants: psycho-social (not organic)
Duration: less than 3 months to
presentation
Mood: depressed, anxious
Behavior: decreased activity or agitation
Cognition: unimpaired or poor responses
Somatic symptoms: fatigue, lethargy,
sleep, appetite disruption
Course: rapid resolution with treatment,
but may precede Alzheimers disease

Treatment of Depression in Older Adults

Use same antidepressants as younger patients
however, start low, go slow, keep going
higher, and allow more time(if some response
has been achieved, may allow up to 10-14
weeks before switching meds).
Older patients may have a shorter interval to
recurrence than younger patients. Thus, they
may need longer maintenance of medication.
Data are not clear if the elderly are more prone
to relapse.

Antidepressants
Among antidepressants, citalopram, sertraline,
venlafaxine, mirtazapine, buproprion, and duloxetine
have minimal drug-drug interactions. Paroxetine and
fluoxetine have most. Try to avoid the latter two
drugs with older persons.
Venlafaxine, duloxetine, fluxoxetine and buproprion are
most activating, sertraline is slightly activating,
citalopram is neutral, and paroxetine is mildly sedating,
and mirtazapine and trazadone are very sedating.
Paroxetine may cause mild anti-cholinergic effects and
mirtazapine causes more pronounced effects.
Mirtazapine(moderate) and trazadone(high) have
higher rates of orthostatic hypotension.

Others
Schizophrenia

A late-onset type
Greater prevalence of paranoid schizophrenia in the
late-onset type

Delusional Disorder

The most common are persecutory

May become violent toward their supposed persecutors

Anxiety Disorders

Panic disorder, phobias, obsessive-compulsive disorder

(OCD), generalized anxiety disorder, acute stress
disorder, and posttraumatic stress disorder (PTSD)

Somatoform Disorders

Hypochondriasis is common in persons over 60 years

of age

Alcohol and Other Substance Use Disorder

Hypnotics, anxiolytics, and narcotics is more common

in old age

Sleep Disorders

Daytime sleepiness, daytime napping, and the use of

hypnotic drugs

Suicide Risk
Other Conditions of Old Age

Vertigo, Syncope, Hearing Loss