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PSYCHOGERIATRY

Dr.Deddy Soestiantoro SpKJ MKes

INTRODUCTION -The most common mental disorders: depression,anxiety disorders,sleep disorders, dementia,delirium,suicide,schizophrenia -Special characteristic of the elderly: -Communication gaps with the elderly -Complexities of treatment

Possible barriers to communications with older adults


-difficult to talk about aging & the effect of aging -want us to listen, hear, care and respond, often complain that nobody is listening -diminished ability to understand -major barriers: professional & scientific language / wrong vocalbulary -social isolation influences makes difficult to overcome -younger adult may have different beliefs & systems -it is still possible to teach anything new /change in health behavior which is very beneficial

-short-term memory & recall as well as learning speed may be diminished and therefore: -attentionspan canbe easily exceeded -sensory loss or decrements prevent good communication (auditory loss,vision loss,physical limitation & mobility problems such as arthritis)
So the relationship mostly influence by communication difficulty, generation gap and physical & cognitive limitation. The best principle is to: START LOW,GO SLOW & MONITORING FREQUENTLY this also suitable for treatment.

PSYCHIATRIC EXAMINATION OF THE OLDER PATIENT -follow the same format as younger adults, -because of the cognitive disorders, must determine whether a patient understands the nature and purpose of examination, and alloanamnesis should be better -autoanamnesis still necessary to preserve the privacy of the doctor-patient relationship and to elicit any suicidal thought or paranoid ideation -one must remember that older adults differ markedly from one another

Psychiatric history
-complete identification, chief complaint, history of present illness, previous illnesses, personal and family history, a review of medications (including OTC med.) that is currently using or has used in the recent past. -childhood & adolescent hystory-information about personality/coping strategies &defense mech. under stress, about friends, sports, hobbies, social activity and works, about future plans / hopes and fears -family hystory and the socio-economic evaluation -marital and sexual hystories

MENTAL STATUS EXAMINATION -General description -Functional assesment -Mood, feeling and affect -Perceptual disturbances -Language output -Visuospatial functioning -Thought -Sensorium and cognition -conciousness, orientation, memory, intellectual tasks / information and intelligence, reading and writing -Judgment NEUROPSYCHOLOGICAL EVALUATION MEDICAL HYSTORY

MENTAL DISORDERS OF OLD AGE


NIMH-ECA USA:----->the most common: -depressive disorders, phobias,alcohol use, and also a high risk for suicide and drug-induced psychiatric symptoms. -can be prevented especially the reversible cause of delirium and dementia -psychosocial risk factors also predispose: loss of social roles, loss of autonomy, the deaths of friends & relatives, declining health, increased isolation, financial constraints, and decreased cognitive functioning.

DEMENTING DISORDERS---->NEUROLOGY -usually in medical illness and in depression the cognitive deficits are mild -some potentially reversible conditions that may resemble dementia: -substances:-psychotropic drugs (antipsychotic, narcotics,sedative hypnotic), polypharmacother., corticosteroids, digitalis, anticholinergic and hypertensive agents,phenitoin, nonsteroidal antiinflammatory agents, -psychiatric disorders (anxiety,depression,mania, delusional / paranoid disorders) -metabolic and endocrine disorders (hepatic/renal failure,volume depletion, hyper / hypothyroidisms, hyper / hyponatremias, etc) -miscellaneous conditions ( fecal impaction, hospitalization, impaired hearing or vision)

DEPRESSIVE DISORDERS
-about 15% of all older adult -risk factors :being widowed and having a chronic medical illness are associated with vulnerability to depression -late onset depression is high rate of recurrence -symptoms:-reduced energy & concentration,early morning/ multiple awakening,decreased appetite,weight loss and somatic complaints, this maybe different with the younger -particularly vulnerable to major depressive episodes with melancholic features, characterized by depression, hypochondriasis,low self-esteem,feelings of worthlessness and self-accusatory trends with paranoid & suicidal ideation.

-cognitive impairment is referred to as the dementia syndrome of depression (pseudodementia),in true dementia intellectual performance usually is global, the impairment is consistently poor,here the deficits are variable in attention and concentration, and less likely to have language impairment or more likely to say I dont know -pseudodementia occurs in 15 % depression in elderly

BIPOLAR DISORDER I -usually begins in middle adulthood, -a manic episode late in life maybe as an organic cause such as an adverse effect of medication or early dementia -symptoms of mania are similar to those in younger adults include an elevated,expansive or irritable mood ; a decreased need to sleep; distractibility; impulsivity and alcohol intake -hostile and paranoid behavior -cognitive impairment ,disorientation,or fluctuating levels of awareness maybe suspected as an organic cause

SCHIZOPHRENIA -usually begins in late adolescence or young adulthood and persist throughout life -first episodes after 65 are rare -women are likely to have a late onset than men -greater prevalence of paranoid schizophrenia in the lateonset type -20%of persons with schizophrenia show no active symptoms by age 65, psychopathology becomes less marked as patients age -residual type :30% --long-term hospitalization is required because cannot care for themselves -respond well to antipsychotic

DELUSIONAL DISORDER
-age of onset usually is between ages 40-55 but it can occur at any time during the geriatric period. -delusions can take many forms,the most common are persecutory,may become violent toward their supposed persecutors,some lock them- selves in their rooms -somatic delusions(believe have a fatal illness)may occur in older persons -pervasive persecutory ideation was present in 4% -occur under physical/psychological stress precipitated by the dead of a spouse,job loss,retirement,social isolation, adverse financial circumstncs ,debilitating medcal illness/ surgery,visual impairment & deafness

-delusions may occur with other disorders such as dementia (Alzheimers type), alcohol use, schizophrenia, depressive disorders,and bipolar I -also result from prescribed medications or early signs of a brain tumor -prognosis mostly fair to good, best results; combination of psycho-pharmacology and psychotherapy -a late onset of delusional disorder called paraphrenia with persecutory delusions, develops over several years, not associated with dementia,maybe a variant of schizophrenia (increased in positive family hystory of schzophrenia)

ANXIETY DISORDERS
-include panic disorder,phobias,obsessive-compulsive disorders,generalized anxiety disorder,acute and post traumatic stress disorders -begin in early or middle adulthood, some appear first time after age 60 -initial onset of panic disorder is rare but can occur -ECA:1 month prevalence rate is 5,5% (phobias 4-8%,panic disorders 1%) -phobias symptoms less severe but the effects are equally / debilitating -may deal with the thought of death with a sense of despair & anxiety rather than with equaminity and sense of integrity

-the fragility of the ANS may account for the development of anxiety after a major stressor, physical disability make to react more severe in post-traumatic stress disorder -OCD may appear for the first time, although the premorbid personality has been already seen, when symptomatic become excessive in desire to orderliness, rituals & sameness and may become inflexible, rigid and always to check things again an again; in contrast to OC personality disorder OCD is characterized by ego-dystonic rituals & obsessions and may begin late in life -treatment both pharmacotherapy & psychotherapy are required, must take to account the bio-psycho-social interplay.

SOMATOFORM DISORDERS
-physical symptoms resembling medical diseases are relevant to geriatric psychiatry because somatic complaints are common among older adults -more than 80% over 65 years of age have at least one chronic disease, usually arthritis or CV problems -after 75, 20% have DM & an average of 4 chronic illnesses

-hypochondriasis is common over 60 (the peak : 40-50), usually chronic, repeated physical examinations help reassure patients that they do not have a fatal illness -unless medically indicated no need for high-risk diagnostic and invasive procedures -telling that the symptoms are imaginary to the patients is counter-productive and usually engenders resentment -we should acknowledge that the complaint is real, and that a psychological & pharmacological approach is indicated

ALCOHOL AND OTHER SUBSTANCES USE DISORDER


-usually began in young or middle adulthood -usually are medically ill, primarily with liver disease -20% of nursing home patients in US have alcohol dependence -overall 10%of all emotional problems & dependence is common -substance-seeking behavior is rarer than in younger adults -may abuse anxiolytic to allay chronic anxiety or to ensure sleep -clinically varies and includes confusion, poor personal hygiene, depression, malnutrition, and the effects of exposure and fall

-sudden onset delirium most often caused by alcohol withdrawl,alcohol abuse also cause chronic gastrointestinal problems -misuse OTC substances including nicotine & caffeine, 35% use analgesics,30% laxatives -unexplained gastrointestinal, psychological, and metabolic problems maybe because of OTC substance abuse

SLEEP DISORDERS
-advance age is the single most important factor -sleep-related phenomena: sleeping problems, daytime sleepiness,daytime napping and the use of hypnotic drugs -clinically higher rates of breathing-related sleep disorder and medication-induced movement disorders -the causes of sleep disturbances: -altered regulatory & physiological systems -primary sleep disorders: dyssomnias esp.primary insomnia,nocturnal myoclonus, restless legs syndrome, sleep apnea; parasomnias: esp. REM sleep behaviour disorder -other mental disorders, -general medical disorders, -social & environmental factors

-interfere conditions : pain,nocturia,dyspnoe & heart burn -lack of a daily structure,and of social or vocational responsibilities contributes to poor sleep -as a result of the decreased lenght of daily sleep-wake cycle, without daily routines may experience an advanced sleep phase, in which go to sleep early and awakening during the night -alcohol, hypnotics & other CNS depressants causing more early awakening, alcohol may also precipitate or agravate obstructive sleep apnea

-when prescribing sedative-hypnotic drugs, monitor for unwanted cognitive, behavioral and psychomotor effects, including memory impairment (anterograde amnesia), residual sedation,rebound insomnia,daytime withdrawal, and unsteady gait -changes in sleep structures involve both REM and NREM -deterioration in the quality of sleep is due to the altered timing of and consolidation of sleep, have a lower amplitude of circadian rhythms,a 12-hour sleeppropensity rhythm and shorter circadian cycles

SUICIDE RISK -5x higher than that of general population


-1/3 report loneliness as the principal reason for considering suicide -10% report financial problems, poor medical health or depression as reasons for suicidal thoughts -75% attempted suicide are woman -60% committed suicide are men -most commonly depression & do not receive attention -violent method are more common -the most common precipitans: illness & loss, most commonly communicate prior to the act -should be no reluctance to question about suicide

OTHER CONDITION OF OLD AGE

-vertigo -syncope -hearing loss

PSYCHOPHARMACOLOGICAL TREATMENT OF GERIATRIC DISORDERS -especially usefull to bring in all medications used -divided doses for psychotropic drugs -liquid preparations sometimes better -avoid polypharmacy and use monotherapy -be carefull with AD reactions -the most common : psychotropic drugs,CV and diuretics OTC medications

PRINCIPLES -the major goals: to improve the quality of life, maintain in the community, avoid/delay in nursing homes placement -basic tenet: individualization of dosage -alteration dosages required because of the physiological changes (renal,liver,CV,GI) -increased risk of orthostatic hypotension from psychotropic drugs is related to reduced functioning of of blood pressure-regulating mechanisms -conclusion- dont forget to remember always: START LOW - GO SLOW and MONITORING FREQUENTLY

ELECTROCOVULSIVE THERAPY
-it can be the most effective treatment option -lowest risk of complications for older individuals with comorbid medical conditions likely to produce drugdisease and drug-drug interactions -ECT can provide a rapid response, which is vitally important in serious ill patients, those at risk due to malnutrition or agitation related to psychiatric ilness, and those at high risk for suicide -ECT modification to prevent musculoskeletal seizures is now considered as safe as, if not safer than, medication for use in frail elderly patients

PSYCHOTHERAPY FOR GERIATRIC PATIENT


In addition to improving relatioships,psychotherapy increases self-esteem and self-confidence, decrease feelings of helplessness and anger, and improves the the quality of life, geriatric psychotherapy has general aim of assisting older adult to have minimal complaints, to help them to make and keep friends of both sexes, and to have sexual relations when they have interest and capacity.

PSYCHOTHERAPY FOR GERIATRIC PATIENTS -Supportive Psychotherapy -Life Review or Reminiscence Therapy -Cognitive Behavior Therapy -Brief ( Time-Limited ) Psychodynamic Psychotherapy -Insight-Oriented Psychotherapy -Integrated Therapy: integration of psychotherapies often is the most effectve way to proceed.

PSYCHIATRIC SYMPTOMS ASSOCIATED WITH SPECIFIC MEDICAL DISORDERS


-Cerebrovascular disease -Cardiovascular disease -Chronic diseases of the lung, kidneys and liver -Arthritis -Thyroid disease, malnutrition, and anemia

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