Psychiatry Of The Elderly

Psychiatry of the elderly Department of psychology The first affiliated hospital of ZZU Huirong guo

Introduction

Introduction  About 15 per cent of the population of developed countries is aged over 65 years, and it is expected that the proportion of elderly people, particularly those aged over 85, will continue to rise  Since the prevalence of mental disorder and particularly dementia increases with age, there has been a disproportionate increase in the demand for psychiatric care for the elderly, and this trend is likely to continue

Introduction  This chapter is about the psychiatric care of the elderly  The most frequent psychiatric disorders of the elderly are listed in Table 10.1

Introduction Table 10.1 Psychiatric disorder in the elderly  Delirium  Dementia  Depressive disorder  Mania  Schizophrenia and paranoid states  Neurosis  Personality disorder  Abuse of alcohol and drugs

Introduction  Although psychiatric disorders at this time of life have s some special features, they do not differ greatly from the psychiatric disorders of younger adults  It is the needs of elderly psychiatric patients or their carers that set then apart from others and so require separate consideration  Before the disorders and needs of the elderly are considered, some information will be given about normal aging

Normal aging There are changes in the brain with age:  the weight of the brain decreases  the ventricles enlarge  and the meninges thicken; the quantity of nerve processes declines and there is a minor and selective loss of the cells with advancing age  senile plaques are increasingly common and ischaemic lesions are present in brain from half of normal subjects aged over 65

Normal aging  These structural changes are accompanied by some psychological changes  From mid-life there is decline in intellectual individual variation  Deterioration of short-term memory and slowness are features of aging

Normal aging  Also, there may be alteration in personality and attitudes such as increasing caution, rigidity, and ‘disengagement’ from the outside world  As people grow old, their use of medical services changes: they consult their doctors more often and they occupy nearly half of all general hospital beds  These demands are particularly large in those aged over 75

Normal aging  Treatment is often made difficult by the presence of more than one disorder, by increased sensitivity to drug side effects, and by social problems  The elderly have special social problems, for example lower earnings and poorer accommodation than younger people. Most live at home, about half with their spouse, and about one in ten with their children

Normal aging  Of those who live alone, many see relatives, friends, and neighbors regularly, but some are very isolated. As more middle-aged women work, there arte fewer people to visit and help the elderly  Although these unsatisfactory social circumstances are typical of most western countries, they are not found everywhere. In some cultures (e.g. the Chinese), the elderly are esteemed and most can expect to live their children

Principles of assessment of psychiatric problems in the elderly  Primary care doctors should be aware of the general health and social circumstances of their elderly patients, and in the United Kingdom doctors are expected to review patients aged 75 years or more regularly  For this reason the assessment of new problems can often be brief. If the patient is not known to the doctor, the following assessment should be completed

Principles of assessment of psychiatric problems in the elderly The aim is to answer three questions:  Can the patient’s care be managed at home?  If so, what additional help is needed by the patient and family?  Can the patient manage his financial affairs?

Principles of assessment of psychiatric problems in the elderly  The assessment should include a medical and psychiatric history and an examination of physical and mental state, as well as a formulation of social problems  Whenever possible the doctor should interview any relatives. When a specialist opinion is required, it is often better to arrange this at the patient’s home where he can be observed in his usual surroundings  The reasons for the request for treatment should be considered carefully, since many such patient’s longstanding problems rather than a change in his medical condition

History-taking  If there is any likelihood of intellectual impairment or deafness, it is often helpful to speak to relatives or other informants before the patient is seen. The following specific information should be obtained during the assessment :  The time and mode of onset of symptoms and their subsequent course  A description of behavior over a typical 24 hours.  Any previous medical and psychiatric history.  The patient’s living conditions and financial position

History-taking  The patient’s ability to look after himself and his finances, and to deal with hazards such as fire.  Any odd or undesirable behavior that may cause difficulties with carers or neighbors.  The availability and attitudes of family and friends, and their ability to help.  Other services already involved in the patient’s care

Examination  A thorough physical examination should be carried out, including an appropriately detailed neurological assessment with particular attention to vision and hearing  Examination of mental state should include a systematic assessment of cognitive functions. Linguistic, visuospatial, and other higher cortical functions should be tested when the differential diagnosis includes a localized or diffuse lesion that could affect these functions

Examination  Physical investigations  If an organic diagnosis is suspected the following investigations may be required, according to the diagnostic suggested by the history; blood count, erythrocyte sedimentation rate, syphilis serology, thyroid function, electrolytes, urea and liver function, plasma calcium, vitamin B12, chest radiograph, skull radiograph, ECG, and EEG. A CT scan is justified when there is a suspicion of a localized lesion

Examination  Psychological assessment  Simple tests such as the Mini-Mental Examination are valuable. Special psychometric testing is useful to measure decline in cognitive function, and sometimes to help to differentiate between organic and functional disorders

Principles of treatment  The treatment of psychiatric disorders in the elderly resembles that of the same conditions in younger adults, although there are some differences in emphasis  These differences can be summarized as follows:  Treatment at home is usually preferable to treatment in hospital.  Caution is needed in drug dosages.  Social measures are important.  There is a need to involve and support families

Principles of treatment  Usually, treatment at home is preferable to treatment in hospital because most elderly people want to be home and they usually function better there

Principles of treatment  Plans need to be responsive to changing needs and should be discussed regularly with the family or other carers to insure that home care dies not place an unreasonable burden on them  Short stays in hospital may be needed for acute problems and allow a holiday for the carers. Long-term care in a home or hospital is needed for a minority of the elderly

Principles of treatment  Any physical disorder causing organic mental disorder should be treated if possible  Any other physical disorders should also receive full treatment since this may benefit the mental state in a nonspecific way. Mobility should be encouraged and is often helped by physiotherapy

Principles of treatment  Use of drugs:  Drug-induced morbidity is common the elderly who may develop side effects at lower doses than for younger people. Drugs that may cause mental symptoms as side effects, most problems arise with drugs used to treat cardiovascular disorders (hypotensives, diuretics and digoxin) and those acting on the central nervous system (antidepressants, hypnotics, anxiolytics, antipsychotics, and antiparkinsonian drugs)

Principles of treatment  Use of drugs:  It is prudent to start with small doses and gradually increase the level to find the minimal dose that is effective  Response to the medication should be reviewed regularly  Many elderly people sleep poorly and some take hypnotics regularly. Such drugs may cause daytime drowsiness, confusion, falls, incontinence, and hypothermia

Principles of treatment  Use of drugs:  If a hypnotic is essential, the minimum effective dose should be used as possible. Chlormethiazole, dichloraphenazone, and medium-or short-acting benzodiazepines are used as hypnotics for the elderly  Despite the need for cause in prescribing, elderly patients should not be denied effective drug treatment, particularly for depressive disorders. Elderly patients may not take the drugs in the way prescribed, particularly if they are living alone, have poor vision, or are confused

Principles of treatment  Use of drugs:  For this reason, the drug regime should be as simple as possible, medicine bottles should be labeled clearly and be easy to open and the patient should provided with memory aids (for example by attaching one tablet of each kind a time chart of the day)  If possible, drug taking should be supervised by one the carers or by a community nurse, both of whom need to be adequately informed of the drug regime.

Principles of treatment  Psychological treatment:  Counseling is an important in the care of the elderly as in the care of younger patients, and joint interviews with the spouse are valuable  Counseling should have clearly defined aims and time course. Patients with memory disorder may be helped by common-sense measures such as the use of notebooks and alarm clocks to aid memory  In residential accommodation the use of color coding of doors and similar features of design can help to reduce disorientation. Interpretative psychotherapy is seldom appropriate for the elderly

Principles of treatment  Social measures:  Many patients can be helped to remain independent by attendance at a club or day center as a way of encouraging them in self-care, domestic skills, and social contacts  Domiciliary occupational therapy may help patients who cannot travel to a day center. More severely impaired patients may benefit from residence in an old people’s home provided that their individual needs and dignity are respected.

Principles of treatment  Support for relatives:  Families should able to discuss problems and receive advice about the patient’s care. It the patient is incontinent, relatives can be helped by the provision of laundry services. Day care or holiday admission can allow carers periods of respite. With such, many relatives can undertake the care of elderly people without undue burden  Although most families care effectively for their elderly members, occasionally they neglect or even abuse the elderly person or misuse their property. Elderly women are more often affected than elderly men and those who have psychiatric disorder may be at greater risk

Psychiatric disorder in the elderly  Delirium  Dementia in the elderly  Alzheimer disease  Vascular dementia  Depressive disorder  Mania  Neurosis and personality disorder  Abuse of alcohol and drugs

Depressive disorder  Depressive disorders are common in later life with a point prevalence of about 10 per cent at age 65, of which 2-3 per cent are severe. Many of these disorders are in people who have had a depressive disorder at an earlier age; first depressive illness decline in incidence after the age of 60 and are rare after the age of 80. The incidence of suicide increase steadily and is usually associated with depressive disorder

Clinical features  There are no fundamental differences between depressive disorders in the elderly and those in younger people, but some symptoms are more common in the elderly. Anxiety and hypochondriacal symptoms are frequest, and depressive delusions, poverty, and physical illness are more common in depressed patients. Occasionally there are nihilistic delusions. Hallucinations of an accusing or obscene kind are also more frequent in the elderly.

Clinical features  A few of the retarded depressed patients have conspicuous difficulty in concentrating and remembering, but they show no corresponding defect in clinical tests of memory function. The possibility of a depressive disorder should be considered whenever an elderly patient develops apparent cognitive impairment, or anxiety or hypochondriacal symptoms.

Course and prognosis  Untreated depressive disorders in the elderly often have a prolonged course, some lasting for years, with treatment, most patients improve considerably within a few months, but about 15 per cent do not recover completely even after vigorous treatment. Long-term follow-up of recovered patients shows that relapse is frequent.  Factors predicting a better prognosis are onset before the age of 70, short duration of illness, good previous adjustment, on concurrent disabling physical illness, and good recovery form previous episodes.

Etiology  In general the etiology of depressive disorders in late life resembles that of similar disorders occurring in earlier life, except that genetic factors may be less important  Neurological and other physical illness seem to be more frequent than among depressed elderly patients, and may act as provoking or maintaining factors.

Differential diagnosis  The most difficult differential diagnosis is between depressive pseudodementia and dementia, and a specialist opinion is often required  The distinction depends on a detailed history from other informants, and careful observation of the mental state and behavior

Differential diagnosis  In depressive pseudodementia mood disturbance usually precedes other symptoms, and the depressed patient’s poor concentration can usually be distinguished from the demented patient’s true failure of memory  The diagnostic problem is made more difficult because dementia and depressive disorder sometimes coexist. Depressive disorder also has to be differentiated from paranoid disorder

Differential diagnosis  When persecutory ideas persecution is justified by his own wickedness; in paranoid disorder he usually resents it as unjustified  Depressive disorder with symptoms of agitation may be mistaken for an anxiety disorder at first, but with careful assessment of the mental state the correct diagnosis can usually be made.

Treatment--drugs  In most respects the treatment of depressive disorders is the same for the elderly as for people of other ages  With elderly patients it particularly important to be aware of the risk of suicide and to treat any intercurrent physical disorder thoroughly.  Antidepressant drugs are effective in the elderly. But should be used cautiously and adjusted in relation to side effects and response

Treatment--drugs  To reduce side effects, the starting dose is about half the usual dose for younger patients and the drug may be given more than once a day. Although it is appropriate to start cautiously, it is important to achieve a full therapeutic dose  After recovery, antidepressant medication should be reduced slowly and then continued in reduced dose for several months, as in younger patients. A few patients require longer maintenance treatment.

Treatment--ECT  Electroconvulsive therapy (ECT) is used for severe and distressing agitation, life-threatening stupor, or failure to respond to drugs  Special care is needed with the anesthesia. Some patients become confused after ECT; if this happens, the intervals between applications should be increased, if a patient responds to ECT, undetected physical disorder is a possible cause

Treatment--ECT  After recovery, antidepressant medication is usually given in a reduced dose for several months, as in younger patients, ort occasionally for longer.

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