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Geriatric psychiatryGeriatric psychiatry„Old age” psychiatry„Old age” psychiatry
Zoltán Hidasi MDZoltán Hidasi MD
Geriatric psychiatryGeriatric psychiatry
What is „Geriatric”?What is „Geriatric”? Physical, mental and social aspectsPhysical, mental and social aspects Mental disorders in generalMental disorders in general Different disorders in the elderlyDifferent disorders in the elderly Psychiatric therapies in the elderlyPsychiatric therapies in the elderly
„„Old age”?Old age”?
Gladys Burrill 92 yGladys Burrill 92 y
Honolulu Marathon 2010.Honolulu Marathon 2010.
Fauja Singh 100 yFauja Singh 100 y
Toronto Marathon 2011Toronto Marathon 2011
(Guinness record)(Guinness record)
Getting older v. living longerGetting older v. living longer
Physical changes – somatic diseasesPhysical changes – somatic diseases Musculosceletal Musculosceletal CardiovascularCardiovascular MetabolicMetabolic EndocrinEndocrin GastrointestinalGastrointestinal Sensory deficitsSensory deficits
Brain (vascular, degenerative, etc.)Brain (vascular, degenerative, etc.)
Getting older v. living longerGetting older v. living longer
Mental changesMental changes PersonalityPersonality
• amplification of character traitsamplification of character traits Cognition, memoryCognition, memory
• mental slowingmental slowing• transformed memory structuretransformed memory structure• summerised experiencessummerised experiences
Emotional changesEmotional changes• Emotional maturityEmotional maturity
Getting older v. living longerGetting older v. living longer
Social changesSocial changes Retirement (financial difficulties)Retirement (financial difficulties) Decrease in social statusDecrease in social status Facing somatic and mental disfunctioningFacing somatic and mental disfunctioning Somatic diseasesSomatic diseases Grief (loss of spouse, brothers or sisters, Grief (loss of spouse, brothers or sisters,
friends)friends) Social isolationSocial isolation Moving to nursing/residential home Moving to nursing/residential home
Mental disorders in elderly?Mental disorders in elderly?QuestionsQuestions
65+ ??65+ ?? Prevalence? 10-25%Prevalence? 10-25% DSM? ICD?DSM? ICD? Child – adult –geriatric psychiatry?Child – adult –geriatric psychiatry? Geriatry – psychiatry –internal medicine?Geriatry – psychiatry –internal medicine? Organic – old age – neuro-psychiatry?Organic – old age – neuro-psychiatry? GP? GP?
Mental disorders in generalMental disorders in general
Biological, psychological, social factors Biological, psychological, social factors (bio-psycho-social model)(bio-psycho-social model)
Internal medical, neurological, psychiatric Internal medical, neurological, psychiatric aspectsaspects
Multidimensonal approachMultidimensonal approach Polimorbidity!Polimorbidity! Syndromatology (atypical) – etiologySyndromatology (atypical) – etiology Cross-sectional –long term courseCross-sectional –long term course
Mental disorders in the elderlyMental disorders in the elderly
DementiaDementia Other „organic mental disorders”Other „organic mental disorders”
Affective disorders (depression)Affective disorders (depression) DeliriumDelirium Delusional disorders (psychosis)Delusional disorders (psychosis) Anxiety disordersAnxiety disorders Substance abuse disordersSubstance abuse disorders
Psychiatric patients getting oldPsychiatric patients getting old
Dementia - SyndromatologyDementia - Syndromatology
Chronic course Chronic course (10% above 65 y, 16-25% above 85 y)(10% above 65 y, 16-25% above 85 y)
Multiple cognitive deficits incl. memory Multiple cognitive deficits incl. memory impairment impairment (intelligence, learning, language, (intelligence, learning, language, orientation, perception, attention, judgement, problem orientation, perception, attention, judgement, problem solving, social functioning)solving, social functioning)
No impairment of consciousnessNo impairment of consciousness Behavioural and psychological symptoms of Behavioural and psychological symptoms of
dementia (BPSD)dementia (BPSD) Progressive - staticProgressive - static Reversible (15%) - irreversibleReversible (15%) - irreversible
Dementia - ClassificationDementia - Classification
SeveritySeverity Mild cognitive impairment (MCI)Mild cognitive impairment (MCI) Mild dementiaMild dementia Moderate dementiaModerate dementia Severe dementiaSevere dementia
Localization Localization Cortical Cortical SubcorticalSubcortical
EtiologyEtiology
Dementia -EtiologyDementia -Etiology Alzheimers disease (60-70%)Alzheimers disease (60-70%) Vascular dementia (10-20%)Vascular dementia (10-20%) Neurodegenerative disorders Neurodegenerative disorders
(Pick, Lewy body dis, Parkinson, Huntington, etc.)(Pick, Lewy body dis, Parkinson, Huntington, etc.) Drugs and toxinsDrugs and toxins Intracranial massesIntracranial masses AnoxiaAnoxia TraumaTrauma Infections Infections (JCD, HIV, etc)(JCD, HIV, etc) NutritionNutrition MetabolicMetabolic PseudodementiaPseudodementia
Affective disorders (depression)Affective disorders (depression)
Major depression prevalence: 10-16%Major depression prevalence: 10-16%
(hospital, residential homes)(hospital, residential homes) Minor depression: 47-53 %Minor depression: 47-53 %
Suicide in elderlySuicide in elderly 2-3 x average over 65 2-3 x average over 65 Major depression in 80%Major depression in 80%
Suicidal attempts in 5 years age groups in Hungary, 2002
(Hungarostudy: Kopp et al)
Suicidal attempts
Depression in old ageDepression in old age
Dysthymic disorder, subthreshold depression Dysthymic disorder, subthreshold depression Atypical syndromatology Atypical syndromatology Cognitive symptoms (attention, concentration, memory Cognitive symptoms (attention, concentration, memory
problems) - pseudodementiaproblems) - pseudodementia Somatic complaints –somatoform symptoms (e.g. pain), Somatic complaints –somatoform symptoms (e.g. pain),
hypochondriasis hypochondriasis negativism, inactivity, loss of energy, fatigue, insomnia negativism, inactivity, loss of energy, fatigue, insomnia psychomotor agitation (or retardation), irritability, anxiety psychomotor agitation (or retardation), irritability, anxiety Psychotic symptoms, paranoid symptoms Psychotic symptoms, paranoid symptoms Comorbid somatic disorders Comorbid somatic disorders Increased suicidal risk Increased suicidal risk
Delusional disorders (psychoses)Delusional disorders (psychoses)
Late onset schizophrenia (over 40 y)Late onset schizophrenia (over 40 y) Very late onset schizophreniform disorder Very late onset schizophreniform disorder
(over 60 y)(over 60 y) Other delusional disordersOther delusional disorders Organic delusional disorderOrganic delusional disorder Delusional symptoms of dementia (BPSD)Delusional symptoms of dementia (BPSD) Multiple etiology, multiple syndromatology Multiple etiology, multiple syndromatology
(schizophreniform, persecutory, hallucinosis, (schizophreniform, persecutory, hallucinosis, coenaesthesias, etc.)coenaesthesias, etc.)
Psychosocial factors
Personality
„Endogenous” origin
Organic (CNS) background
Sensory impairment
Other biological factors
Delusional disorder in elderly
Anxiety disordersAnxiety disorders
High prevalenceHigh prevalence Atypical symptomsAtypical symptoms Somatoform/behavioural symptomsSomatoform/behavioural symptoms Psychosocial stressorsPsychosocial stressors ComorbidityComorbidity
somaticsomatic psychiatricpsychiatric
Substance abuseSubstance abuse
Alcohol/medication abuseAlcohol/medication abuse Common comorbidityCommon comorbidity
somaticsomatic psychiatric (anxiety, depression, etc.)psychiatric (anxiety, depression, etc.)
Psychiatric patients getting oldPsychiatric patients getting old
Schizophrenia / bipolar disorderSchizophrenia / bipolar disorder Personality disorderPersonality disorder Neurotic disordersNeurotic disorders
anxiety, somatoform, etc.anxiety, somatoform, etc.
Changes in clinical picture, therapeutical Changes in clinical picture, therapeutical response, etc.response, etc.
Bio-psycho-social changesBio-psycho-social changes Multidimensional approachMultidimensional approach
Psychiatric therapies in the Psychiatric therapies in the elderlyelderly
PharamcotherapyPharamcotherapy Other biological therapies (ECT)Other biological therapies (ECT) Psychotherapies –social therapiesPsychotherapies –social therapies
Improving cognitive functioningImproving cognitive functioning RehabilitationRehabilitation Treating primary or associated mood-anxiety Treating primary or associated mood-anxiety
disorderdisorder
PharmacotherapyPharmacotherapy
Aspects of pharmacotherapyAspects of pharmacotherapy Mental status, neurological/somatic statusMental status, neurological/somatic status Social statusSocial status EtiologyEtiology
Special aspectsSpecial aspects PolimorbidityPolimorbidity Pharmacokinetics (interactions) Pharmacokinetics (interactions) Dosage (low)Dosage (low) Side effects (cognitive, other)Side effects (cognitive, other)
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