Mental health and older Mental health and older peoplepeople

prepared by hassan abu prepared by hassan abu rahmarahma

Supervised bySupervised by: : Dr. Abd Al Kareem RadwanDr. Abd Al Kareem Radwan

•Background and epidemiologyBackground and epidemiology•AGEING AND HEALHAGEING AND HEALH• Older people mental health prevalence and impact of Older people mental health prevalence and impact of

mental health problemsmental health problems

•Prevalence 0f mental disorder 1n relation to Prevalence 0f mental disorder 1n relation to

demographic factors demographic factors Inter-relation between Inter-relation between physical and mental disorderphysical and mental disorder

•Inter-relation between disability and mental disorderInter-relation between disability and mental disorder•Older hospital setting patient in generalOlder hospital setting patient in general

•Older people in nursing and residential homesOlder people in nursing and residential homes

Background and Background and epidemiologyepidemiology

•Improved living standard and success in Improved living standard and success in combating many diseases have led to combating many diseases have led to

increase life expectancyincrease life expectancy •industrialized societies people are living industrialized societies people are living

healthier and longer than ever beforehealthier and longer than ever before •In the UK between 1971and2003 the In the UK between 1971and2003 the

number of people over 65 changed 28% number of people over 65 changed 28% and 2002 life expectancy for female 81 and 2002 life expectancy for female 81

years and 76 for maleyears and 76 for male •People aged 85 are fastest rising populationPeople aged 85 are fastest rising population

•England currently over6000 people over England currently over6000 people over 100 yrs100 yrs

•STAGE POPULATION STAGE POPULATION POPULATION POPULATION STRUCTURESTRUCTURE

•11--THE FIRST AGE OF THE FIRST AGE OF SOCIOLIZATIONSOCIOLIZATION

•22 - -SECOND AGE OF SECOND AGE OF WORK AND CHILD-WORK AND CHILD-

REARINGREARING

•22__THIRD AGE POST THIRD AGE POST EMPLOYMENTEMPLOYMENT

BIRTH BIRTH DECADDECAD

EE

FIRT FIRT AGEAGE

SECOSECOND ND

AGEAGE

THIRD THIRD AGEAGE

190019002121767633

19501950212167671111

19901990242455552121ACENTURY OF CHANGE ACENTURY OF CHANGE

PRECNTAGE DISTRIBUTION BY PRECNTAGE DISTRIBUTION BY AGES OF LIFE FOR THE BRITISH AGES OF LIFE FOR THE BRITISH

POPULATIONPOPULATION

لإلحصاء • المركزي الجهاز عن صادر إحصائي تقرير لإلحصاء يشير المركزي الجهاز عن صادر إحصائي تقرير يشيرطرأ تحسن للمسنين العالمي اليوم بمناسبة طرأ الفلسطيني تحسن للمسنين العالمي اليوم بمناسبة الفلسطيني

أدى الفلسطينيين المسنين أوضاع أدى على الفلسطينيين المسنين أوضاع ارتفاع على ارتفاع الى الىنحو إلى الحياة قيد على البقاء نحو معدالت إلى الحياة قيد على البقاء خالل 66--55معدالت خالل سنوات سنوات

. الماضيين العقد ونصف .العقد الماضيين العقد ونصف العقد

نحو • من المسنين عمر نحو وارتفع من المسنين عمر الذكور 67.067.0وارتفع من لكل الذكور سنة من لكل سنةعام عام واإلناث و 71.871.8إلى إلى 19921992واإلناث للذكور و سنة للذكور سنة سنة 73.373.3سنةلعام لعام لإلناث   20062006لإلناث البقاء توقع معدل ارتفاع أدى وقد ،   البقاء توقع معدل ارتفاع أدى وقد ،

  السن كبار أعداد ارتفاع إلى الوالدة عند الحياة قيد   على السن كبار أعداد ارتفاع إلى الوالدة عند الحياة قيد على. الفلسطينية األراضي .في الفلسطينية األراضي في

العام • منتصف العام ففي منتصف اإلحصاء 20092009ففي اإلحصاء حسب حسباألفراد ) السن كبار نسبة بلغت األفراد ) الفلسطيني، السن كبار نسبة بلغت سنة سنة 6060الفلسطيني،

األراضي% 4.44.4فأكثر( فأكثر( في السكان مجمل األراضي% من في السكان مجمل منبواقع ) بواقع ) الفلسطينية و% 4.94.9الفلسطينية الغربية الضفة و% في الغربية الضفة % % 3.73.7في

) في السن كبار نسبة أن العلم مع ، غزة قطاع ( في في السن كبار نسبة أن العلم مع ، غزة قطاع فيحوالي بلغت قد مجتمعة المتقدمة حوالي الدول بلغت قد مجتمعة المتقدمة من% من% 16.016.0الدول

كبار نسبة تبلغ حين في الدول، تلك سكان كبار إجمالي نسبة تبلغ حين في الدول، تلك سكان إجماليحوالي مجتمعة النامية الدول في حوالي السن مجتمعة النامية الدول في فقط% فقط% 6.06.0السن

. الدول تلك سكان إجمالي . من الدول تلك سكان إجمالي من

AGEING AND HealthAGEING AND Health

•Added life to years not just more to lifeAdded life to years not just more to life

•A growing body of evidence counter the stereotype that A growing body of evidence counter the stereotype that ageing is inevitable associated with sicknessageing is inevitable associated with sickness

•The optimistic some of studies factor such as The optimistic some of studies factor such as diet, ,marital stability, exercise,education,mental diet, ,marital stability, exercise,education,mental

stimulationstimulation

•And social involvement are associated with longevity aAnd social involvement are associated with longevity a

And quality of the lifeAnd quality of the life

Some study in Sweden for people aged 85.more than three Some study in Sweden for people aged 85.more than three quarters were identified as having high levels of subjective quarters were identified as having high levels of subjective

well being measured by high and moderate levels on well being measured by high and moderate levels on morale scalemorale scale

•The combination of this higher frequency of the physical ill healthThe combination of this higher frequency of the physical ill health •And disability with other factor associated with ageing cognitiveAnd disability with other factor associated with ageing cognitive •Impairment ,socio economic deprivation and social support Impairment ,socio economic deprivation and social support

deficitdeficit•This factor increase incidence of commonest metal health This factor increase incidence of commonest metal health

problemproblem•Depression, anxiety disorder among oldest oldDepression, anxiety disorder among oldest old •Trends for increasing proportion of older people in population and Trends for increasing proportion of older people in population and

having less disability and independent . Depend on continuing having less disability and independent . Depend on continuing socialsocial

•,,economic ,and health care improvementeconomic ,and health care improvement •Older people live alone without family support structure present Older people live alone without family support structure present

a special challenge and need for innovation by health care a special challenge and need for innovation by health care providersproviders

Older people mental health prevalence and impact Older people mental health prevalence and impact of mental health problemsof mental health problems

•Mental disorder are common in general population affecting more than a Mental disorder are common in general population affecting more than a quarter of all people at some time in their life WHO 2001quarter of all people at some time in their life WHO 2001

• •Mental disorder accounted for four of 10 leading cause of the of Mental disorder accounted for four of 10 leading cause of the of

disabilitydisability

•Point prevalence rate for adult experiencing any mental disorder are 10Point prevalence rate for adult experiencing any mental disorder are 10 %%

•To 15%To 15% •The frequency of mental illness in elderly may be under-reported" make The frequency of mental illness in elderly may be under-reported" make

diagnosis in the presence of physical co-morbiditydiagnosis in the presence of physical co-morbidity “ “ •Depressive and anxiety disorder affect between 1-7 people1-10Depressive and anxiety disorder affect between 1-7 people1-10

•Dementia and delirium of 11-17 and 1-25 {beekman1999,chew graham Dementia and delirium of 11-17 and 1-25 {beekman1999,chew graham 2004}2004}

•SOME study in UK lower levels of common mental disorder in aged 60SOME study in UK lower levels of common mental disorder in aged 60 •And older these community studies are individual living in private houseAnd older these community studies are individual living in private house

•Exclude people in situation ,temporary hospitalized or homelessExclude people in situation ,temporary hospitalized or homeless •UK 1996 33200 people living in hospital and 350000 older people UK 1996 33200 people living in hospital and 350000 older people

having care in homes as mental disorderhaving care in homes as mental disorder

Prevalence 0f mental disorder 1n relation to Prevalence 0f mental disorder 1n relation to demographic factorsdemographic factors

•11--gendergender

•1male to2 female1male to2 female

•22--MARITAL STATUSMARITAL STATUS

•Marital disruption is consistently associated with higher rate of common Marital disruption is consistently associated with higher rate of common mental disorder UK 7%MEN 12%FEMAL divorced status and separation mental disorder UK 7%MEN 12%FEMAL divorced status and separation associated mental disorder associated mental disorder

proportion divorce in Palestine 11.65 proportion divorce in Palestine 11.65% %

• 33--socio-economic statussocio-economic status

•problem increase after 29 yrs that effects income ,social class problem increase after 29 yrs that effects income ,social class unemploymentunemployment

•,,,,financial strain and education status impact by disorder prevalencefinancial strain and education status impact by disorder prevalence

•

Inter-relation between physical and Inter-relation between physical and mental disordermental disorder

•Inter-relations between physical and psychological health are evident with in Inter-relations between physical and psychological health are evident with in all age however the frequency of negative association –co-morbidity rise with all age however the frequency of negative association –co-morbidity rise with

ageage •The frequency of interaction and severity of its effects are magnified in olderThe frequency of interaction and severity of its effects are magnified in older•Much research has explored the relationship between depression and cardiacMuch research has explored the relationship between depression and cardiac

•patient’ compare with non depressed cardiac patient .the mortality ratepatient’ compare with non depressed cardiac patient .the mortality rate• threefold increased in cardiac patient have major depressionthreefold increased in cardiac patient have major depression

•Epidemiological study has explored the dynamic of the interaction betweenEpidemiological study has explored the dynamic of the interaction between

•Physical illness and mental disorderPhysical illness and mental disorder •Physical illness appear to be an important risk factor for development ofPhysical illness appear to be an important risk factor for development of

•several mental agoraphobia in older people may be commonly precipitatedseveral mental agoraphobia in older people may be commonly precipitated

•By stork and falls rather than associated with panic disorder. patient withBy stork and falls rather than associated with panic disorder. patient with •Chronic medical illness have increased risk of depressive illnessChronic medical illness have increased risk of depressive illness

•Older people have vascular disease prescribed medication may make moodOlder people have vascular disease prescribed medication may make mood disorderdisorder

Inter-relation between Inter-relation between disability and mental disorderdisability and mental disorder

•study appear disability resulting from physical illness are study appear disability resulting from physical illness are associated with common mental disorder especially depressionassociated with common mental disorder especially depression

•The disability arising from physical ill health has been estimated The disability arising from physical ill health has been estimated to beto be

•Cause of up 70%of new cases of depression in older peopleCause of up 70%of new cases of depression in older people •Depression cause disability featuresDepression cause disability features

•11--reduce motivationreduce motivation •

•22--psychomotorretardationpsychomotorretardation •

• 33 - -poor sleeppoor sleep •

•44--lack of energylack of energy •

•55 - -avoidance and anhedoniaavoidance and anhedonia •Are likely to limit activity and physical disability . They are Are likely to limit activity and physical disability . They are

mutual reinforcement processmutual reinforcement process

Older hospital setting patient in generalOlder hospital setting patient in general

older people occupy tow –third of general older people occupy tow –third of general hospital hospital beds beds And exhibit a high prevalence of co-morbid And exhibit a high prevalence of co-morbid mental disordermental disorderPredominantly delirium dementia and Predominantly delirium dementia and depression depression

Level of patient with depression 50% Level of patient with depression 50% {ames 1994} {ames 1994}

Co-exist with medical condition especially Co-exist with medical condition especially chronic illness sush as ischemic heart disease chronic illness sush as ischemic heart disease ,stroke ,cancer ,chronic lung ,stroke ,cancer ,chronic lung disease ,Alzheimer's ,and Parkinson disease disease ,Alzheimer's ,and Parkinson disease likely to be prevalent At levels three time in likely to be prevalent At levels three time in the community the community

Problem affect mental disorder in Problem affect mental disorder in hospitalhospital

1-length of stay1-length of stay2- use of resource2- use of resource3- cost of care 3- cost of care 4- prognosis 4- prognosis

the complex range of physical and emotional and social the complex range of physical and emotional and social problems problems are demand high level of skill from care staff and resourceare demand high level of skill from care staff and resourcethe recognition of mental problems in physical ill older people the recognition of mental problems in physical ill older people is made more difficult by the inter action of illness featureis made more difficult by the inter action of illness feature

Example Example

depression symptom of anorexia .poor sleeping , and weightdepression symptom of anorexia .poor sleeping , and weightloss result from variety of physical condition loss result from variety of physical condition

physical feature such as aches pains fatigue may be aspect physical feature such as aches pains fatigue may be aspect of mental disorder of mental disorder

should be have screening measure in the hospital to identify should be have screening measure in the hospital to identify mental health problem such as geriatric depression scalemental health problem such as geriatric depression scale

Older people in nursing and residential homesOlder people in nursing and residential homes

Another setting isAnother setting is high prevalence of mental disorderhigh prevalence of mental disorder among older people with absence optimal managementamong older people with absence optimal management

Is residential careIs residential care

Care home are differentiated on the basis of whether they Care home are differentiated on the basis of whether they provide personal and social carprovide personal and social car

Research indicate that new admissions to all types of care Research indicate that new admissions to all types of care

homes in the UK increasingly oldhomes in the UK increasingly old

Residents are more disabled than previously with higher Residents are more disabled than previously with higher level of cognitive impairmentlevel of cognitive impairment

Prevalence level of dementia 50%Prevalence level of dementia 50%

Depression in USA PREVALENCE 20% TO 40% ofDepression in USA PREVALENCE 20% TO 40% of residentsresidents

•homes scored adequately in respect homes scored adequately in respect of non-restrictive care of non-restrictive care

practice ,standardpractice ,standard

•Of décor and cleanliness and Of décor and cleanliness and facilitiesfacilities

•For activity and recreationFor activity and recreation

•

Mental disorder are common when Mental disorder are common when residential facilities is poor ,limited social residential facilities is poor ,limited social interaction and daily activityinteraction and daily activityChallengesChallenges

11--staffing levels and skill mix match the type staffing levels and skill mix match the type and complexity of client needs “supportand complexity of client needs “support””

22 - -training of stafftraining of staff 33 - -absence of policy interventionabsence of policy intervention

44--costscosts

mental health and older people specific disordermental health and older people specific disorder

•11 - -depressiondepression

•22 - -anxiety disorderanxiety disorder

•33 - -dementiadementia

•44 - -deliriumdelirium

depressiondepression

•Prevelance major depression among Prevelance major depression among older people 1% to 4% and in minor older people 1% to 4% and in minor

depression 4% to 12% . Increased over depression 4% to 12% . Increased over aged 80%aged 80%

•Older people with depression have longer Older people with depression have longer duration of episodes and shorter time of duration of episodes and shorter time of

relapse than younger personsrelapse than younger persons

•30%30% remain chronicly depressedremain chronicly depressed

•The The longer duration of episodes longer duration of episodes appearappear

•To be co-existing physical illnessTo be co-existing physical illness

•To be poor self health statusTo be poor self health status

•To be depressed severityTo be depressed severity

•Inadequacy social supportInadequacy social support

•Adverse life eventAdverse life event

Depression ,loneliness and Depression ,loneliness and social supportsocial support

•The social environment plays The social environment plays crucial part in determining the crucial part in determining the quality of older people livesquality of older people lives

•Inters personal relationship have Inters personal relationship have been found to act buffer been found to act buffer between adverse event and between adverse event and depressiondepression

•Loneliness is associated with Loneliness is associated with living alone and social isolationliving alone and social isolation

Vulnerability factor for Vulnerability factor for lonelinessloneliness

•FemaleFemale

•Chronic health problemChronic health problem

•Marital statusMarital status

•Loneliness cause to increase Loneliness cause to increase depression and caused increased depression and caused increased

mortality ratemortality rate

Suicide and depressionSuicide and depression

•Elderly people Elderly people have the highest have the highest

rate of completed rate of completed suicide rate of any suicide rate of any

age groupage group

Assessment of depression and Assessment of depression and suicide risk in older peoplesuicide risk in older people

•Depression in older people commonly Depression in older people commonly complicatescomplicates

•because co-morbid medical illness or dementiabecause co-morbid medical illness or dementia

•The clinical presentation may be typical and The clinical presentation may be typical and meet full criteria for depressive disordermeet full criteria for depressive disorder

•Stigma prevent seek help for emotional Stigma prevent seek help for emotional problemproblem

Useful questions for uncovered Useful questions for uncovered depressiondepression

•Are you sadAre you sad ? ?•Are you sleeping poorlyAre you sleeping poorly ? ?

•Do you worry to muchDo you worry to much? ? •What have you enjoyed doing laterWhat have you enjoyed doing later ? ?

•Rating scaleRating scale •during the past month ,have you often been bother during the past month ,have you often been bother

by feeling down ,depressed or hopeless? Yes or noby feeling down ,depressed or hopeless? Yes or no

•During the past month have you often been bothered During the past month have you often been bothered by little interest or pleasuer in doing things ?yes or by little interest or pleasuer in doing things ?yes or

nono

Depression managementDepression management

•Ani depression treatmentAni depression treatment

•Psychological treatmentPsychological treatment

•Cognitive treatmentCognitive treatment

•Problem solving therapyProblem solving therapy

Antidepressant treatmentAntidepressant treatment

•50%50% to60% of older people improvedto60% of older people improved

•Studies have indicated that older Studies have indicated that older patient treated with antidepressants patient treated with antidepressants should stay 12 month to two year'sshould stay 12 month to two year's

•Older patient are have more side Older patient are have more side effect because of higher levels of effect because of higher levels of multiple drug prescribingmultiple drug prescribing

Antidepressant drugAntidepressant drug

•11 - -SSRI fluxetine, fluvoxamineSSRI fluxetine, fluvoxamine

•22 - -tricyclic imipramine , clomipraminetricyclic imipramine , clomipramine

•33--monoamone oxidase monoamone oxidase inhibition ,phenelzine,selegilineinhibition ,phenelzine,selegiline

•44 - -atypical bupropion ,mitrazapine , atypical bupropion ,mitrazapine , nefazodonenefazodone

•55 - -SNRI duloxetine ,venlafaxineSNRI duloxetine ,venlafaxine

Other antidepressant Other antidepressant substancesubstance

•Folk remediesFolk remedies

•Extract of st john wortExtract of st john wort

•55--hydroxytryptophan and tryptophanhydroxytryptophan and tryptophan

•Is amioacde available as dietary supplement and Is amioacde available as dietary supplement and alternative treatment {conventional } difficult alternative treatment {conventional } difficult conclusion about efficacyconclusion about efficacy

Psychological therapiesPsychological therapies

•Is important and enhancing the Is important and enhancing the effect of medication and reducing effect of medication and reducing relapse follow cessation of treatment relapse follow cessation of treatment and it is consistently found to be and it is consistently found to be more acceptable than other more acceptable than other

treatmenttreatment

Cognitive behavior therapyCognitive behavior therapy

•Most establish treatment for Most establish treatment for depression and the aims to alter depression and the aims to alter dysfunctional beliefs and negative dysfunctional beliefs and negative thoughts that characterize depression thoughts that characterize depression

by sessions by sessions

• CBT need some adaptation for work CBT need some adaptation for work with older people because of different with older people because of different life experience and value related egolife experience and value related ego

•

Problem solving therapyProblem solving therapy

•Defining the problem and goal Defining the problem and goal selecting and Appling means of selecting and Appling means of

achieving the goalachieving the goal

Model of care :community Model of care :community mental health team for older mental health team for older peoplepeople •The involvement of community mental The involvement of community mental health teams for older people in health teams for older people in depression management is associated depression management is associated with improved outcomeswith improved outcomes

•Co ordinate by a multi-disciplinary team Co ordinate by a multi-disciplinary team compared with normal primary care compared with normal primary care delivered improvement for disable elderly delivered improvement for disable elderly receiving home carereceiving home care

•Regular monitoring physical health review, Regular monitoring physical health review, antidepressant prescribing and promotion antidepressant prescribing and promotion of social involvmentof social involvment

Collaborative and case Collaborative and case managementmanagementapproachesapproaches

•Primary care occupies a strategic potion in Primary care occupies a strategic potion in the management of late life depression and the management of late life depression and more feasible treatment setting for all more feasible treatment setting for all except the sever and complex presentationexcept the sever and complex presentation

•Approaches appliesApproaches applies

•Chronic disease model to care, uses Chronic disease model to care, uses evidence based guideline, adherence evidence based guideline, adherence program telephone support, with rapid direct program telephone support, with rapid direct access to specialist advice and supportaccess to specialist advice and support

Anxiety disorderAnxiety disorder

•Is co morbid with depressionIs co morbid with depression•Anxiety symptom and disorder among Anxiety symptom and disorder among

older people are associated with older people are associated with disability ,reduce equality of life, disability ,reduce equality of life, increase use health servicesincrease use health services

•Prevalence 10% making these mental Prevalence 10% making these mental disturbance in the late lifedisturbance in the late life

•The rate of anxiety disorder are around The rate of anxiety disorder are around twice a high among women as mentwice a high among women as men

Vulnerability factorVulnerability factor

•Lower level of educationLower level of education

•External locus of controlExternal locus of control

•Resent loss of familyResent loss of family

•Physical illnessPhysical illness

Other factors induce anxietyOther factors induce anxiety

•Aspect of environmentAspect of environment

•Medication side effects {table 17.3}Medication side effects {table 17.3}

•Alcohol intoxication or withdrawalAlcohol intoxication or withdrawal

•**factors contribute to poor recognitionfactors contribute to poor recognition

•11--other common mental disorderother common mental disorder

•22 - -medical co-morbiditymedical co-morbidity

•33 - -early age of onest and no treatmentearly age of onest and no treatment

Treatment for anxiety disorder Treatment for anxiety disorder in later lifein later life

•Tricyclic antidepressantTricyclic antidepressant

•11--clomiparmine hydrochlorideclomiparmine hydrochloride

•22 - -imipramin hydrochlorideimipramin hydrochloride

•General anxiety improved with anti General anxiety improved with anti depressants drugdepressants drug

benzodiazepinesbenzodiazepines

•Commonly usedCommonly used

•Beneficial effect on symptoms of Beneficial effect on symptoms of panic and general anxiety disorderspanic and general anxiety disorders

•Side effect drowsiness {driving Side effect drowsiness {driving accident risk}accident risk}

Psychological treatmentPsychological treatment

•CBT IS EFFECTIVE for older peopleCBT IS EFFECTIVE for older people

•Situational exposure , relaxation Situational exposure , relaxation technique ,self control technique ,self control desensitization and cognitive desensitization and cognitive restructuringrestructuring

dementiadementia

•Major health public problemMajor health public problem•It is neurodegenerative syndrome characterized It is neurodegenerative syndrome characterized

by global ,progressive impairment of cerebral by global ,progressive impairment of cerebral function .it is primary disturbs higher brain function .it is primary disturbs higher brain function such as memory ,thinking, orientation , function such as memory ,thinking, orientation , comprehension, calculation learning , language comprehension, calculation learning , language and judgmentand judgment

•Manifests in loss memory {resent event } and Manifests in loss memory {resent event } and loss executive function such as ability to loss executive function such as ability to organise complex tasks or make decisionorganise complex tasks or make decision

•Demintia affect about 7%of people aged over Demintia affect about 7%of people aged over 65 years and 30% aged over 90 years65 years and 30% aged over 90 years

Subtype of dementiaSubtype of dementia•11 - -Alzheimer diseaseAlzheimer disease •22 - -vascular dementiavascular dementia

•33 - -lewy bodies and frontal lobe dementialewy bodies and frontal lobe dementia•Alzheimer disease is the commonest 50% of cases Alzheimer disease is the commonest 50% of cases

slow onset slow deteriorationslow onset slow deterioration•Vascular dementia abrupt onset step –wise Vascular dementia abrupt onset step –wise

deterioration ,early gait ,seizure, urinary deterioration ,early gait ,seizure, urinary disturbance and history of strokedisturbance and history of stroke

•[[greater prevalence of hypertension and strokegreater prevalence of hypertension and stroke

•Important risk factor for dementia age and family Important risk factor for dementia age and family historyhistory

Cerbrovaccular diseaseCerbrovaccular disease

•Risk factorRisk factor

•11 - -raised blood pressureraised blood pressure

•22 - -DMDM

•33 - -HIGH CHOLESTROLHIGH CHOLESTROL

•44 - -High fat in takeHigh fat in take

55 - -obesityobesity

66 - -smokingsmoking

assessmentassessment•Patient need to link primary health carePatient need to link primary health care and and

secondary ,social services voluntary secondary ,social services voluntary organizationorganization…………

•Stigma can effect on treatment so Stigma can effect on treatment so patient and family need educationpatient and family need education

•Clinical assessment memory Clinical assessment memory impairment aphasia agnosia, apraxia impairment aphasia agnosia, apraxia

function disturbance {instrumental function disturbance {instrumental activities of daily living}activities of daily living}

•Physical examination is very importantPhysical examination is very important

Mini-mental state Mini-mental state examinationexamination

•25-3025-30 normalnormal

•18-2418-24 mild to moderate impairmentmild to moderate impairment

•1717 or less impairment in daily activityor less impairment in daily activity

treatmenttreatment

•Prevention strategies and interventions to slow disease Prevention strategies and interventions to slow disease progressprogress

•11 - -blood pressure and vascular factorblood pressure and vascular factor

•22 - -nutrition ,diet and dietary supplementnutrition ,diet and dietary supplement

•11--omega 3 polyunsaturated fatty acid {oily fishomega 3 polyunsaturated fatty acid {oily fish

•33 - -limits vitamin C and Elimits vitamin C and E

•44--limit green tealimit green tea

55 - -ginkgo biloba {leaf decorative tree}ginkgo biloba {leaf decorative tree}

33 - -life style social involvement , physical exercise and life style social involvement , physical exercise and cognitive activitiescognitive activities

Drug treatmentDrug treatment

•11 - -Cholinesterase inhibitorCholinesterase inhibitor

•11 - -donepezildonepezil

•22 - -rivastigminerivastigmine

•33 - -galantaminegalantamine•22--atypical neuroleptic drug atypical neuroleptic drug treat behavioral treat behavioral

manifistation of demintia {lewy bodeis}manifistation of demintia {lewy bodeis}

Psychosocial interventionPsychosocial intervention1-enviromental modification aroma, music, reduce noisy , 1-enviromental modification aroma, music, reduce noisy , exerciseexercise

2-oriantation places time person 2-oriantation places time person 3-reminiscence therapy {talked about past } 3-reminiscence therapy {talked about past }

carer supportcarer support1-professional and organization practice 1-professional and organization practice

2-communty mental health old age services2-communty mental health old age services

deliriumdelirium

•know as confusional state ,is a common and know as confusional state ,is a common and serious of mortality and morbidity among serious of mortality and morbidity among older hospitalized patient, the core diagnostic older hospitalized patient, the core diagnostic criteria for delirium are acute generalized criteria for delirium are acute generalized impairment of consciousness and attention, impairment of consciousness and attention, global disturbance of cognition and global disturbance of cognition and perceptual abnormalitiesperceptual abnormalities

•Key features rapid onset ,fluctuating course , Key features rapid onset ,fluctuating course , disturbance of the sleep walk disturbancedisturbance of the sleep walk disturbance

•Delirium may be mistaken for avarity o other Delirium may be mistaken for avarity o other disorder including mood disorder including mood disorder,demintia,psychotic illnessdisorder,demintia,psychotic illness

Aeti0logy is multifactorialAeti0logy is multifactorial1- head injury1- head injury2- renal, hepatic failar2- renal, hepatic failar3- hypoglycemia3- hypoglycemia4-heart failar ,shock4-heart failar ,shock5- electrolyte imbalance5- electrolyte imbalance6-substance intoxication6-substance intoxication7- infection7- infectiontow and six factor may present tow and six factor may present in single patientin single patient

Prevention and early Prevention and early interventionintervention

•The prompt detection of delirium is The prompt detection of delirium is important as it is potentially reversibleimportant as it is potentially reversible

•Patient risk factor needPatient risk factor need

•Good nurse practitioner ,team workGood nurse practitioner ,team work

•Encourage patient to Encourage patient to exercise .walking ,mental exercise .walking ,mental

stimulation ,discussing current event, stimulation ,discussing current event, reduce hypnotic drug,relaxation,treatment reduce hypnotic drug,relaxation,treatment

medical problemmedical problem

managementmanagement

•Environmental and supportive Environmental and supportive intervention are a crucial part of intervention are a crucial part of

management of distress and management of distress and disturbed behavior of the deliriumdisturbed behavior of the delirium

Delirium rating scale itemDelirium rating scale item

•Temporal onset , perceptual Temporal onset , perceptual disturbance , disturbance , psychomotor behavior , psychomotor behavior , cognition status, physical disease , sleep cognition status, physical disease , sleep wake disturbance , mood and fluctuation wake disturbance , mood and fluctuation

of featuresof features

Pharmacological approachePharmacological approache

•Anti-psychotic drug especially that Anti-psychotic drug especially that are less sedative ,ant cholinergicare less sedative ,ant cholinergic

•Benzodiazepines related alcohol Benzodiazepines related alcohol withdrawalwithdrawal

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