Old age psychiatry

Question 1

Focus of geriatric depression scales

Answer 1

Psychiatric symptoms because many elderly have somatic symptoms

Question 2

Features to ask about to distinguish dementia from depression in the elderly

Answer 2

Rate of mental decline

Orientation

Concentration

Memory problems

Language and motor skills

Question 3

Language and motor skills in dementia vs depression

Answer 3

Slow but normal in depression, impaired in dementia

Question 4

Memory in dementia vs depression

Answer 4

No insight in dementia, noticed + worried about in depression

Question 5

Orientation in dementia vs depression

Answer 5

No loss of orientation in depression (time, date, place)

May become lost in familiar locations in dementia

Question 6

Rate of mental decline in dementia vs depression

Answer 6

Rapid in depression, slower in dementia

Question 7

Features of neurotic disorders in the elderly

Answer 7

Hypochondriasis

Non-specific anxiety

Question 8

Aetiology of neuroses in the elderly

Answer 8

Bio: Organic brain change, physical illness, immobility (loss of confidence)

Psycho: Major loss, impaired self-care

Social: Loss of independence, loneliness, lack of social support

Question 9

Clincal features of late-onset schizophrenia (aka paraphrenia)

Answer 9

Hallucinations very common

Delusions, particularly persecutory + partition (10-20% delusions only)

Negative symptoms very uncommon

Question 10

Aetiological factors in late-onset schizophrenia

Answer 10

Bio: Organic brain pathology, esp cerebrovascular; genetics; sensory impairments

Psycho: Premorbid personality (schizoid, paranoid)

Social: Isolation, major life events

Question 11

Prevalence of depression in >65

Answer 11

Approx 10% overall

1% in community, 10% in outpatients

Up to 30% in inpatients and nursing homes

Question 12

Aetiological factors in mood disorders >65

Answer 12

Bio: Brain changes (mania in men), physical illness (60-75% of cases)

Social: Major losses, lack of supportive/confiding relationship

Question 13

Striking symptoms of depression in older adults

Answer 13

Severe psychomotor retardation

Cognitive impairment (esp with effortful tasks)

Depressive delusions (nihilistic, poverty, physical illness)

Paranoia +/- derogatory/obscene auditory hallucinations

Anxiety, hypochondriasis, abnormal illness behaviour (incl sudden deterioration of pre-existing disease)

Question 14

Pharmacological management of depression in older adults

Answer 14

1st line: SSRIs due to SE profile

Other options: SNRIs (e.g. venlafaxine) TCAs (with caution!)

Question 15

Non-pharmacological management of depression in older adults

Answer 15

ECT

CBT, bereavement counselling

Question 16

Physical r/v in adults with depression

Answer 16

Thyroid status

ECG, BP

Question 17

Treatment of mania in older adults

Answer 17

Acute: Haloperidol, risperidone

Prophylactic: Lithium, w/ extreme caution in levels (esp in dehydration, infection, diuretics)

Question 18

Principles of monitoring Li levels in older adults

Answer 18

take levels 10-14h after last dose

Allow 5-7d to stabilise after increase in dosing regimen

Aim for 0.4-0.8 mmol/L

Question 19

Poor prognostic factors for depression in >65

Answer 19

Time: Onset >70y

Illness: Long duration, psychotic symptoms

Hx: Poor previous adjustment/illness

F/U events: Concurrent physical illness, major life events during F/U period

Prognosis generally good though

Question 20

Prevalence of suicide in the elderly

Answer 20

approx 20% of all suicides, more likely to be lethal

Question 21

Prevalence of self-harm in the elderly

Answer 21

5% of all cases, more likely to represent failed suicide attempt

Question 22

Prognosis of self-harm in elderly

Answer 22

8% complete suicide within 3 years

Question 23

General prescribing principles for the elderly

Answer 23

Start low, go slow with increases

Longer maintenance periods

Caution while stopping pre-existing psych treatment regimens even (especially) if stable on them for long times

Sensitivity to cardiac, anticholinergic + EPSE