Old age psychiatry Flashcards
Focus of geriatric depression scales
Psychiatric symptoms because many elderly have somatic symptoms
Features to ask about to distinguish dementia from depression in the elderly
Rate of mental decline
Orientation
Concentration
Memory problems
Language and motor skills
Language and motor skills in dementia vs depression
Slow but normal in depression, impaired in dementia
Memory in dementia vs depression
No insight in dementia, noticed + worried about in depression
Orientation in dementia vs depression
No loss of orientation in depression (time, date, place)
May become lost in familiar locations in dementia
Rate of mental decline in dementia vs depression
Rapid in depression, slower in dementia
Features of neurotic disorders in the elderly
Hypochondriasis
Non-specific anxiety
Aetiology of neuroses in the elderly
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
Clincal features of late-onset schizophrenia (aka paraphrenia)
Hallucinations very common
Delusions, particularly persecutory + partition (10-20% delusions only)
Negative symptoms very uncommon
Aetiological factors in late-onset schizophrenia
Bio: Organic brain pathology, esp cerebrovascular; genetics; sensory impairments
Psycho: Premorbid personality (schizoid, paranoid)
Social: Isolation, major life events
Prevalence of depression in >65
Approx 10% overall
1% in community, 10% in outpatients
Up to 30% in inpatients and nursing homes
Aetiological factors in mood disorders >65
Bio: Brain changes (mania in men), physical illness (60-75% of cases)
Social: Major losses, lack of supportive/confiding relationship
Striking symptoms of depression in older adults
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)
Pharmacological management of depression in older adults
1st line: SSRIs due to SE profile
Other options: SNRIs (e.g. venlafaxine) TCAs (with caution!)
Non-pharmacological management of depression in older adults
ECT
CBT, bereavement counselling
Physical r/v in adults with depression
Thyroid status
ECG, BP
Treatment of mania in older adults
Acute: Haloperidol, risperidone
Prophylactic: Lithium, w/ extreme caution in levels (esp in dehydration, infection, diuretics)
Principles of monitoring Li levels in older adults
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
Poor prognostic factors for depression in >65
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
Prevalence of suicide in the elderly
approx 20% of all suicides, more likely to be lethal
Prevalence of self-harm in the elderly
5% of all cases, more likely to represent failed suicide attempt
Prognosis of self-harm in elderly
8% complete suicide within 3 years
General prescribing principles for the elderly
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
