Old Age Psychiatry

Question 1

Transient causes of Amnesia

Answer 1

Head injuries
Post ECT
Alcoholic Amnesia

Question 2

Persistent amnesia causes

Answer 2

Dementia
Korsakoff's psychosis
TBI
Hypothyroidism
B12 deficiency

Question 3

Depression in the elderly

Answer 3

Depression in the elderly can be precipitated by medication changes e.g. propranolol, digoxin, steroids, L-dopa or acute medical illness
Depression in the elderly can have some features that are more striking than in younger adults
- Severe psychomotor retardation
- Cognitive impairment
- Depressive delusions
- Paranoia
- Somatic syndrome

Question 4

Management of Depression in the Elderly

Answer 4

The management of depression in elderly patients follows many of the same principles as in younger adults, however diagnostic tools such as the geriatric depression scale (GDS) should be used

• SSRIs are recommended due to reduced cardiotoxicity. If there is no effect within 8 – 9 weeks, there should be trial of another antidepressant or augmentation with lithium. Use of TCAs is discouraged
• Supportive psychological therapy can be beneficial e.g. CBT
• Elderly often respond well to ECT, particularly where there are concerns about suicidal ideation. The risk associated with general anaesthetic may be significant

Question 5

Anxiety in Elderly

Answer 5

Anxiety symptoms in the elderly tend to be non-specific or hypochondriacal
- Obsessional, phobic, dissociative and conversion disorders are less common
CBT can be effective

Question 6

Management of Bipolar in Elderly

Answer 6

Antipsychotic medication is useful, but lithium will require increased monitoring therefore valproate or carbamazepine may be more useful
- Social support may be more complex in the elderly

Question 7

Psychosis in the Elderly

Answer 7

Persecutory delusions are commonest in these patients
- Long standing psychotic illness
- Late onset psychotic illness (late paraphrenia), in this persecutory delusions and auditory hallucinations are common. Thought disorder is less common
- Psychotic illness associated with brain disease, this is common with hallucinations and delusions in dementia
Sometimes elderly people suffering of psychotic disorders are difficult to treat in the community, and therefore the use of the mental health for detention is slightly more common
Management differs slightly
- Risperidone is the most effective antipsychotic medication, but low doses should be used

Question 8

Pharmacodynamics in elderly when prescribing psychotropic medication

Answer 8

• There are fewer dopaminergic neurones, therefore there are increased extra-pyramidal side effects with neuroleptics
• There is a reduction in cholinergic receptors
• Decreases in noradrenergic activity increase vulnerability to mood disorders
• There is increased sensitivity to narcotics and sedative hypnotics due to decreased receptors

Question 9

General principles of prescribing

Answer 9

• Start with a low dose and titrate slowly, maximum drug efficacy is usually achieved at lower doses than in adults
• Beware of postural hypotension, arrhythmias and sedation
• Drug interactions are common due to polypharmacy
• There is increased sensitivity to EPSEs and anti-cholinergic side effects
• Always consider suicide risk