Psychiatric Care: Older Adult

Question 1

Erickson: Aging and the Life Cycle

1. Young Adulthood
2. Middle-Aged
3. Elderly

Answer 1

1. Intimacy vs Isolation (20-40)
2. Generativity vs Self-Absorption (40-64)
3. Integrity vs Despair (65+)
   (Fear of death is usually a mid-life issue)

Question 2

Other Tasks of Elderly

1. Reminiscence
2. Loss
3. On time normative incidents do not usually result in ______.
4. ______ are usually pain, disability, abandonment, and dependency

Answer 2

Crisis

Fears

Question 3

Learning - The ability to gain new skills and information may be ______ in elderly, especially verbal learning.

Answer 3

Slower

Question 4

Memory in Elderly
Immediate - ______
Short-Term - ______
Long-Term - ______

Answer 4

Immediate remains intact
Short-Term remains intact
Long-Term is most affected by aging (retrieval is less efficient, the elderly need more clues)

Question 5

Intelligence - The ability to use information in an ______ way or ______ knowledge to specific circumstances

Answer 5

Adaptive

Apply

Question 6

Benign Forgetfulness - The elderly have age associated ______ memory problems. Cognitive problems are due to ______.

Answer 6

Mild
Anxiety
(Examples include forgetting names, misplacing items, difficulty w complex problem-solving)

Question 7

Psychiatric Evaluation - Include information from caregiver/family. Allow more _____ due to slower response. Family Hx. Review of all ______. Alcohol and substance abuse Hx.

Answer 7

Time

Medications (OTC, Rx, Herbal)

Question 8

MSE - General description. Moods, feelings, affect. Perceptual disturbances. Language output. Visual-spatial functioning - some decline is normal with age.

Answer 8

MMSE - Affected by educational level. Median score for 9-12 years of school is 26, HS diploma 28. Less sensitive in those with high intelligence. Less specific in those below average intelligence.

Question 9

Cognitive disorders, depressive disorders, phobias, and alcohol use are ______ mental disorders of old age. This results in a high risk for ______.

Answer 9

Common, Suicide
Risk factors are loss of social roles, loss of autonomy, deaths, declining health, increased isolation, financial constraints, and decreased cognitive functioning.

Question 10

Delirium is ______ and fluctuating. Altered state of consciousness result in reduced awareness of and ability to respond to the ______. ______ deficits in attention, concentration, thinking, memory, and goal-directed behavior are almost always present.

Answer 10

Acute
Environment
Cognitive

Question 11

Features of delirium may be accompanied by ______, ______, emotional ______, ______ in the sleep wake cycle, psychomotor slowing or hyperactivity, and is usually abrupt.

Answer 11

Hallucinations
Illusions
Lability
Alterations

Question 12

Causes of delirium are

I WATCH DEATH

Answer 12

Infectious
Withdrawal
Acute metabolic
Trauma
CNS Pathology
Hypoxia
Deficiencies
Endocrinopathies
Acute Vascular
Toxins/Drugs
Heavy Metals

Question 13

Treatment of delirium includes treating the underlying ______. Close ______, especially by family, frequent reorientation, ______ restraints (may worsen confusion), ______ only if behavioral attempts fail.

Answer 13

Cause 
Supervision
Avoid
Medications
(Avoid polypharmacy, Low dose neuroleptic is Tx of choice unless withdrawal is cause then short acting benzodiazepine)

Question 14

What affects cognition, memory, language, personality change, abstract thinking, aphasias, visual spacial functioning, level of awareness and alertness are usually intact in early stages?

Answer 14

Dementia

Question 15

What differentiates dementia from delirium?

Answer 15

Level of awareness and alertness usually intact in early stages of dementia

Question 16

Amnestic disorders differs from delirium and dementia because major problem is short term ______ only. Impairment may be due to ______ in mamillary bodies or ______ changes in the dorsal medial nucleus of the thalamus. Most common cause is ______.

Answer 16

Memory
Hemorrhage
Degenerative
Alcoholism

Question 17

Only ______ is more common in geriatric population than dementing disorders. 5% have severe dementia and 15% mild dementia in those over 65. Age over 80 years 20% have severe dementia. Name most common causes (3) and risk factors (3)

Answer 17

Arthritis

Alzheimer’s disease, Vascular Dementia, Alcoholism

Age, Family Hx, Female Gender

Question 18

Noncognitive Sx Accompanying Dementia:
Mood disorders: \_\_\_\_\_\_
Pathological \_\_\_\_\_\_ and \_\_\_\_\_\_ occurs.
Irritability
Excessive \_\_\_\_\_\_ outbursts that occur after task failure are "catastrophic reactions" and can be avoided by educating family members to avoid confrontation.

Answer 18

Depression
Laughter, Crying
Emotional
(Delusions or hallucinations occur during the course of dementias in nearly 75%)

Question 19

Behavioral problems in dementia include

Answer 19

Agitation, restlessness, wandering, violence, shouting, social and sexual disinhibition, impulsiveness, sleep disturbances

Question 20

Dementia and Treatable Conditions:

10-15% of cases that include

Answer 20

Heart disease, Renal disease, CHF, Endocrine disorder, Vitamin deficiency, Medication misuse, Primary mental disorders.

Question 21

Dementia of the Alzheimer’s Type (DAT):

Answer 21

50-60% of patients w dementia. %5 who reach 65 have DAT and 15-25% who are 85+. Occupy 50% of all nursing home beds.

Question 22

Treatment of Behavior Problems:
______ should not be first choice, unless pt is psychotic and should be on a PRN basis. Consider the likelihood of ______ and ______ first. Consider using ______ methods if at all possible.

Answer 22

Neuroleptics
Depression
Anxiety
Behavioral

Question 23

Medications for behavioral problems include

Answer 23

Valproic acid (Depakote), Trazodone (Deseryl), Buspirone (Buspar), Benzodiazepines - may aggravate confusion.

Question 24

Social recommendations should include refering to ______ group or other support groups, continue preventative care, caregiver stress.

Answer 24

Alzheimer’s

Question 25

______ occurs in 15% of all oder adult community residences and nursing home patients. It accounts for 50% of older adult admissions to a ______ facility. ______ is not a risk factor, but widowhood and chronic medical illnesses are.

Answer 25

Depression
Psychiatric
Age

Question 26

With depression pt may have more ______ complaints such as decreased energy, sleep problems, pain, weakness, GI disturbances. Increases risk of ______. For those w a medical condition depressive Sx significantly reduce survival.

Answer 26

Somatic
Suicide
(Increases use of primary care medical resources)

Question 27

Medications or the medical illness may cause ______. Rule out medical causes. Use psychological ______ such as hopelessness, worthlessness, guilt. ______ occurs in about 15% of depressed older patients and 25-50% of patients with dementia are depressed.

Answer 27

Depression
Psychological
Pseudodementia

Question 28

Depression in older adults may have ______ which are usually persecutory or hypochondriacal in nature. Need treatment w both ______ and ______. ______ may be treatment of choice.

Answer 28

Delusions
Antidepressant
Antipsychotic
ECT

Question 29

Bereavement is ______ grief. May be ______ in elderly. Consider major depression if marked psychomotor retardation, lasts over 2 months, marked impairment, or SI.

Answer 29

Normal

Prolonged

Question 30

Bipolar disorder episoded persist into old age. Do organic workup if ______ is over 65. Usually more ______ than euphoric and ______ rather than grandiose. May have dysphoric mania, with pressured speech, flight of ideas, hyperactivity, but thought content is morbid and pessimistic.

Answer 30

Onset
Irritable
Paranoid

Question 31

Treatment of bipolar shows ______ is an effective treatment, but decreased renal clearance and neurotoxic effects may be more common. Valproic acid is also helpful for ______ disturbances.

Answer 31

Lithium

Behavioral

Question 32

Anxiety disorders are ______ in elderly. May occur first time after age 60, but not usually. Most common are ______ especially ______. Elderly more likely to use ______. May be due to medical causes or depression.

Answer 32

Common
Phobias
Agoraphobia
Axniolytics

Question 33

20% of nursing home patients have ______ dependence. Sudden onset delirium in hospitalized patients usually from ______. Consider in patients with ______ problems. May misuse OTC. 35% use analgesics, and 30% use laxatives.

Answer 33

Alcohol
Withdrawal
Gastrointestinal

Question 34

The brain is more ______ to alcohol as it ages. Due to changes in ______, a given amount may produce a higher blood alcohol level than in a younger individual. May worsen normal changes in sleep and sexual functioning. Interacts w other medications.

Answer 34

Sensitive

Metabolism

Question 35

For alcohol ______ use lorazepam (Ativan) or oxazepam (Serax) in elderly because of rapid metabolism.

Answer 35

Detoxification

Question 36

Psychopharmacology:
Evaluate physically first, including ECG.
Bring in all meds.
Should give meds 3-4 times over 24 hours.

Answer 36

Washout of psychotropic meds sometimes beneficial.
Major goals are to improve quality of life, maintain in community, and delay or avoid nursing home placement.
Start at lower doses.

Question 37

When using psychopharmacology watch for all drug ______. ______ may be a problem. Cognitive dysfunction may require help with medication regimen.

Answer 37

Interactions

Compliance

Question 38

Metabolism changes cause decrease in lean body mass and total body ______. Increase in body fat, prolongs _____ life. Hepatic metabolism decreases, as well as production of albumin. Decreased renal function.

Answer 38

Water

Half

Question 39

Prescription insights:
25% of all Rx for people over 65
40% of all hypnotics are for over 65
75% of older people use OTC

Answer 39

Who the F cares?

Question 40

Antidepressants:
SSRI - Depression with \_\_\_\_\_\_
SNRI - Depression with \_\_\_\_\_\_ or diabetic \_\_\_\_\_\_.
TCA's - Depression with \_\_\_\_\_\_ \_\_\_\_\_\_.
Assess, teach and monitor.

Answer 40

Anxiety
Pain, Neuropathy
Chronic Pain

Question 41

Psychostimulants may benefit in ______ older patients who are treatment resistant. ______ may augment analgesia for patients on pain meds.

Answer 41

Depressed

Amphetamines

Question 42

Antipsychotics are used for psychosis and behavioral disturbances. Can have SE at ______ doses. Give a _____ week trial at least. No need to use prophylactic antiparkinsonian agents, but the risk of ______ increases with age.

Answer 42

Lower
Four
EPS

Question 43

Low potency agents (mellaril, thorazine) have ______ effects such as orthostatic hypotension, sedation, cognitive impairment. Atypicals may be of most benefit (Clozapine, olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole)

Answer 43

Increased

Question 44

Anxiolytic rate of use is ______. May cause anterograde ______. May accumulate in ______ if long acting so may increase ataxia, insomnia, and confusion. If needed ______ and ______ are drugs of choice.

Answer 44

High
Amnesia
Tissues
Oxazepam (Serax)
Lorazepam (Ativan)
Buspirone may be of benefit. Takes several weeks to work

Question 45

Geriatric psychotherapy goals are to have minimal ______, make and keep friends of both sexes, have ______ if interested and capable. Grief and loss are central issues. ______ therapy directly lessens the elder’s sense of isolation. Family support is crucial.

Answer 45

Complaints
Sex
Group

Question 46

40% of nursing home patients were placed in ______ last year. Without ______ they have better muscle tone, less rage, greater sense of mastery.

Answer 46

Restraints

Restraints