Psychiatric Care: Older Adult Flashcards
Erickson: Aging and the Life Cycle
- Young Adulthood
- Middle-Aged
- Elderly
- Intimacy vs Isolation (20-40)
- Generativity vs Self-Absorption (40-64)
- Integrity vs Despair (65+)
(Fear of death is usually a mid-life issue)
Other Tasks of Elderly
- Reminiscence
- Loss
- On time normative incidents do not usually result in ______.
- ______ are usually pain, disability, abandonment, and dependency
Crisis
Fears
Learning - The ability to gain new skills and information may be ______ in elderly, especially verbal learning.
Slower
Memory in Elderly
Immediate - ______
Short-Term - ______
Long-Term - ______
Immediate remains intact
Short-Term remains intact
Long-Term is most affected by aging (retrieval is less efficient, the elderly need more clues)
Intelligence - The ability to use information in an ______ way or ______ knowledge to specific circumstances
Adaptive
Apply
Benign Forgetfulness - The elderly have age associated ______ memory problems. Cognitive problems are due to ______.
Mild
Anxiety
(Examples include forgetting names, misplacing items, difficulty w complex problem-solving)
Psychiatric Evaluation - Include information from caregiver/family. Allow more _____ due to slower response. Family Hx. Review of all ______. Alcohol and substance abuse Hx.
Time
Medications (OTC, Rx, Herbal)
MSE - General description. Moods, feelings, affect. Perceptual disturbances. Language output. Visual-spatial functioning - some decline is normal with age.
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.
Cognitive disorders, depressive disorders, phobias, and alcohol use are ______ mental disorders of old age. This results in a high risk for ______.
Common, Suicide
Risk factors are loss of social roles, loss of autonomy, deaths, declining health, increased isolation, financial constraints, and decreased cognitive functioning.
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.
Acute
Environment
Cognitive
Features of delirium may be accompanied by ______, ______, emotional ______, ______ in the sleep wake cycle, psychomotor slowing or hyperactivity, and is usually abrupt.
Hallucinations
Illusions
Lability
Alterations
Causes of delirium are
I WATCH DEATH
Infectious Withdrawal Acute metabolic Trauma CNS Pathology Hypoxia Deficiencies Endocrinopathies Acute Vascular Toxins/Drugs Heavy Metals
Treatment of delirium includes treating the underlying ______. Close ______, especially by family, frequent reorientation, ______ restraints (may worsen confusion), ______ only if behavioral attempts fail.
Cause Supervision Avoid Medications (Avoid polypharmacy, Low dose neuroleptic is Tx of choice unless withdrawal is cause then short acting benzodiazepine)
What affects cognition, memory, language, personality change, abstract thinking, aphasias, visual spacial functioning, level of awareness and alertness are usually intact in early stages?
Dementia
What differentiates dementia from delirium?
Level of awareness and alertness usually intact in early stages of dementia
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 ______.
Memory
Hemorrhage
Degenerative
Alcoholism
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)
Arthritis
Alzheimer’s disease, Vascular Dementia, Alcoholism
Age, Family Hx, Female Gender
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.
Depression
Laughter, Crying
Emotional
(Delusions or hallucinations occur during the course of dementias in nearly 75%)
Behavioral problems in dementia include
Agitation, restlessness, wandering, violence, shouting, social and sexual disinhibition, impulsiveness, sleep disturbances
Dementia and Treatable Conditions:
10-15% of cases that include
Heart disease, Renal disease, CHF, Endocrine disorder, Vitamin deficiency, Medication misuse, Primary mental disorders.
Dementia of the Alzheimer’s Type (DAT):
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.
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.
Neuroleptics
Depression
Anxiety
Behavioral
Medications for behavioral problems include
Valproic acid (Depakote), Trazodone (Deseryl), Buspirone (Buspar), Benzodiazepines - may aggravate confusion.
Social recommendations should include refering to ______ group or other support groups, continue preventative care, caregiver stress.
Alzheimer’s
______ 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.
Depression
Psychiatric
Age
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.
Somatic
Suicide
(Increases use of primary care medical resources)
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.
Depression
Psychological
Pseudodementia
Depression in older adults may have ______ which are usually persecutory or hypochondriacal in nature. Need treatment w both ______ and ______. ______ may be treatment of choice.
Delusions
Antidepressant
Antipsychotic
ECT
Bereavement is ______ grief. May be ______ in elderly. Consider major depression if marked psychomotor retardation, lasts over 2 months, marked impairment, or SI.
Normal
Prolonged
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.
Onset
Irritable
Paranoid
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.
Lithium
Behavioral
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.
Common
Phobias
Agoraphobia
Axniolytics
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.
Alcohol
Withdrawal
Gastrointestinal
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.
Sensitive
Metabolism
For alcohol ______ use lorazepam (Ativan) or oxazepam (Serax) in elderly because of rapid metabolism.
Detoxification
Psychopharmacology:
Evaluate physically first, including ECG.
Bring in all meds.
Should give meds 3-4 times over 24 hours.
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.
When using psychopharmacology watch for all drug ______. ______ may be a problem. Cognitive dysfunction may require help with medication regimen.
Interactions
Compliance
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.
Water
Half
Prescription insights:
25% of all Rx for people over 65
40% of all hypnotics are for over 65
75% of older people use OTC
Who the F cares?
Antidepressants: SSRI - Depression with \_\_\_\_\_\_ SNRI - Depression with \_\_\_\_\_\_ or diabetic \_\_\_\_\_\_. TCA's - Depression with \_\_\_\_\_\_ \_\_\_\_\_\_. Assess, teach and monitor.
Anxiety
Pain, Neuropathy
Chronic Pain
Psychostimulants may benefit in ______ older patients who are treatment resistant. ______ may augment analgesia for patients on pain meds.
Depressed
Amphetamines
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.
Lower
Four
EPS
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)
Increased
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.
High Amnesia Tissues Oxazepam (Serax) Lorazepam (Ativan) Buspirone may be of benefit. Takes several weeks to work
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.
Complaints
Sex
Group
40% of nursing home patients were placed in ______ last year. Without ______ they have better muscle tone, less rage, greater sense of mastery.
Restraints
Restraints
