Psychiatry of old age Flashcards
1
Q
prevalence of mental health disorder in the elderly
A
20-25%
2
Q
what is the most common mental health disorder in the elderly
A
depression (10.3%)
3
Q
prevalence of dementia in those over 65 and over 80 years old
A
- 5% > 65 years old
- 20% > 80%
4
Q
methods of cognitive testing
A
- Folestein’s Mini mental state exam
- montreal Cognitive Assessment (MOCA)
- Addenbrooke’s Cognitive Assessment (ACE-R)
5
Q
components of the mental state examination
A
- Appearance
- Behaviour
- Speech
- Mood
- Affect
- Thoughts
- Perceptions
- Risks
- Cognition
- Insight
6
Q
investigations that should be done
A
- blood tests
- ECG
- EEG
- X-rays
- Neuroimaging - CT scans, MRI scans, PET scans
- Toxin screens
- Others
7
Q
depression in later life
A
- most common mental illness in > 65s
- it is not a normal consequence of aging
- sadness/ grief are normal responses to life events - e.g bereavement, loss of social status, change in role, transition to assisted living
- associated with;
1. Unnecessary suffering
2. Impaired functional status
3. Increased mortality
4. Increased use of healthcare resources
5. Under-diagnosed and treated
rates;
- 2-10% in community settings
- 30% of hospitalized older people
- 40% of patients with cancer/MI
8
Q
Risk factors for depression in the elderly
A
- family history less likely
- females > males
- social isolation
- widowed/ divorced/ separated
- lower socioeconomic status
- co-morbid physical ill health
- Pain
- insomnia
- impaired cognitive or functional status
9
Q
Nursing home residents and depression
A
- cognitive impairment/ dementia increases the incidence and reduces the detection of depression
- prevalence in Nursing home:
— 10-20% cognitively intact
— 50-70% cognitively impaired
10
Q
physical illness and depression in the elderly
A
- risk of depression increases with;
1. recent onset of physical illness
2. Greater severity
3. Functional impairment
4. limited mobility
5. Poor pain management
6. Multiple illnesses - can be the first presentation of stroke/ CVA. diabetes, hypothyroidism
11
Q
Suicide in the elderly
A
- depression is a major risk factor
- less frequent attempts
- more likely to be successful
- highest rate - caucasian men > 65 years old
- risk factors for suicide;
1. hopelessness, insomnia, agitation, impaired concentration, psychosis, alcohol/drug misuse
2. Older age, male sex, living alone, bereaved
3. Physical illness, pain and previous attempts
12
Q
diagnosis of depression in the elderly
A
- history, informant history and thorough MSE and risk assessment
- MMSE and cognitive assessment
- physical work-up including bloods, scans etc to rule out organic illness
13
Q
depression in the elderly can present in an atypical fashion
A
- men - more likely to present with anger, irritability, withdrawl, apathy, and alcohol misuse
- women - more likely to acknowledge sadness
- agitation, anxiety, physical complaints prominent
- biological symptoms
- pseudo-dementia
14
Q
psychotic depression in the elderly
A
- more common in elderly than general adult population
- most severe form of depression - symptoms can be difficult to treat and more liklely to relapse
- delusions - mood congruent. Poverty, guilt, worthlessness, inadequacy, nihilistic. Can be somatic/ paranoid
- hallucinations are uncommon
15
Q
Management of depression in the elderly
A
- Biological
- SSRIs first line, often sertraline, escitalopram, Citalopram
- venlafaxine and Mirtazapine are often used as a second line agents
- may require augmentatino with a second antidepressant, atypical antipsychotics, lithium
- consider ECT in treatment resistance, psychotic depression or when a rapid response is needed
- minimum 6-9 months after remission of symptoms - Psychological
- CBT
- interpersonal therapy
- less often psychodynamic or psychoanalytical approaches
- Bereavement counselling or supportive psychological therapies
- other psychotherapy if more appropriate - systemic/ family therapy - Social
- day centres - structured and supported social activities
- home help - manage ADLs, promote independence, dignity and remain in their own home
- social groups - active retirment, Men’s shed initiative, clubs
- respite if necessary
16
Q
anxiety disorders in the elderly
A
- 5-15% prevalence
- most cases treated in primary care
- presence of an anxiety disorder increases risk of development of depression by 20%
- management is similar as for young adults:
— treat co-morbid depression
—- anxiety management skills, mindfulness
— CBT, social interventions
—- notably: avoid benzodiazepines – sensitivity to side effects
17
Q
psychosis in the elderly - classification
A
- Old psychosis - i.e graduates of general adult population
- New psychosis - late onset paraphrenia/ Psychotic spectrum disorder. Arises between 40-59
- New psychosis - very late onset Schizophrenia (VLOSP) > 60 years
18
Q
Psychotic spectrum disorders
A
- most likely to be diagnosed as delusional disorder
- presence of delusional beliefs often systematized and quite elaborate. Content is often plausible and non-bizarre
- significant emotional investment in belief system
- relative absence of major mood symptoms or other psychotic symptoms
- prevalence 5-6% population
- more likely to be female
- premorbid personality traits: poor adjustment, 45% show paranoid/ Schizoid personality traits. Tend to have poor relationships but good educational and occupational adjustment
- often chronic and longstanding. Resistant to treatments. Antipsychotics may attenuate intensity of beliefs/ preoccupation with them
- psycho-social supports and risk reduction strategies
- treat co-morbidities
