Psychogeriatrics Flashcards
what are some masquerades of depression in geriatric patients?
psychosomatic symptoms cognitive impairment pain irritability psychotic symptoms substance abuse
what are the common drugs for substance abuse in geriatric patients
alcohol abuse
prescribed medications- benzos opiates
In addition to the normal psychiatric history what other things are important to assess in a geriatric patient?
- Cognition
- Medical comorbidities
- Functional assessment
- Risk assessment- active/passive suicidality
- Detailed personal/developmental history (may need to get collateral information)
• Ascertain how they cope with resilience
• What are their strengths
What are their vulnerabilities
what are the SSRIs that we typically prescribe for a geriatric patient with depression?
Sertraline and citalopram
what are some practice points of prescribing psychotropic medications for psychogeriatric patients
start low go slow; lower doses of psychotropic medications; matching drugs to the patient e.g. consider the SE
options for managing depression in geriatric patients?
CBT
Drugs (SSRIs/SNRIs/Mirtazapine/TCAs/anti-psychotics etc)
ECT
An elderly patient presents with late onset mania what are some risks you need to screen for?
Financial risk risk of reputation risk of harm to self or others risk of neglect suicidality sexual dishibition
how might an elderly patient present with mania?
irritated rather than elevated mood
over familiarity with others
disinhibition
erratic behaviour
where is best to take a psychogeriatric interview and why?
elderly patients with psychiatric issues are better assessed in their home. We can address things like • Food in the kitchen • House clean and habitable • Medications • Personal grooming Etc
what are in the investigations included for an ‘organic work up’ of a geriatric patient presenting with late onset psychiatric symptoms?
- Routine blood tests- FBE UEC LFT Ca TFTs
- MSU
- CXR and neuroimaging
- Needs to be tailored to the patient
Depends on the history and medications
what age group defines very late onset schizophrenia?
Very late onset schizophrenia- greater 65 yrs old
what are some issues to consider with dementia patients with BPSD?
increased carer burden/burden on nursing staff
increased cost of management
earlier institutionalisation
stigma
poorer prognosis and lower functional ability
what do we mean by the term ‘graduates’ in psychogeriatric medicine?
elderly patients with longstanding early onset schizophrenia–>
positive symptoms tend to attenuate
negative symptoms tend to worsen
what type of delusions are common in late onset psychosis?
persecutory delusions
misidentification delusions
what is different about the typical delusions of late onset schizophrenia as compared to early onset schizophrenia?
late onset schizophrenia delusions tend to be more realistic and not fantastical like early onset schizophrenia
what is the meaning of ‘phantom boarder’ syndrome, and what is it a feature of?
delusion where the patient believes that their house is inhabitated by unwelcome guests
feature of late onset schizophrenia
what are some practice points we need to consider if we had to prescribe psychotropic medications for affective disorders in geriatric patients?
- have all the non-pharmacological approaches/measures been exhausted?
- what other drugs is this patient on that may potentially interfere with this medication?
- what is the renal function of this patient?
- what is the lowest effective dose for the shortest amount of time- start low go slow
- organise medication review in at most 3 months
why might it be difficult to distinguish thought disorder in psychogeriatric patients?
geriatric patients may have cognitive impairment which may affect communication/language abilities. The only way we assess thought disorder is through speech and language.
what is the number one cause of psychosis in late life?
dementia
what are some characteristics of late onset schizophrenia?
premorbid long history of suspiciousness/isolation/difficulties in relationships
delusions are usually persecutory; partition delusions; phantom boarder syndrome
deafness and visual impairment is often associated
very poor insight
females >males
Hallucinations in more than one modality (e.g. olfactory/somatic)
–> greater than 45 yrs old
what does partition delusions?
patients have a delusion that other people are trying into get into their house
how might we distinguish late onset schizophrenia or early onset schizophrenia?
Usually late onset schizophrenia patients do NOT present with thought disorder, and hence if you have a geriatric patient with thought disorder you should be thinking of early onset schizophrenia that has not been diagnosed.
Think late onset schizophrenia if there are partition delusions
can we distinguish between very late onset schizophrenia and dementia associated with psychosis?
not really…. It is really hard to tell the difference
how might we treat late onset schizophrenia?
psychotic medications are not that great in elderly patients due to SE and reduced efficacy, drug interactions etc
So really mainstay treatment is establishing a therapeutic relationship with them and risk assessment and risk management!! –> refer for psychogeriatric assessment
the threshold for admitted patients with late onset schizophrenia is quite high.
optimise other medical comorbidities, provide family/carer support, discuss legal issues e.g. EPOA and disability support
Environmental modifications, address visual/hearing impairments
what anti-psychotics can we use in BPSD?
risperidone/olanzapine first line
quetiapine is another option
what are some complications of old age schizophrenia?
increased risk of tardive dyskinesia risk of isolation, poverty, self neglect increased risk of suicide poor management of medical comorbidities polypharmacy harm to others increased risk of substance abuse
