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GERIATRIC

PSYCHIATRY
M. Surya Husada Vita Camellia
Psychiatry Department
Medical Faculty - USU

Definition
Geriatric

Psychiatry is concerned
with preventing, diagnosing, and
treating psychological disorders
in older adults
Geriatric
Psychiatry
also
promoting longevity
Persons with a healthy mental
adaptation to life have been
found to live longer than those
stressed with emotional problem
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Epidemiology
Late

aduthood/old age : begin at age 65


In Indonesia : begin at age 60
Divided into young old (ages 65-74),
old-old (ages 75-84), and oldest old
(age 85 and beyond)
Also divided into well-old (those who
are healthy) and sick-old (persons with
an infirmity that interferes with daily
functioning and that requires medical or
psychiatric care)
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The

life expectancy in USA :


approaching 80 % (an average of 74
for men and 81 for women)

People

at least 85 years old now


constitute 10 % of those 65 and
older and is the most rapidly growing
segment of the older population
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Biology Of Aging
The

aging process (senescence) is


characterized by a gradual decline in
the functioning of all the bodys system
(cardiovascular, respiratory, endocrine,
immune, etc)
Cognition : mild memory loss common,
it called benign senescent forgetfulness
New material can be learned, however
it requires more repetition and practice
than in younger patient
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IQ

doesnt decrease
Persons of low socioeconomic
status are at a higher risk for
cognitive decline than persons in
higher groups
Cognitive
decline slowed in
persons who are involved in
continual
learning
and
stimulation
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Change

in cellular DNA and RNA structures :


intracellular organelle degeneration
Change in immune system : impaired T-cell response
to antigen
Change in musculoskeletal : reduction in lean muscle
mass and muscle strength
Change in integumen : graying of hair results from
decreased melanin production
Change in genitourinary and reproduction : decreased
glomerular filtration rate and renal blood flow
Change in special senses : Inability to accommodate
(presbyopia)
Change in cardiovascular : increase in size and
weight of heart
Change in GIT : decreased blood flow to gut and liver
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Change

in endocrine : adrenal
androgen decreases
Change in respiratory : decreased vital
capacity
Change
in
neurotransmitter
:
norepinephrine decrease in CNS
Change in brain : decrease in gross
brain
weight,
ventricle
enlarge,
widened
sulci,
gyral
atrophy,
decreased cerebral blood flow and
oxygenation
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Medical Illness
The

leading five causes of death in the


elderly are :
Heart disease
Cancer
Stroke
Alzheimers disease
Pneumonia
Benign prostatic hyperplasia : 75% of
men over age 75
Urinary incontinence : 20% of the
elderly
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These

common disorders result in behavior


modification
Arthritis : restrict activity and alter lifestyle
They will hide or deny their disability to
maintain self-esteem.
Hypertension : result in CNS effects ranging
from headaches to stroke, pharmacotherapy
for this condition can result in mood and
cognitive disorders
Difficulties
with
convergence,
accommodation, and macular degeneration
are sources of visual disability
These sensory changes frequently interact
with psychopathological disabilities, serving
to magnify psychopathological deficit
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Psychiatric Illness
The

most common disorders of old age are


depressive
disorder,
cognitive
disorders
(dementia), phobic disorders, and alcohol use
disorders
Older adults (over age 75) have one of the
highest risks for suicide
Many mental disorders of old age can be
prevented, ameliorated, or even reversed
Special importance are the reversible causes of
delirium and dementia, if not diagnosed
accuaretly and treated in timely fashion, these
conditions can progress to an irreversible state
requiring a patients institutionalization
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Dementia of the Alzheimers


type
Most

common type of dementia


Women > men
Characterized : gradual onset and
progressive
decline
of
cognitive
functioning
Impaired of memory, aphasia, apraxia,
agnosia, and disturbances in executive
functioning
Neurologic defect (gait disturbances)
eventually appear
About
50%
of
patients
with

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Etiology

: selective loss of cholinergic


neurons, reduced gyral volume in the
frontal and temporal lobes, microscopic
alteration include senile plaques and
neurofibrillary tangles
Treatment : There is no known prevention
or cure
Treatment is palliative
Some patients show improvement in
cognitive and functional measures when
treated with donepezil or memantine
Psychosis of Alzheimers type is treated
pharmacologically
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Vascular Dementia
The

second most common type of


dementia
It has focal neurologic signs and
symptoms
Also has an abrupt onset and a
stepwise, deteriorating course
Other Dementias : Dementias due to
Huntingtons disease, dementia due
to normal pressure hydrocephalus,
parkinson disease, and other cause
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Depressive disorders
About

15% of all older adult community


residents and nursing home patients
Common signs and symptoms : reduced
energy and concentration, sleep problems
(especially early morning awakening and
multiple awakening), decreased appetite,
weight loss, and somatic complaints
Cognitive impairment in depressed geriatric
patients is referred to as the dementia
syndrome of depression (pseudodementia),
which can be confused with easily with true
dementia
Pseudodementia : 15% of depressed older
patients
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Bipolar I disorder
Usually

begins in middle adulthood


A vulnerability to recurrence remains, so
patients with a history of bipolar I disorder
may display a manic episode late in life
Signs and symptoms in older are similar to
those
in
younger
persons
:
elevated/expansive/irritable mood, decrease
need to sleep, distractibility, impulsivity,
and often excessive alcohol intake
Hostile and paranoid behavior is usually
present
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Treatment

: lithium remains the


treatment choice for mania, but its
use by older patients must be
monitored
carefully
because
its
reduced renal clearance makes lithium
toxicity a significant risk
Neurotoxic effects are also more
common in older persons than in
younger adults
Other drugs : carbamazepine, valproic
acid and divalproex
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Schizophrenia
Signs

and symptoms : emotional


blunting, social withdrawal, eccentric
behavior, and illogical thinking
Delusions
and
hallucinations
are
uncommon
Usually begins in late adolescence or
young adulthood and persists throughout
life
Women > men (late onset schizophrenia)
About 20% patients show no active
symptoms by age 65
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Treatment

: Older persons with


schizophrenic symptoms respond well
to antipsychotic drugs
Medication
must be administered
judiciously,
and
lower-than-usual
dosages are often effective for older
adults
Antipsychotic : clozapine, risperidone,
olanzapine, quetiapine, ziprasidone,
aripiprazole,
haloperidol,
chlorpromazine
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Delusional disorder
Can

occur
under
physical
or
psychological
stress
and
maybe
precipitated by the death of a spouse,
loss of job, retirement, social isolation,
debilitating medical illness or surgery,
visual impairment, and deafness
Usually occurs between ages 40 and 55
The most common are persecutory type
May results from medication or be early
signs of a brain tumor

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Anxiety disorder
Signs

and symptoms of phobia in older


adults are less severe than in those that
occur in younger persons, but the effects are
more debilitating for older patients
Obsessions and compulsions may appear for
the first time in older adults, although older
adult with obsessive-compulsive disorder
usually had demonstrated evidence of the
disorder when they were younger
When
symptomatic,
patients
become
excessive in their desire for orderlines and
rituals
Other anxiety disorder : panic disorder,
generalized anxiety disorder, acute stress21

Anxiety

disorders begin in early or


middle adulthood, but some appear
for the first time after age 60
The most common disorder are phobia
(4-8%)
Treatment : must take into account the
biopsychosocial interplay producing
the disorder
Both
pharmacotherapy
and
psychotherapy are required

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Alcohol and other substance use


disorders
Older

adults with alcohol dependence usually


give history of excessive drinking that began
in young or middle adulthood
They usually are medically ill, divorced, or
never married
The clinical presentation are varies and
includes confusion, poor personal hygiene,
depression, malnutrition, and the effects of
falls
Unexplained gastrointestinal, psychological,
and metabolic problems should alert clinicians
to over-the-counter substance abuse
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Alcohol

and other substance use


disorder account for 10% of all
emotional problems in older
persons
Dependence
on
hypnotics,
anxiolytics, and narcotics is more
common in old age than in
generally recognized
35
%
use
over-the-counter
analgesics
30% use laxatives

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Sleep disorders
As

a results of the decreased length of


their daily sleep-wake cycle, older persons
without daily routines may experience an
advanced sleep phase in which they go to
sleep early and awaken during the nigth
Changes in sleep structure involve both
REM and non REM sleep
The REM changes : redistribution of REM
sleep throughout the night, more REM
episodes, shorter REM episodes, and less
total REM sleep
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The

nonREM changes : decreased


amplitude
of
delta
waves,
lower
percentage of stage III and IV sleep, and a
higher percentage of stages I and II sleep
Among
the primary sleep disorders,
dyssomnias are the most frequent,
especially primary insomnia, nocturnal
myoclonus, restless legs syndrome, and
sleep apnea
Alcohol usage can also interfere with the
quality of sleep and can cause sleep
fragmentation
and
early
morning
awakening
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THANKYOU

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