Geriatric Psychiatry

Geriatric Psychiatry Marie Cecilia Y. Tan, MD, DPBP Section of Psychiatry Optimal Aging Center Makati Medical Center

Story of Mr. B • 80-yr old married Filipino, retired lawyer; with visual impairment • CC: sudden and escalating psychomotor agitation, confusion, and psychosis of 2 weeks • HPI: • 3 wks: family squabble over sale of property; wife threatened to leave him • Before this, they said he was “normal” • s/sx: nervous, irritable, paranoid, irrelevant remarks, restlessly pacing, very repetitive, repetitively dialing house no. while at home, confused • 3 days: hardly slept

Questions…How do we manage Mr. B holistically? • 1. How do we explain his sudden behavioral problems? • 2. What are the possible causes of his behavioral problems? • 3. What are the aspects that need to be assessed? • 4. How do we manage his problem behaviors?

Outline of Lecture I. Geriatric Psychiatry definition and History II. Second Half of Life Developmental Phases III. Medical Assessment of the Elderly Psychiatric Patient IV. Common Psychiatric Illnesses of Old Age V. Management

Question.How do we explain his behavioral problems? • 3 yrs: forgetful, lost, quiet, less interactive, repetitive, non-specific words (“it” and “thing”) • (+) for Warning Signs/Red Flags for Probable Dementia

Story of Mr. B • Lawyer, retired 5 yrs ago • His likes: • gardening, playing golf, meeting up with friends, bringing grandchildren out • 3 yrs: • less motivated to do things; less interactive in conversations; he said, he would rather stay home as he felt easily tired

Initial Impression? • Probable Dementia • Behavioral and Psychological Symptoms of Dementia [BPSD] • DSM-IV: Dementia, with delusions and behavioral disturbance

Geriatric Psychiatry defined… • Initially called Old Age Psychiatry • Branch of medicine concerned with: • Promoting longevity • Preventing, diagnosing, treating physical and psychological disorders in older adults • Mental disorders of these patients often differ in clinical manifestations, pathogenesis, and pathophysiology from d/o of younger adults • Older people may have: • Coexisting chronic medical illnesses and disabilities, many medications, cognitive impairments

Geriatric Psychiatry -- History • The growth of the field began in the US, in 1978, at the annual American Psychiatric Association (APA) meeting in Atlanta, GA • American Association for Geriatric Psychiatry (AAGP) • American Journal of Geriatric Psychiatry (AJGP)

Cognition defined… • Memory- remote and recent • Attention- ability to focus, shift, and sustain • Language- speaking, understanding, reading, writing • Orientation to space and time • Visuospatial function • Praxis- ability to carry out motor activities with intact motor functions • Executive functions • ability to respond to information in the environment and execute a logical, goal-directed plan • Initiate, organize, plan; concepts of insight and judgment

Functional Capacity Activities of Daily Living [ADLs] Instrumental Activities of Daily Living [IADLs] Complex tasks that require a higher level of functional independence; abilities necessary to function in the community Driving, using public transportation, managing meds, managing finances, doing laundry, cooking, cleaning, using appliances, using the telephone, shopping, attending to hobbies • Elemental activities necessary for an individual to care for oneself within a limited environment • Eating, bathing, dressing, toileting, grooming, transferring, walking

Human Development in the Second Half of Life • Little attention has been paid to the developmental stages in the 2nd half of life—as if by then, everything is programmed, locked in motion, and ready to decline. • Work of Erik Erikson • Different stages in life framed in terms of dichotomies • 6 of the 8 developmental stages occur in the 1st half of life • 5 occur by adolescence • Only 1 addresses later life

Erikson’s 8 Developmental Stages Stage Psychosocial Issue or Crisis Trust vs. mistrust Autonomy vs. shame, doubt Initiative vs. guilt Industry vs. inferiority Identity vs. identity diffusion Intimacy vs. isolation Generativity vs. stagnation Integrity vs. disgust, despair • Infancy [birth to abt. 1 year] • Early childhood [1-3 yrs.] • Play age [3 - 5] • School age [6-11] • Adolescence • Young adult [21-40] • Adulthood [40-65] • Mature age [>65]

Newly Described Developmental Potential in the 2nd Half of life– Biological Considerations • The 1st 3 yrs of life are NO longer seen as the period when hard-wiring or development of the central nervous system is completed. • Those who study human development are finding more evidence that learning and psychological development are LIFELONG and greatly influenced by the ongoing diversity of human experience. • Findings from biological research reveal that brain plasticity and creative potential continue to unfold through new phases of adult physical and emotional development.

Newly Described Developmental Potential in the 2nd Half of life– Biological Considerations • Fascinating findings of ongoing capacity for learning and creative development in the 2nd half of life • Challenge the mind, the brain biologically responds in positive ways – anatomically and physiologically– regardless of age • A stimulating environment results in individual neurons sprouting new dendritic branches, affecting neurotransmission • Nerve cell bodies and nuclei increase in size • Latest findings from research on neuroplasticity point strongly to the remodeling effects that lifelong experiences and constructive challenges have on the brain, especially in modifying synapses.

Newly Described Developmental Potential in the 2nd Half of life– Psychological Considerations • Developmental growth: changes at different points in the life cycle—changes in how we view and experience life in a combined psychological, emotional, and intellectual sense • Wisdom: developmental mix of age, knowledge, emotional and practical life experience, and brain function which allows us to integrate those pieces to achieve insight that we can apply to a variety of life circumstances. • Creativity: bringing something new into existence that is of value, be it a great work of art, innovative volunteerism, or a fabulous new recipe

Newly Described Developmental Potential in the 2nd Half of life– Psychological Considerations • Dr. Gene Cohen • Research has demonstrated the significant influence on mental health – even in the midst of mental disorder– of accessing what he has referred to as Human-Potential Phases in the second half of life. • Represent the combination of neurobiological, cognitive, and emotional development with the passage of time • Expressed in the positive push from within us toward new perspectives, new impetuses for change, and new forms of creative expression from mid-to-later life • Inner orientations toward mental wellness that continue throughout the life cycle, right to the end.

Four 2nd Half of Life Developmental Phases [Human-Potential Phases]– by Dr. Gene Cohen • Mid-Life Re-Evaluation Phase [Mid-to-late 30s through the Mid-60s] • Developmental impetus– internal drive for re-evaluation, exploration, and transition • Typically occurring in 40s and 50s • Midlife crisis? • Quest energy rather than crisis anxiety • Motivated by a new developmental inner push to re-evaluate their lives and work in order to make them more gratifying • Combines the capacity for insightful reflection with a powerful desire to create meaning in life.

Four 2nd Half of Life Developmental Phases [Human Potential Phases] • Liberation Phase [Mid-50s to Mid-70s] • Developmental impetus– internal drive for liberation, experimentation, and innovation • Typically occurring in 60s to early 70s • Creative endeavors are charged with the added energy of a new degree of personal freedom that comes both psychologically from within us, and externally through retirement • Creative expression often includes translating a feeling of “If not now, when?” into action. • People tend to feel comfortable about themselves by this time • A new comfort level for experimentation and innovation • Retirement often provides a new feeling of finally having time to try something new • New comfort and confidence is accompanied by a desire to do the right thing and a feeling of “what can they do to me?”

Four 2nd Half of Life Developmental Phases [Human Potential Phases] • Summing-Up Phase [Late-60s into the 90s] • Developmental impetus– internal drive for recapitulation, resolution, contribution • Typically occurring in 70s and older • The desire to find larger meaning in the story of their lives through a process of looking back, summing-up, and giving back • Creative expression includes a recapitulation and review of one’s life through personal story-telling, memoirs, and autobiography. • Wanting to contribute to society---volunteerism, community activism, philanthropy • Reflection on what remains unresolved or unfinished

Four 2nd Half of Life Developmental Phases [Human Potential Phases] • Encore Phase [Late-70s to the end of life cycle] • Developmental impetus– internal drive for reflection, continuation, and celebration of self, family, community, culture, and spirituality • Typically during late-70s, becoming more pronounced during one’s 80s to the end of life • Plans and actions are shaped by the desire to restate and reaffirm major themes in one’s life, but also to explore novel variations on those themes. • Continues to be motivated by life’s energy and the audience of others. • Celebrate one’s place in family, community, and in the spiritual realm • Celebratory reunions promote solidarity by bringing families together

Medical Assessment of the Elderly Psychiatric Patient • Medical issues are important considerations in the management of the elderly person with mental illness. • Acute illnesses and chronic comorbidities may be confused with psychiatric disease, exacerbate behavioral symptoms, or interfere with therapy. • Any abrupt changes in an older person’s mental or physical health is a problem, and is due to a disease or external factors and should NOTbe considered as part of normal aging.

Medical Assessment of the Elderly Psychiatric Patient • Often, the problems are the result of multiple rather than single causes. • It is important for older people to have a thorough medical and neurological evaluation when psychiatric problems present acutely. • Importance of close attention to details of the patient’s history, which may uncover the existence of a medical problem. • Attention to physical examination and screening laboratory tests.

Medical Assessment of the Elderly Psychiatric Patient • As individuals grow older, maintaining social independence, functional mobility, and cognitive abilities becoming increasingly important. • Functional decline is often the presenting symptom of medical illness in older people, and in some instances, may be the only symptom. • Functional assessment must be part of the evaluation of any geriatric patient. • Good health in old age entails the maintenance of optimal function, stability in chronic disease, and adequate support systems.

Common Medical Illnesses in the Elderly Diseases Prevalence 53% 52% 50% 42% 35% 30% 25% 25% 24% 23% • Eye diseases [cataracts, glaucoma] • Hypertension • Arthritis • Dementia • Cerebral vascular dse. • Coronary artery dse. • Peripheral vascular dse • Diabetes mellitus • Ear disease [hearing loss] • Depression/anxiety

Medical History—History of Present Illness • Be aware of the atypical presentation of illness common in the elderly. • Falls, incontinence, or functional loss can be the initial sign of an underlying illness, and may be the only sign. • Geriatric syndromes!!!- • Visual /hearing impairment, dementia, delirium, depression, frailty, gait impairment • May be the only sign of an underlying depression or delirium • Psychiatrist should view the onset of geriatric syndrome as a flag, warranting further cognitive and behavioral assessment.

Medical History—History of Present Illness • Get the list of medications!!! • Rx for daily and as needed medicines • Over-the-counter medications, vitamin and nutritional supplements, herbal preparations • Ask the px what she uses of pain; any sleeping pills? • Use of alcohol?

Medical History—Past Medical History, Family Hx • Past operations/Confinements • Occurrence of delirium during hospital stays or after surgery? • Family history • Presence of longevity, neurodegenerative diseases e.g. dementias, parkinson’s; mood d/o

Medical History—Social History • Living environment • Living independently? Assisted living? • Capability to continue this arrangement? • Driving? • Is home environment safe? Safe access to the bathroom? Are there stairs? • Living environment suitable for his disability?

Medical History—SocialHistory • Support systems • Do patients have family who can give support? • Friends and other social supports they can see on a regular basis? • Religious or spiritual guidance? Attend regular church/worship? • Involvement in social, civic, or religious groups? • Experience of significant losses of family and friends who provided support? How have the losses impacted mood and level of functioning? • Good relationship between the px and identified caregiver? Neglect or abuse? • If no family, what other resources are available for px to maintain independence? Nursing home be considered?

Medical History—SocialHistory • Daily Activities • What does the person do with his time? • “What do you do all day?” • “What is your typical day?” • Is px still employed • Are the involved in other activities • What did px enjoy doing in the past? • Is px able to see and hear well enough to enjoy reading, television, radio, etc?

Functional Assessment • Assessment of independent functional status-- IADLs & ADLs • This is essential because impairment cannot be predicted by the number or severity of medical diagnoses in an individual patient. • Identifying functional impairments allows the clinician to attempt to modify those factors that may contribute to any disability and can affect other treatment decisions. • Impairments in ability to purchase or cook food, or even to feed oneself, can have enormous nutritional consequences. • Impairments in ADLs have also been identified as risk factors for falls and institutionalization

Physical Examination • First impressions are telling. • Observations of grip strength when shaking hands • Deformities, skin rash, or pallor • Muscle tremor • Speech character and content • Use of eyeglasses, hearing aids • Use of cane or walker • Mobility, gait • Vital signs • Addition of pain

Neurological Exam • Testing of mental status, vision, hearing • Falls are a serious problem among older adults, with potentially devastating consequences, including institutionalization and death • Test the gait and balance---let px walk • Posture, pace, steps, arm swing, turn, • Do romberg’s maneuver [testing px’s balance] • Stand with eyes closed and arms held out in front of the body • Test postural reflexes • Tap px from the back and ask px to keep his balance

Neurological Exam • Test for cognition • Mini-Mental Status Examination • 30 items • Orientation- 5; Immediate recall- 3; attention and calculation- 5; delayed recall- 3; language- 9 • Draw a clock [Clock-drawing test]

Outline of Lecture I. Geriatric Psychiatry definition and History II. Second Half of Life Developmental Phases III.Medical Assessment of the Elderly Psychiatric Patient IV. Common Psychiatric Illnesses of Old Age V. Management

Common Psychiatric Illnesses in the Elderly • 1. Depression • 2. Delirium • 3. Dementia

Depression in Old Age • There are many faces of depression in the elderly. • Devoid of classic signs and symptoms of depression • Very common • One of the most most underdiagnosed conditions in old age • Often inadequately treated

I am depressed… ASK… “What do you mean by depressed?”

Major Depression-- Criteria • 5 or more of the symptoms: • 1. 2- week period • 2. Change from previous functioning • 3. Clinically significant impairment in social or occupational functioning

Major Depression-- Criteria • Depressed mood • Anhedonia (loss of interest) • Appetite change/weight change • Sleep disturbance • Psychomotor agitation or retardation • Feeling of worthlessness or guilty • Poor concentration • Suicidal thoughts

Major Depression-- Lack of Recognition? • Reluctance to acknowledge symptoms • Symptoms may mislead clinicians • Fatigue may be seen as medical problem • Sleep difficulty seen as primary problem • Depression seen as “normal reaction.” • Functional disability regarded as inevitable

Depression: Red Flags!!! • 1. Persistently low mood • 2. Disinterest in previously pleasurable activities • 3. Low energy/lethargy • 4. Clear change from previous disposition • 5. Interferes in daily functioning

Language of Depression in the Elderly • True or false? • Growing older causes mental disease. It is not possible to live to a ripe old age without having experienced significant mental disorder of any kind.

False • Growing older does NOT cause mental disease. • It is possible to grow old without experiencing significant mental disorder • REMEMBER!!! Depression or any other mental conditions are NOT part of the normal aging process.

Language of Depression in the Elderly • “I am a little bit down…” • I have been feeling a bit sad since my wife died…” • “I have been worried lately…” • Physical and somaticnature of complaint: • Multiple pains [headache, neck tension, backache] • Preoccupied with bowel functions or gastrointestinal complaints [constipation, sense of bloatedness] • Unexplained health worries • Prominent cognitive symptoms [memory and concentration problems] • Fatigue/tires easily; interrupted sleep; loss of appetite

Language of Depression in the Elderly • Social withdrawal or avoidance of social interaction • Prominent loss of interest and pleasure [anhedonia] • Irritability without subjective complaints of sadness • Concurrent experience of nervousness • Signs of functional impairment or otherwise unexplained functional decline • Expressing a sense of helplessness or hopelessness • Expressing a sense of emptiness • Expressing feelings of uselessness

Geriatric Psychiatry