Aging & Geriatric Psychiatry ppt presentation

Aging & Geriatric Psychiatry

1. AGING & GERIATRIC PSYCHIATRY Moderator – Dr Swapna B Presenter – Dr Sujith Babu Kallan TOMCH&RC 16/02/2023

2. CONTENTS Introduction Aging & theories Epidemiological studies Principles of geriatric psychiatry Psychiatric disorders in elderly Recent advances Conclusion References

3. INTRODUCTION Older people with mental health problems present particular challenges to the practice of old age psychiatry and the organization of its services. They are often physically as well as mentally frail, and this affects presentation and course. Dementia comprises a substantial part of the clinical practice.

4. AGING The definitions of - middle age is defined as age between 44 and 60 years . “elderly” between 60 and 75 years “long-livers” over age 90. With increasing longevity, the timetable for brain aging has changed as well. - World health organization (WHO)

5. AGING The growth of the older population during the 20th century is attributable to several factors. In the latter half of the last century, the greater longevity resulted primarily from an increase in average life span, that is, adults lived longer as a result of declines in mortality from pneumonia, heart disease, and other chronic diseases.

6. Genomic Theories of ageing Genomic theories premise that ageing is primarily associated with changes in the genetic constitution of the organism. Support for genomic theories stems largely from the characteristic life expectancies of mammalian and non-mammalian species. Theories proposing a primarily genetic basis for ageing were strengthened by the demonstration that human diploid cells exhibited a highly reproducible lifespan when cultured in the laboratory.

7. Genomic Theories of ageing (a) Information transfer With increasing chronological age the probability of transcription and translation errors increases, resulting in the accumulation of deleterious mutations late in life. (b) Somatic mutation Age-related physiological changes were ascribed to accumulated mutations in the nuclear DNA ( nDNA ) of somatic cells

8. Genomic Theories of ageing (c) Epigenetic mechanisms Epigenetic errors, i.e. errors in the control of gene expression rather than mutations in DNA or protein, have been proposed as major primary causal factors in senescence. The pattern of DNA methylation is established during development and is cell type-specific, and changes in methylation can occur both during ageing and in cancer cells.

9. Genomic Theories of ageing (d) Mitochondrial decline The central role of mitochondria in energy production means that defects may be of major metabolic significance, and the demonstration of increased levels of mtDNA deletions and base-substitutions in aged human neurons, heart, and skeletal muscle suggest a causative role for mtDNA mutations in ageing.

10. Genomic Theories of ageing (e) Telomere loss The enzyme telomerase which is responsible for telomere synthesis is active during early embryonic and foetal development but its activity is down-regulated in all human somatic cells before birth. The rate of telomere loss with ageing varies between chromosomes and there is evidence that, in addition to the common human telomere profile, each person exhibits an individual profile.

11. Stochastic theories of ageing Stochastic theories of ageing propose that cumulative adverse random changes at the cellular level ultimately overwhelm the capacity of an organism to survive, with ageing representing the preceding period of functional decline. Rate of living Waste product accumulation Macromolecule cross-linkage Post-synthetic modification Free radical damage

12. EPIDEMIOLOGICAL STUDIES A French population study of people aged 65 years and over found a point prevalence of 14% for anxiety disorder, 11% for phobia, 3% for major depression, and 1.7% for psychosis , using an interview to make DSM-IV diagnoses (Ritchie et al., 2004). Other surveys have shown a high prevalence of psychiatric disorder among older people in sheltered accommodation and in hospital. One-third of the residents in old people’s homes have significant cognitive impairment. In general hospital wards, between one-third and half of the patients aged 65 years or over have some form of psychiatric illness

13. EPIDEMIOLOGICAL STUDIES

14. EPIDEMIOLOGICAL STUDIES The prevalence of dementia rises continuously in old age, approximately doubling every 5 years, reaching 45% in those aged 95 or older. Rates of delirium rise from 1–2% to at least 14% in those over 85 years of age.

15. EPIDEMIOLOGICAL STUDIES

16. Principles of geriatric psychiatry An international consensus statement defined the essential elements of a mental health service for older people as follows (Wertheimer, 1997): primary health care team specialist old age psychiatry team inpatient unit rehabilitation daycare availability of respite care range of residential care facilities family and social supports liaison with geriatric medicine education of health care providers about the needs of older people with psychiatric problems

17. Abuse and neglect of the elderly Abuse and neglect of the elderly by family members, caretakers, or acquaintances, raises the importance of safeguarding awareness for all health care professionals working with the elderly. Its psychiatric relevance arises in part from the finding that people with dementia are particularly likely to be abused.

18. Abuse and neglect of the elderly Elder abuse This term refers to actions by a carer or other trusted person that cause harm or create a serious risk of harm to an elderly person (whether or not harm is intended), or to failure by a caregiver to satisfy the elderly person’s basic needs or protect them from harm. The term ‘elder maltreatment’ is also used.

19. Abuse and neglect of the elderly Five forms of elder abuse are recognized—physical, psychological, sexual, financial, and neglect. Prevalence rates of 2–10% are reported, with a higher risk if: the abused person has dementia the carer and the abused person live together the abused person is socially isolated (e.g. lacks close friends) the carer has a psychiatric disorder or misuses alcohol the carer is heavily dependent (e.g. financially) on the person who is being abused

20. Psychiatric disorders in the elderly Depressive disorder in the elderly Bipolar disorder in the elderly Anxiety disorders in the elderly Schizophrenia-like disorders in the elderly Personality disorder in the elderly Dementia Delirium in elderly

21. Depressive disorders in the elderly Avasthi, Ajit; Grover, Sandeep. Clinical Practice Guidelines for Management of Depression in Elderly. Indian Journal of Psychiatry 60(Suppl 3):p S341-S362, February 2018. | DOI: 10.4103/0019-5545.224474

22. Clinical features and treatment of psychiatric disorders in the elderly Depressive disorder in the elderly One-third of depressed elderly patients have severe retardation or agitation. A recent study reported that hypochondriasis and somatic symptoms were more common. Depression may be masked by other symptoms, like hypochondriacal complaints. Psychotic depression in the elderly has a greater overall severity and more prominent hypochondriacal delusions.

23. Depressive pseudodementia Some depressed elderly patients present with ‘pseudodementia’— they have conspicuous difficulty with concentration and remembering, but there is no major defect of memory. Differentiation of these patients from those with early dementia is important and can be difficult. Depressive pseudodementia is a strong predictor of subsequent dementia.

24. Depressive pseudodementia Features that suggest depressive pseudodementia include the following: The patient’s complaint of memory disturbance tends to be greater than the informant’s account of memory problems in everyday life. Depressive symptoms that pre-dated the memory difficulties. ‘Don’t know’ responses and poor involvement with neuropsychological tests (these features are characteristic). A personal or family history of mood disorder.

25. Depressive disorder in the elderly - ETIOLOGY The major etiology for depression in late life is related to vascular factors. Alexopoulos et al. (1997) coined the term ‘vascular depression’. There is now diverse evidence for a multifaceted and bidirectional relationship between late-life depression and vascular disease. Meta-analysis shows that cardiovascular disease, diabetes, stroke, and a composite vascular risk score are all significant risk factors for depression in the elderly. Hypertension, smoking, and dyslipidemia are not

26. Depressive disorder in the elderly - TREATMENT SSRIs are preferred to tricyclic antidepressants because of their lower risk to cause side effects and cardiotoxicity. For patients who do not respond to the maximum tolerated dose of an antidepressant, it may be necessary to use a combination of drugs, or to combine medication with psychological treatment. ECT is appropriate for depressive disorder with severe and distressing agitation, suicidal ideas and behaviour , life-threatening stupor, or failure to respond to drugs

27. Depressive disorder in the elderly - TREATMENT Factors that predict a good prognosis for depression in old age include the following: onset before the age of 70 years short duration of illness good previous adjustment the absence of disabling physical illness good recovery from previous episodes religiosity (self-reported faith, or belonging to a religious group).

28. Empty Nest Syndrome Empty Nest Syndrome(ENS) has been a term that used in psychology for the past five decades. It is a term used to describe the long-lasting maladaptive responses exhibited by parents once their last child moves out of their household and thereby leaves the two middle aged / aging parents alone at home. These responses include depression, sadness, anxiety, guilt, somatic symptoms, anger, resentment, irritability, frustration and loneliness. Badiani F, De Sousa A. The empty nest syndrome: Critical clinical considerations. Indian Journal of Mental Health. 2016;3(2):135-42.

29. Empty Nest Syndrome Sometimes these responses may be the start of a major psychopathology like major depressive disorder, anxiety disorders and rarely a psychotic reaction. This syndrome has often been compared to post-partum depression as parents face loss of their children as well as loss of reproductive roles of mothering or fathering a child. Badiani F, De Sousa A. The empty nest syndrome: Critical clinical considerations. Indian Journal of Mental Health. 2016;3(2):135-42 .

30. Empty Nest Syndrome It is believed that women are more likely to suffer from the ENS It is not recognized as a psychiatric disorder in any classification system followed worldwide but is rather viewed as a transition life epoch that many people undergo. Badiane F, De Sousa A. The empty nest syndrome: Critical clinical considerations. Indian Journal of Mental Health. 2016;3(2):135-42 .

31. Bipolar disorder in the elderly A 1990, study of mania in old age, found that a depressive episode immediately after the manic episode occurs more frequently in elderly. Mixed affective episodes are more common than in younger patients. A history of bipolar disorder appears to increase the risk of dementia. Lithium prophylaxis remains valuable, but blood levels should be monitored with particular care and kept at the lower end of the therapeutic range (0.4–0.6 mmol/l).

32. Anxiety disorders in the elderly Symptoms of anxiety disorders among the elderly are often non-specific, with features of both anxiety and depression. Hypochondriacal symptoms may be prominent. Personality disorder is a predisposing factor, while physical illness and life events such as retirement or a change of accommodation may act as precipitants. A first onset of panic attacks in an elderly person should always prompt a search for an underlying physical or depressive disorder. The approach to treatment is with a preference for psychological and behavioral interventions. In practice, medication is often prescribed first-line, and should be done cautiously

33. Schizophrenia-like disorders in the elderly

34. Schizophrenia-like disorders in the elderly A history of schizophrenia is associated with a threefold increase in risk of dementia at age 65 years, with a lesser but still significant increased risk at older ages. All elderly patients who present with a first onset of schizophrenia-like features should be assessed carefully to exclude a delirium, dementia, or organic psychosis due to a neurological or medical disorder such as neurosyphilis, HIV, or neoplasm.

35. Schizophrenia-like disorders in the elderly ETIOLOGY Familial aggregation is much less common. There is no familial association with neurodegenerative or cerebrovascular disorders. Schizoid or paranoid personality traits are common in older people who develop late onset psychotic disorders. Deafness is also a risk factor.

36. Schizophrenia-like disorders in the elderly Antipsychotic medication is the mainstay of treatment of late-onset schizophrenia. Lower doses (10–20% of a ‘normal’ dose) are often sufficient. Cautious use of antipsychotic medication is required due to the risk of tardive dyskinesia. Atypical antipsychotics probably have a lower risk of tardive dyskinesia than do typical antipsychotics in this age group, but recent concerns that they may increase cerebrovascular events in the elderly.

37. Personality disorder in the elderly Some personality traits and disorders attenuate with age, while others remain or become exaggerated. The decline is mainly attributable to a decline in Cluster B personality disorders, whereas obsessive–compulsive and schizoid characteristics may become more prominent . Schizoid or paranoid traits may become accentuated by the social isolation of old age, sometimes to the extent of being mistaken for a delusional disorder or schizophrenia.

38. DEMENTIA Dementia is an acquired global impairment of intellect, memory, and personality, but without impairment of consciousness. It is usually but not always progressive. The syndrome of dementia is caused by a wide range of diseases, but the majority of cases are due to Alzheimer’s disease, which is the commonest cause, followed by vascular dementia and dementia with Lewy bodies. Only a small proportion of cases are currently potentially reversible.

39. DEMENTIA Although dementia is a global or generalized disorder, it often begins with focal cognitive or behavioural disturbances. ICD-10 requires impairment in two or more cognitive domains (memory, language, abstract thinking and judgement, praxis, visuoperceptual skills, personality, and social conduct), sufficient to interfere with social or occupational functioning. Deficits may be too mild or circumscribed to fulfil this definition, and are then called mild cognitive impairment

40. DEMENTIA

41. DEMENTIA

42. DEMENTIA

43. DEMENTIA

44. DEMENTIA

45. DEMENTIA

46. ALZHEIMERS DISEASE In 1907, Alois Alzheimer reported the case of Auguste D, a woman with presenile dementia whose brain exhibited unusual neuropathological features. It was Alzheimer’s colleague, Emil Kraepelin, who named the disease. For many years the disease was thought to be rare and limited to presenile forms of dementia, but classic studies suggested that it is the commonest cause of senile dementia. About 60% of dementia is attributable to Alzheimer’s disease.

47. ALZHEIMERS DISEASE

48. ALZHEIMERS DISEASE

49. ALZHEIMERS DISEASE

50. VASCULAR DEMENTIA Vascular dementia is said to be the second commonest cause of dementia after Alzheimer’s disease. Onset is usually in the late sixties or the seventies. With large-vessel disease, onset is often relatively acute and follows a stroke, in which case the term post-stroke dementia is used. Emotional and personality changes may appear first, followed by impairments of memory and intellect that characteristically progress in stages. Depression is frequent, and episodes of emotional lability and confusion are common, especially at night.

51. VASCULAR DEMENTIA

52. LEWY BODY DEMENTIA

53. LEWY BODY DEMENTIA

54. Behavioural and psychological symptoms of dementia

55. Treatment of dementia Non-pharmacological treatment of behavioural and psychological symptoms

56. Treatment of dementia Pharmacological treatment of behavioural and psychological symptoms

57. Drug treatment of Alzheimer’s disease Cholinesterase inhibitors The drugs currently available are donepezil, rivastigmine, and galantamine. NMDA-type glutamate receptor antagonist Memantine

58. Delirium in the elderly Delirium is the result of an interaction between individual vulnerability factors (e.g. brain disease, sensory impairment) and external insults (e.g. physical illness, medication), the rates of which both increase with age. In vulnerable elderly patients relatively mild physical, psychological, or environmental upsets may be sufficient to bring about acute disturbances of mental functioning. Delirium in elderly patients is frequently missed or misdiagnosed as dementia or depression by medical and nursing staff.

59. Delirium in the elderly

60. Delirium in the elderly- MANAGEMENT Address the underlying causes Behavioural control – The drug treatment of the symptoms and behaviour of delirium in the elderly is similar to that of younger patients, although it is necessary to start with lower doses, such as haloperidol 0.5 to 2 mg orally, or intramuscularly if necessary, repeated until the disturbance is controlled.

61. Delirium in the elderly- MANAGEMENT Prescriptions should be for short periods only (up to 24 h) to encourage review of the effects and the necessary dosage. Once the delirium has resolved, the medication should be reduced/discontinued over a period of 3 to 5 days. Prevent/treat complication Rehabilitation and family support

62. RECENT ADVANCES Several anti-amyloid agents have been and are being investigated as treatments for Alzheimer’s disease, (aducanumab is currently under FDA review). Amyloid and tau PET radiotracers are available to aid the diagnosis of Alzheimer’s disease. Promising agents under investigation for treatment of neuropsychiatric symptoms of dementia include pimavanserin , brexpiprazole , escitalopram, mirtazapine, dextromethorphan/quinidine formulations, lithium and gabapentin.

63. RECENT ADVANCES Esketamine , although approved by the FDA for use in general adults, failed to demonstrate efficacy in phase 3 trial specifically conducted in elderly patients with treatment-resistant depression. There is preliminary evidence that psychedelics may be beneficial in the treatment of end of life and cancer-related depression and anxiety. Evidence for the therapeutic use of cannabinoids in the elderly

64. CONCLUSION In the elderly, there is interplay between biological, psychological, and social issues in the presentation of mental illness. Thorough evaluation, including assessment of the patient’s internal and external environment, is necessary for accurate diagnosis and treatment. In neuropsychiatric disorders, localization of signs and symptoms should also be attempted to improve understanding of the patient’s condition and to improve clinical management.

65. REFERENCES Shorter Oxford Textbook of Psychiatry 7 th edition Sadock BJ. Sadock VA. Comprehensive Textbook of Psychiatry 10 Ed. Vol 1 & 2. Lippincott William and Wilkins New Oxford Textbook of Psychiatry 2 ND edition Avasthi, Ajit; Grover, Sandeep. Clinical Practice Guidelines for Management of Depression in Elderly. Indian Journal of Psychiatry 60(Suppl 3):p S341-S362, February 2018. | DOI: 10.4103/0019-5545.224474 Badiane F, De Sousa A. The empty nest syndrome: Critical clinical considerations. Indian Journal of Mental Health. 2016;3(2):135-42. Awais Aftab, Jeffrey A. Lam, Fred Liu, Anjan Ghosh & Martha Sajatovic (2021) Recent developments in geriatric psychopharmacology, Expert Review of Clinical Pharmacology, 14:3, 341-355, DOI: 10.1080/17512433.2021.1882848

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