Mental & Psychological Problems

in Older Persons王春波醫生 Dr WONG Chun Por JP

Specialist in Geriatric Medicine

MBBS(HKU) FHKCP FHKAM(Medicine) MHA(UNSW)

MRCP(UK) FRCP(London) FRCP(Edinburgh) FRCP(Glasgow)

Outline

Normal Ageing of the Brain

Dementia

Depression

Delirium

Anxiety

Tips

Normal Ageing of the Brain

Decreased hippocampal, frontal and temporal lobe volumes – normal

Neurotransmitters and myelin sheath degenerated

Atherosclerosis of blood vessels

Degenerative plaques and tangles

Cognitive Functions

Impaired Visual and verbal memory, visuo-spatial abilities, immediate memory or the ability to generate words or name objects – normal

Impaired Control and maintenance of attention and immediate memory – normal

Memory best at 16-18 of age

Vocabulary and verbal reasoning even better at 60

Dementia 認知障礙症Alzheimer’s Disease 阿爾茲海默氏症 63%

Vascular Dementia 20%

Other degenerative diseases

Parkinson’s Disease with Dementia

B12 deficiency

Alcohol

Brain Tumor

Prevalence of Dementia

100,000 cases now

Alzheimer’s Disease

Dr Alois Alzheimer

(1864-1915)

1906 first case

Mild Cognitive Impairment

A slight but noticeable and measurable decline in cognitive abilities, including memory and thinking skills.

Changes that are serious enough to be noticed by the individuals experiencing them or to other people.

But not severe enough to interfere with daily life or independent function.

Cognitive Deficit

Executive function

Language

Working (immediate) memory

Spatial memory

Verbal memory

Impairment in Social Function

Impairment in Independent Living

Independent Living

Shopping

Managing finance

Household duties

Appropriate social behavior

Symptoms to watch for

Getting lost in familiar places

Repetitive questioning

Odd or inappropriate behaviors

Forgetfulness of recent events

Repeated falls or loss of balance

Personality changes

Decline in planning and organization

Changes in diet/eating habits

Changes in hygiene

Increased apathy

Changes in language abilities, including comprehension

Later Stage

Inappropriate outbursts of anger

Problems recognizing friends and family members

Restlessness, agitation, anxiety, tearfulness, wandering—especially in the late afternoon or at night

Hallucinations, delusions, suspiciousness or paranoia, irritability

Loss of impulse control (shown through undressing at inappropriate times or places or vulgar language)

V Late Stage

Weight loss

Seizures

Skin infections

Difficulty swallowing

Groaning, moaning, or grunting

Increased sleeping

Lack of bladder and bowel control

Drugs

Aricept

Exelon (oral and patch)

Ebixa

Reminyl

Behavioral Problem

Quetiapine

Olanzapine

Risperidone

Risk Factors

High blood pressure, diabetes, poor nutrition and social isolation are associated with a higher probability of developing a neurodegenerative condition

Heart disease

Family history of dementia

Psychological factors such as stress and depression also negatively affect the healthy aging process

Tips to prevent

Treat Hypertension, High Cholesterol, Heart Disease

Exercise your body

Stop smoking, reduce drinking

Healthy Diet

Extensive Social Network

Tips for care

Keep patient safe from accident

No arguments

Keep in comfort

Reminiscing

DepressionIn the Elderly

Outline

Depression and Ageing

Common Diseases in Elderly

Depression affecting Diseases

Diseases affecting Depression

Elderly suicide

Decreasing rate

Prevalence of elderly depressionin different care settings

Care setting Prevalence of depressive symptoms

Prevalence of major

depressive disorder

Community 15% 1-3%

Primary care 20% 10-12%

Acute hospital 20-25% 10-15%

Long term care 30-40% 16%

Risk factors for depressionin general

female gender

low education

loss of partner

cognitive decline

somatic diseases

functional impairment or disability

High Risk Groups with diseases

Current alcohol /substance-use disorder 

Specific comorbid conditions: dementia, stroke, cancer, arthritis, hip fracture, myocardial infarction, chronic obstructive pulmonary disease, and Parkinson’s disease

Functional disability (especially new functional loss)

Widow/widowers 

Caregivers 

Social isolation/absence of social support  

Diminished perception of light in one's environment 

Depression affecting Diseases

amplification of pain and disability

delayed recovery from illness and surgery

worsening of drug side effects

excess use of health services

cognitive impairment

Subnutrition

increased suicide- and nonsuicide-related death.

Somatic Disease vs Disabilities

Disability, especially disability regarding participation, self-care, or social activities is strongly related to late-life depression.

Somatic diseases in itself are less of a risk for depression, except that somatic diseases are related to disability.

Relationship was stronger for people of 60-69 years old than for those older than 70 years

Prevalence of depressionafter major disease

Depressive symptoms were prevalent in 38.3% of the subjects during the post-event year; in about 19.1%, symptoms were mild.

Risk factors: age, smoking, poor general health, poor well-being, and neuroticism. 

Drugs & Depression

Steroids

Narcotics

Sedative/hypnotics, Benzodiazepines

Antihypertensives

H2 antagonists

Beta-blockers

Antipsychotics

Immunosuppressives, Cytotoxic agents

Geriatric depression scale

Count for symptoms

Depressive symptoms

Depressed or irritable mood, frequent crying

Loss of interest, pleasure (in family, friends, hobbies, sex)

Weight loss or gain (especially loss)

Sleep disturbance (especially insomnia)

Fatigue/loss of energy

Psychomotor slowing/agitation

Diminished concentration

Feelings of worthlessness/guilt

Suicidal thoughts or attempts, hopelessness

Psychosis (i.e., delusional/paranoid thoughts, hallucinations)

History of depression, current substance abuse (especially alcohol), previous coping style

Recent losses or crises (e.g., death of spouse, friend, pet; retirement; anniversary dates; move to another residence, nursing home); change in physical health status, relationships, roles

Treatment

Drug Treatment

Psychological Counseling

DeliriumIn the Elderly

Confusion

Acute brain failure associated with autonomic dysfunction, motor dysfunction and homeostatic failure

A disturbance of consciousness that is accompanied by a change in cognition that cannot be better accounted for by a pre-existing or evolving dementia

= Acute Confusional State

Causes

Infection

Drugs

Electrolytes

Pain

Management

Treat the precipitating cause

Comfort the patient

Avoid accidents

Restraints

Chemical Sedation

AnxietyIn the Elderly

Geriatric Giant

Twice as common as dementia

4-8 x as common as major depression

Causing significant impact on the quality of life, morbidity, and mortality of older adults

10-15% of older adults

Types

General Anxiety Disorders or specific phobia 90%

Obsessive Compulsive Disorders, Post-traumatic stress and Panic attacks 10%

Cognitive Symptoms

Hyper-vigilance to threat

Seeing oneself as vulnerable

Perceiving the demands of life as exceeding the available resources to cope

Risk Factors

A lack of social supports

A recent traumatic event

Medical illnesses and medications

Poor self-rated health

Presence of another psychiatric illness (particularly another anxiety disorder or depression)

An early-onset anxiety disorder

Female gender

Physical symptoms

Restlessness

Fatigue

Muscle tension

Insomnia that interfere with social or occupational functioning

Headaches, back pain, or a rapid heartbeat

Short of breath, sweating, hot flushes, urine frequently

Worry about everything

Phobias

Persistent irrational fear of a situation, object, or activity

Desire to avoid the phobic situation

Drugs

SSRI (Selective Serotonin Reuptake Inhibitors)

Benzodiazepines

Cognitive Behavior Therapy

For children and younger adults

Conclusion

The brain is the most mysterious organ

Complex, varied, inconsistent

Need support from friends and family to persevere

Tranquility, Serenity, Peace of Mind are the most wanted gift of mankind