Aging & Geriatric Psychiatry ppt presentation

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

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

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.

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)

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.

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.

• (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

• (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.

• (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.

• (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.

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.
(a) Rate of living
(b)Waste product accumulation
(c) Macromolecule cross-linkage
(d)Post-synthetic modification
(e) Free radical damage

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

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.

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

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.

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.

• 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

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

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

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.

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.

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.

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

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

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).

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.

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.

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.

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).

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

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.

• 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.

• 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.

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.

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.

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

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.

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.

Behavioural and
psychological symptoms of dementia

Treatment of dementia
• Non-pharmacological treatment of behavioural
and psychological symptoms

Treatment of dementia
• Pharmacological treatment of behavioural and
psychological symptoms

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

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.

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.

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

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.

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

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.

REFERENCES
• Shorter Oxford Textbook of Psychiatry 7th edition
• Sadock BJ. Sadock VA. Comprehensive Textbook of Psychiatry 10
Ed. Vol 1 & 2. Lippincott William and Wilkins
• New Oxford Textbook of Psychiatry 2ND 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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