Psycho-geriatrics

1. Common things
a. Anxiety 25%
b. Depression 25%
c. Sleep problem 25%
d. Dementia 15%
e. Excess alcohol use 20%
f. Psychosis 6%
g. Schizophrenia 3%
h. Delusional disorder 0.03%
2. 3 topics
a. Delirium
b. Dementia
c. Depression
3. Delirium
a. Could have dementia & delirium
b. Symptoms
i. Fluctuating awareness & attention
ii. Cognitive changes
iii. Develop in short time, acute
iv. psychiatric presentation of medical issue (yelling) only sign!!
v. Differential UTI/ bed sore/ temperature/pain
c. Risk factor for dementia
d. Cholinergic + dopamine + serotonin
e. Management
i. Pharmacological Treat underlying cause
1. Haloperidol 0.25mg ON or 0.5mg
2. Quetiapine
3. Risperidone 0.25mg or 0.5mg
4. Atypical neuroleptics
ii. Non-pharmacologicalReorientate
4. Depression
a. Common
b. Under-diagnosed (subtle presentation, somatic symptoms) & under-
treated
c. Source (sense of loss, expectation, compare)
d. Scale Geriatric Depression Scale(30, 15 items 8/15)
e. Causes- bio, psy, social
f. Causes of secondary depression
i. Head trauma
ii. Infection
iii. CVA, CHF, MI
iv. Metabolic disturbance
v. Thyroid
g. Iatrogenic depression
i. Benzodiazepine
ii. Cardiac & antihypertensive drug
iii. Stimulant and appetite suppressant
iv. Steroid
 v. Antibiotics
vi. Antineoplastic agent
h. Risk factor
i. Female
ii. Widow
iii. Medical illness
iv. Functional disability
v. Family or personal history
vi. Social isolation
vii. Life events
viii. Drugs
ix. Caregiving (careres of people with dementaia)
i. Peculiar featues
i. Minimisation of sadness
ii. Somatization (disproportionate complaints a/w physical disorder)
iii. Trivial act of deliberate self-harm
iv. Pseudodementia (depression p/w dementia)
v. Depression superimposed on dementia
j. Consequences
i. Poor comorbidity control
ii. Suicide
iii. Dementia
k. Why suicide rate higher in elderly than adult
i. Frail
ii. More determined;
iii. Ways of suicide is more fatal/ highly-lethal
iv. Impulsive- just dont know and suddenly did that (should not ask
about plan!!)
l. How to assess whether the person is safe from suicide
i. Changes in mindset (What had changed in past two weeks?)
(What if ur husband did that? Do u think of other more lethal
ways? Have u ever put into ur familys shoes)
ii. Coping
m. Elderly suicide completers
i. 80% had major sychiatric disorder
n. Key question
i. Any major changes in ur lfie in preceding 3 months?
ii. Have u thought u would be better off dead?
iii. Any important health changes within the past year?
o. Assessment of suicidal risk
i. Planning
ii. Preparation
iii. Precaution against recovery
iv. Finl rite
v. Verbal cues
vi. Suicide
p. Drugs
i. SSRI
ii. TCA-good but dangerous (suicide lapse)
iii. ECT
 q. When to refer
i. When diagnosis in doubt
ii. When depression is severe (psychotic, not eating, suicide)
r. Psychotherapy
i. CBT= T, M, B
ii. IPT=medical model of depression
iii. 4areas
s. Patient contact
i. Empathic
ii. Therapeutic alliance
iii. Assess safety issue
5. Dementing disorder
a. Memory impairment
i. Aphasia
ii. Apraxia
iii. Agnosia
iv. Excetive functioning
b. Prevalence in Malaysia- increased- live to get dementia
c. 3 causes
i. Alzheimiers (mixed)
ii. Vascular dementia (mixed)
iii. Lewy body dementia
d. Risk factor
i. Age
ii. Genetic (PS1 and PS2, APP, apoE)
iii. Female
iv. Family history
v. Head trauma
vi. Low education
vii. Cardiovascular dysfunction
e. Amyloid (protein)
i. Beta amyloid deposition
ii. Microglial activation
iii. Neurofibrillary tangles (collection of junk cause
inflammation)(Tau=normal protin tostabilise microtubule)
iv. Neuronal loss/ neurochemical changes
v. Dementia
f. Management
i. Anti-cholinergic end stage
1. Benapasel (once daily)
2. Patch
3. Rivastigmine (patch- better release!!)
4. Memantine ()
ii. NMDA receptor prex2 a dayvent glutsamte excitoticity]
g. 10 warning signs
i. Memory
ii. Changes in mood & behavior
iii. Changes in personality
iv. Misplace things
v. Loss of initiative
 h. Investigation
i. Neuropsychological teslonger than MMSEt)
ii. Neuroimaging
1. Age<60
2. Duration >2 years
3. Unexplained neurological symptoms
4. Sudden onset of rapid decline
i. Behavioural psychological symptoms of demntia
i. Delusion people steal things//not my home//spuse is an
imposter//
ii. Hallucination vivid small people Lewy body)
iii. Apathy & depression==? Need to distinguish
1. Cholinestherase=> apathy
2. SSSROi
3. Antipsychotic is not good but no choice use carefully
4.
6. Cognitive impairment screening
a. Not used routinely
b. Quick test
i. 3 words recall
ii. Clock drawing test
iii. Namig animal
iv. Mini COG
c. Labile frontal lobe
7. Lewy body
a. Visuospatial impairment//
b. PE= parkinson symdrome
c. Sensitive to antipsychotic!!--> can kill
8. Sleep disorder
a. Screen for depression
b. Wake up early (ask what time sleep)
c. Less deep sleep wake up easy
d. Management (sleep hygiene sleeping pill)
i. No coffee, caffeine drink
ii. Get out of bed if cant sleep for 15 min
iii. Do something with no visual stimulation (read, listen music)
iv. Sleeping pill max 4 weeks
9. Anxiety disorder
a. SSRI (Fluoxetine is sedating), not benzodiazepine
10.Drug interaction