Geriatric Psychiatry

Psychiatric Problems of Older Persons

  • Loss is ubiquitous in old age, yet prevalence of major depressive disorder (MDD) and dysthymia is lower than in younger adults

    • Proposed reasons

    • Rarity of late-onset depression

    • Higher mortality among depressed persons

    • Fewer disorders precipitated by emotional upheaval or substance abuse

  • Presentation of depression differs

    • Prominent physical complaints or cognitive changes → may mimic dementia

  • Suicide incidence in elders: 40/100{,}000 (highest in older White men)

    • Survivors’ attributions differ by gender of decedent

    • Male suicide → assumed physical illness

    • Female suicide → assumed mental illness

  • Close link between physical & mental health

    • Emotional problems worsen the course of chronic medical illness

Mental Disorders of Old Age (ECA Findings)

  • Most common: depressive disorders, cognitive disorders, phobias, alcohol use disorders

  • High risk for

    • Suicide

    • Drug-induced psychiatric symptoms

  • Many disorders are preventable, reversible, or ameliorable, esp. delirium & some dementias

Neuropsychological Evaluation in Elders

  • Comprehensive battery preferred, though multi-hour testing may be impractical

  • Domains & representative tests

    • Gross cognition: Mini-Mental State Examination (MMSE)

    • Intelligence: WAIS-R / WAIS-III

    • Basic attention: WAIS Digit Span

    • Processing speed: WAIS Digit Symbol, Trailmaking A, Stroop A/B

    • Motor dexterity: Finger tapping (right & left)

    • Language: Boston Naming Test; WAIS Vocabulary

    • Visual–perceptual/spatial: WAIS Picture Completion, Block Design; Rey–Osterrieth copy; Beery VMI

    • Learning & memory: 8- to 10-word list; WMS Logical Memory & Visual Reproduction; Rey–Osterrieth recall

    • Executive functions: Trailmaking B; Stroop C; Wisconsin Card Sorting; Verbal fluency (FAS/category); Design fluency

Psychosocial & Pharmacological Risk Factors

  • Psychosocial risks: loss of roles/autonomy, bereavement, health decline, isolation, finances, ↓ cognition

  • Drug-induced symptoms caused by

    • Age-related pharmacokinetic changes

    • Excess dose / non-adherence / poly-prescribing

    • Hypersensitivity

  • Nearly entire spectrum of psychiatric disorders can be drug-induced

Dementing Disorders

  • Second only to arthritis as a cause of disability >65 y

    • Prevalence ≥65 y: severe dementia 5\%; mild 15\%

    • ≥80 y: severe \approx 20\%

  • Risk factors: age, family history, female sex

  • Clinical picture

    • Gradual loss of previously attained functions

    • Cognitive, memory, language, visuospatial deficits; behavioral issues (agitation, wandering, disinhibition, sleep issues, delusions/hallucinations in \approx 75\%)

  • Potentially treatable in 10\text{–}15\% (e.g.

    • Systemic: heart, renal, CHF

    • Endocrine: hypo-thyroid

    • Vit.

    • Drug misuse

    • Depression)

  • Cortical vs. subcortical classification

    • Subcortical: Huntington, Parkinson, NPH, vascular, Wilson → movement disorders, gait apraxia, apathy, akinetic mutism (may mimic catatonia)

    • Cortical: Alzheimer, CJD, Pick → aphasia, agnosia, apraxia

  • Prion diseases

    • Familial CJD, Gerstmann–Sträussler–Scheinker, fatal familial insomnia (AD inheritance, PRNP mutation)

    • Acquired: kuru (Fore cannibalism), iatrogenic (grafts, cadaveric hormones)

    • Sporadic CJD: \approx 1/1{,}000{,}000 annually; mean onset 65 y; rare <30 y

Depressive Disorders in the Elderly

  • Prevalence: \approx 15\% of community & nursing-home elders have depressive symptoms

  • Risk factors: widowhood, chronic medical illness (age per se not a risk)

  • High recurrence in late-onset cases

  • Symptoms: ↓ energy/concentration, sleep fragmentation (esp. early awakening), ↓ appetite, weight loss, somatic focus

  • Melancholic features more common: hypochondriasis, worthlessness, sex/sin guilt, paranoia, suicidality

  • Depression-related cognitive dysfunction (“pseudodementia”)

    • Occurs in \approx 15\% of depressed elders

    • Distinguish from degenerative dementia

    • Variable attention; “I don’t know” responses; recognition > free recall; minimal language impairment/confabulation

    • Yet 25\text{–}50\% of neurodegenerative dementia patients are concurrently depressed

  • Geriatric Depression Scale (15-item short form); score >5 ⇒ probable depression

Schizophrenia

  • Typically begins in youth; first diagnosis >65 y rare

  • Late-onset (after 45 y) described; more common in women; predominantly paranoid subtype

  • Prognosis

    • 20\% symptom-free by 65 y

    • 80\% residual impairment; psychopathology diminishes with age

    • Residual subtype in \approx 30\% (negative symptoms dominate) → often requires long-term hospitalization

  • Elders respond to antipsychotics but need lower doses

Delusional Disorder

  • Onset usually 40–55 y but possible at any geriatric age

  • Forms

    • Persecutory (most common): spying, poisoning, harassment → potential violence or reclusiveness

    • Somatic: conviction of fatal illness

  • Prevalence of pervasive persecutory ideation >65 y: \approx 4\%

  • Triggers: spousal death, retirement, isolation, finance, medical illness, sensory loss

  • Rule out dementia, mood disorders, schizophrenia, substance/med-induced, tumors

  • Prognosis fair–good; best with psychotherapy + pharmacotherapy

  • Paraphrenia: late-onset persecutory delusions (>60 y) without dementia; possibly schizophrenia variant; ↑ if FHx schizophrenia

Anxiety Disorders

  • 1-month prevalence ≥65 y: 5.5\% (ECA)

    • Phobias: 4\text{–}8\% (most common)

    • Panic disorder: 1\% (new-onset rare)

  • Impact: milder signs yet equally or more disabling due to mobility limits

  • Existential factors: confronting mortality; Erikson’s integrity vs. despair

  • PTSD more severe owing to comorbid physical illness

Obsessive-Compulsive Disorders

  • OCD may first appear in late life, though many had obsessive-compulsive personality traits earlier

  • Features: ego-dystonic rituals/obsessions → rigidity, checking, orderliness

Somatic Symptom Disorders

  • Somatic complaints common: >80\% of >65 y have ≥1 chronic illness (arthritis, CV disease)

    • After 75 y: 20\% have diabetes; average 4 chronic conditions

  • Hypochondriasis prevalent >60 y (peak 40–50 y); chronic, guarded prognosis

  • Management: frequent but low-risk examinations; validate pain; avoid unnecessary invasive tests; employ psychologic/pharm interventions

Alcohol & Substance Use Disorders

  • Alcohol dependence often longstanding from youth/midlife

    • Typical elder drinker: medically ill (liver), divorced/widowed/never-married male, arrests, homelessness, Wernicke–Korsakoff

  • Nursing home prevalence: 20\% alcohol dependence

  • Overall, substance disorders = 10\% of geriatric emotional problems; hypnotic, anxiolytic, narcotic dependence under-recognized

  • Presentation: confusion, poor hygiene, depression, malnutrition, falls, exposure

    • Hospital delirium → often alcohol withdrawal

    • Consider abuse in chronic GI issues

  • OTC misuse: analgesics (35 %), laxatives (30 %); nicotine, caffeine

Sleep Disorders in Late Life

  • Age is main risk factor; elders report ↓ sleep quality, ↑ daytime naps, ↑ hypnotic use

  • Higher rates of

    • Breathing-related sleep disorder

    • Medication-induced movement disorders

  • Primary sleep disorders

    • Dyssomnias: primary insomnia, nocturnal myoclonus, restless legs, sleep apnea

    • Parasomnias: REM sleep behavior disorder (almost exclusively older men)

  • Contributing factors: pain, nocturia, dyspnea, GERD, lack of routine, institutionalization, alcohol

  • Pharmacologic caveats: monitor for anterograde amnesia, residual sedation, rebound insomnia, gait instability

  • Sleep architecture changes ≥65 y

    • REM: redistributed, ↑ episodes, shorter duration, ↓ total REM

    • NREM: ↓ delta amplitude, ↓ stages 3–4, ↑ stages 1–2, ↑ awakenings

    • Circadian: ↓ amplitude, 12-h sleep-propensity rhythm, shorter cycles; ↓ melatonin, altered adenosine response

Suicide Risk in the Elderly

  • Highest of any age group; white men >65 y have rate ≈5\times general population

  • Reasons reported by suicidal elders

    • \approx 33\% loneliness

    • \approx 10\% each: finances, poor health, depression

  • Demographics

    • Completions: 60\% male; attempts: 75\% female

    • Methods: completions → firearms/hanging; attempts → 70\% overdose, 20\% cutting

  • Most completers had unrecognized psychiatric disorder (mainly depression)

  • Precipitants: illness & loss (elders) vs. job/finance/family (younger)

  • Many communicate intent; clinicians must inquire directly—no evidence of iatrogenic suggestion

Other Common Geriatric Conditions

Vertigo

  • Common → activity avoidance/fear of falls

  • Etiologies: anemia, hypotension, arrhythmia, cerebrovascular, basilar insufficiency, ear disease, acoustic neuroma, benign positional vertigo, Ménière

  • Often psychological component; assess secondary gain

  • Anxiolytic overuse ⇒ dizziness

  • Tx: meclizine 25\text{–}100\,\text{mg}/day

Syncope

  • Mechanism: transient cerebral hypoperfusion → LOC

  • Requires full medical work-up

  • Causes (Table 25-6)

    • Cardiac: structural (aortic stenosis, mitral prolapse/regurgitation, HCM, myxoma); electrical (tachy-, brady-arrhythmias, block, sick sinus); ischemia/infarct

    • Situational hypotension: dehydration, orthostatic, postprandial, micturition, defecation, cough, swallow

    • Reflex: carotid sinus, vasovagal

    • Drugs: vasodilators, CCBs, diuretics, \beta-blockers

    • CNS: cerebrovascular insuff., seizures

    • Metabolic: hypoxemia, glucose extremes, anemia

    • Pulmonary: COPD, pneumonia, PE

Hearing Loss

  • Prevalence

    • ≥65 y: \approx 30\%

    • ≥75 y: \approx 50\%

  • Clue: “I can hear but not understand.” Most benefit from hearing aids

Elder Abuse

  • Affects \approx 10\% >65 y

  • Defined (AMA): act/omission causing harm/threatened harm

    • Physical, psychological, financial, material, sexual abuse; neglect (withholding necessities)

  • Victims: very old, frail, co-reside with often dependent abuser; both parties minimize

  • Interventions: legal, housing, medical, psychiatric, social services

Spousal Bereavement

  • Widowhood prevalence ≥65 y: women 51\%, men 14\%

  • Highly stressful; depressive sx peak within months, usually decline ≤1 y

  • ↑ Mortality among survivors; highest in those with psychiatric illness or spouse’s suicide

Psychopharmacological Treatment Principles

  • Goals: improve quality of life, keep patients in community, postpone nursing-home placement

  • Pre-treatment assessment: full medical exam + ECG; collect all current meds (polypharmacy)

  • Dosing guidelines

    • Divide total daily dose (3–4×) to avoid peaks (except bedtime dosing for hypnotic effect)

    • Use liquids if swallowing issues

    • Monitor BP, pulse, side-effects

    • Frequent reassessment; attempt washout & baseline re-eval when possible

  • Epidemiology of drug use

    • ≥65 y: highest medication users (25 % of Rx’s)

    • \approx 250{,}000 U.S. hospitalizations/yr from adverse drug reactions

    • Psychotropics, CV, diuretics most common; 40 % of hypnotics dispensed to >75 y

    • OTC usage: 70\% elders vs. 10\% young adults

  • Pharmacokinetic considerations

    • ↓ renal & hepatic clearance (renal, liver, CV disease)

    • ↓ gastric acid affects absorption

    • Body composition: ↓ lean, ↑ fat → prolonged action of lipid-soluble drugs

    • Altered receptor sensitivity (e.g., ↑ orthostatic hypotension)

  • Core rule: “Start low, go slow.” Use minimal effective dose; know interactions

Psychotherapy for Geriatric Patients

  • Modalities: insight-oriented, supportive, cognitive, group, family; psychoanalysis possible if appropriate

  • Targets age-related issues

    • Adapting to multiple losses (friends, roles)

    • New roles (retirement)

    • Acceptance of mortality

  • Benefits

    • ↑ interpersonal functioning, self-esteem, confidence

    • ↓ helplessness, anger; ↑ quality of life

    • Can improve physical sx (e.g., urinary incontinence, gait, alertness) even in cognitively impaired

  • Therapeutic stance

    • More active, supportive, flexible; anticipate need to liaise with physicians/family when incapacity arises

    • Elders may idealize therapist; gradual collaboration encouraged; sometimes therapist must maintain an idealized role to permit progress.