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.