Points of Geriatric Psychiatry o Epidemiology n n

Points of Geriatric Psychiatry o Epidemiology n n o o Normal aging Psychiatry disorders or problems commonly seen n o Prevalence of mental disorder Barriers to mental health service utilization Dementia, depression, delirium, sleep problems, anxiety, suicide Treatment n n Pharmacotherapy, Psychotherapy Treatment models

Mental disorders among older adults--ECA community inpatients Cognitive impairment 4. 9 30. 2 Affective disorders 2. 5 18. 5 Anxiety disorders 5. 5 5. 2 Alcoholism 0. 9 2. 6 Schizophrenia 0. 1 0 Somatization 0. 1 0 Personality disorders 0 8. 3 Others 0 7. 9

Normal aging -- neuropsychiatry o Brain structure n Decrease in gross brain weight n Widened sulci, gyral atrophy, Ventricles enlarge n Increased transport across BBB n Prefrontal lobes are disproportionately affected by aging changes n Subcortical monoaminergic cell populations are subject to prominent decline in aging

Normal aging -- neuropsychiatry o Cognition n Takes longer to learn new materials n IQ remains stable until age 80 n Verbal ability maintained with age n Psychomotor speed declines n Encoding ability diminishes n Simple recall declines

Normal aging -- Sleep o Latency to sleep onset o Frequency of awakening o Total stage-3, & -4 sleep o Total stage-1, & -2 sleep o Redistribution of REM sleep

Features of Mental Problems among the elderly o Highly comorbid with n n o Complication of psychopathology n n o Medical illness Disabilities Cognitive dysfunction Distinct clinical courses Barrier to assess mental health resources

Long-term care (LTC) facilitieso 4. 13% elders in LTC facilities in 1995 o 8% of nation’s total health care costs o Mean age increased in LTC facilities o Very disabled o Options and setting becoming diverse Jones A: Vital Health Stat 13 2002: 1 -116 Gabrel C and Jones A: Vital Health Stat 13 2000: 1 -83 USA data

Barriers to geriatric mental health care o Poorly served by the mental health system n n n o Fewer visits for mental health care Rely more heavily on primary care physicians Low rate of depressive elders taking antidepressant Possible reasons n n n Stigma Low rate of case identification by primary physicians o Multiple medical illnesses divert physicians’ attention o Depression and anxiety may be viewed as normal Neglect by family

Life events o o o Death of significant others Medical ill of oneself or partner Disability Financial issues Relationship with family Retirement

Somatic Symptoms Physical Illness Depressive Disorder

Cognitive deterioration Dementia Depression (pseudodementia)

Delirium譫妄

Causes of delirium o o o Drugs and alcohol Intracranial causes Metabolic and endocrine disorders Systemic infections Postoperative states

Late life depression o o Late-onset vs. early onset Vascular depression Subsyndromal depression Depression-executive dysfunction syndrome

Suicide Increases with: age bereavement isolation deteriorating health pain Actual & attempted are closely linked

Vascular depression hypotheiss o o Subtype Vascular risk factors, neuroimaging findings More cognitively impaired, more disabled, more psychomotor retardation, less insight Disruption by vascular lesions of striato-pallodo -thalamo-cortical pathways

Medications associated with depression o Antihypertensions n n n o o Reserpine Methyldopa βblockers Oral contraceptives Steroids BZD H 2 antagonists n n Cimetidine Ranitidine o Chemotherapy n n o …. . Interferon Psychoactive substances n n n Alcohol Opiates Amphetamine withdrawal

Treatment o o Treating underlying medical conditions & reducing disability Psychopharmacology: selection depends on n n o o Side effect profiles Concurrent conditions and medications Target symptoms Previous treatment responses ECT Psychotherapy

Sleep disorders o o Lack of social or vocational activity Disturbed circadian rhythm n n o o o living in nursing home, without daily routines degenerative brain Breath related sleep disorders Alcohol or drugs induced sleep disorders Sleep related accidents

Neuropsychiatric syndrome o Post Stroke syndrome n o Depression, anxiety, apathy, psychosis, mania, emotional lability Parkinson’s disease and Parkinsonism n Depression, anxiety, mania, psychosis, drug induced psychosis

Principles of pharmacological treatment o o o Pretreatment medical evaluation Given in equally divided dose Reduced dose to 1/4~1/2 as the young need Simplified medicine Slow titration from low dose Know the interaction between medicine

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