psychological issues in elderly
DESCRIPTION
theories of ageing and psychological disorders in elderlyTRANSCRIPT
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Psychology of ageing
Dr. DOHA RASHEEDY ALYLecturer of Geriatric Medicine
Department of Geriatric and GerontologyAin Shams University
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Ageing
Aging is a process of general, irreversible, and progressive physical deterioration that occurs over time.
This process usually occurs after sexual maturation and continues up to the time of maximum longevity (life span) for members of a species.
Death is the final event.
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Biologically, ageing is defined as a
deteriorative process. Socially too, ageing appears as a time of loss
of roles and relationships. Thus it is not surprising that consideration of
adjustment should have such a prominent role in the psychological study of ageing.
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Definition(Conceptual)
Normal Ageing without biological or mental pathology
Optimal Ageing’ Successful ageing’ Ageing under development enhancing and
age-friendly environmental conditions Pathological Ageing
Ageing process determined by pathological processes.
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Conceptions of Age
Chronological age—number of years elapsed since person’s birth
Biological age—age in terms of biological health
Psychological age—individual’s adaptive capacities
Social age—social roles and expectations related to person’s age
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Normal ageing
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Theories of ageing
Aging processes occur at the biological, psychological and social levels. There are any number of different theories of aging, which are generally specific to each discipline. The truth is, no one is really certain why we age, although we are beginning to identify different processes which regulate or govern the rate of aging.
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Psychological Theories of ageing
Life span Selective optimization:
Socioemotional selectivity
Cognition and aging
Personality and aging
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Life Span Development Theory
Life-Course Theories ·Erikson's developmental stages, which here
approaches maturity as a process. Within each stage the person faces a crisis or dilemma that the person must resolve to move forward to the next stage, or not resolve which results in incomplete development
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Psychological Theories of ageing
Life span
Selective optimization:
Socioemotional selectivity
Cognition and aging
Personality and aging
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Selective Optimization WithCompensation Theory
Optimization = Engagement in behaviors that will enrich ones life and help people age successfully.
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Psychological Theories of ageing
Life span
Selective optimization:
Socioemotional selectivity
Cognition and aging
Personality and aging
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Socioemotional Selectivity Theory
The theory that social exchanges and interactions are reduced over time.
As one ages a person may become more selective with whom they choose to spend their time with. Emotional closeness may become more important with significant others. The idea to which one can selectively choose with whom they want to dedicate their time for becomes more important as ones ages. * (quality verses quantity)
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Psychological Theories of ageing
Life span
Selective optimization:
Socioemotional selectivity
Cognition and aging
Personality and aging
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Cognitive and Aging Theories
“The theory of cognition is the age-related decline in fluid cognitive performance (the efficiency or effectiveness of performing tasks of learning, memory, reasoning and spatial abilities.) However, crystallized abilities are more stable across the life span and may even increase with age. (Representing social cultural influences on general world knowledge)”. (Bonder, 2009)
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Cognitive and Aging Theories
Cognitive changes with aging are well documented and affect a broad range of functions. There are at least three fundamental cognitive-processing affected: the speed at which information can be processed, working memory, and sensory and perceptual skill.
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Perhaps the most predictable of all cognitive
changes is the reduced speed of information processing and response. Slowed execution of component perceptual and mental operations can affect attention, memory, and decision making and can influence performance even on tasks that have no obvious speed requirements (Salthouse 1996).
Processing Speed
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Working memory refers to short-term retention and manipulation
of information held in conscious memory, Examples include consciously recalling a telephone number long enough to write it down, mentally calculating the sale price of an item that is reduced by 15%. Information fades from working memory within about 2 seconds, so to keep details “alive” for a longer time requires active rehearsal or continuing refocusing of attention.
Aging is associated with a decline in working memory skills, especially when active manipulation of information is required (e.g., repeating numbers backward as opposed to forward). Reductions in working memory, in turn, place limits on other complex cognitive skills, including reasoning and other executive processes, and learning and recall of new information
Working Memory
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Most older adults experience decrements in visual
and auditory acuity and other perceptual changes. Some, but not all, of the age-related visual changes can be corrected by glasses, and although hearing aids help with detection of low-frequency tones, they often amplify background noise. In effect, many older adults find it hard to hear or see well, especially with competing background noise and poor lighting conditions.
Recent studies suggest a strong correlative link between sensory and perceptual changes and cognitive performance in old age
Sensory and Perceptual Changes
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These changes increase the likelihood of
processing overload in circumstances that may have once presented little challenge.
In advanced old age, even basic activities such as walking or maintaining postural control become less automatic, with the result that older persons must devote more conscious cognitive resources to these activities.
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Genetic factors About 50% of cognitive variability in old age can be traced to genetic factors.
Health Optimally healthy elderly persons outperform those with medical illnesses on many cognitive tests.
Education Education accounts for up to 30% of cognitive variability in old age. Mental activity Mentally stimulating activities correlate with higher cognitive performance
and reduced longitudinal decline. Physical activity Aerobic fitness is associated with better cognitive performance in old age. Expertise Aging experts may develop compensatory strategies to maintain a high level of
performance despite some erosion in underlying cognitive skills. Personality and mood Depression correlates with self-perceived memory failure and with
performance impairments if symptoms are severe. Social and cultural milieu Everyday memory lapses may be judged more critically when
experienced by older people than by young adults. Cognitive training Cognitively unimpaired older persons benefit from practice and training
in specific cognitive skills. Sex differences Cognitive aging trends are similar for the two sexes, but women may show
decrements on spatial tasks at an earlier age than men, and men may show decrements on verbal tasks at an earlier age than women.
Racial and ethnic differences Performance differences favoring elderly white persons have been reported on some cognitive tests, but when education is equated across groups, these differences are reduced or eliminated.
moderating variables
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Psychological Theories of ageing
Life span
Selective optimization:
Socioemotional selectivity
Cognition and aging
Personality and aging
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Personality & Aging Theories
Theories focus on the nature and extent of personality stability and how they change over a persons life span.
Developmental Explanations and Personality Trait Explanations based on the “big five”:
1) neuroticism 2) extroversion 3) openness to experience 4) agreeableness 5) conscientiousness
Many believe that personality traits are more stable later in life whereas “goals, values, coping styles and control beliefs” are more that likely to change. (Bonder, 2009)
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Personality and emotions have not been studied as thoroughly as
cognition in old age. Moreover, it is unknown whether observations about personality made within the confines of a particular generation and culture can be generalized to other places and times.
Core features of personality remain stable throughout adulthood, and any marked change in mood or social behavior may indicate a disorder. However, more subtle reordering of personal priorities and shifts in coping styles are common with normal aging. It is particularly important not to measure older people’s coping by youthful standards.
Emotion-focused coping may be a sign of personality development rather than regression, particularly if the problem being faced (e.g., bereavement or serious illness) is difficult to resolve through action.
Personality and Emotional Changes
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In one study comparing the emotions of younger to
older people, volunteers were asked to state how often in the previous year they had experienced each of 46 different emotions. The results showed that older people experience stronger direct feelings of anxiety in the form of fear or being scared, whereas younger people tend to experience more guilt-related anxiety.
Older people also report fewer experiences of depression, hostility or shyness. So, the overall structure of emotion between older and younger people seems similar, but the strength the relationship and frequency of emotional experience does differ.
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It appears that older people do experience less intense
emotions. It may also help to explain why they find the emotional dysregulation of early stage Alzheimer's so troubling. In some situations the elderly may show very little or no emotion where some might be expected; in other situations they may be moved to tears in a display of emotion that may seem out of place.
Variation in emotional pattern is something that needs to be considered in any assessment of the elderly by younger people. Caution against using phrases such as, 'flattened affect', or 'emotionally labile', should be exercised in the realization that what is being observed is, in fact, perfectly normal.
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1. Adjust to declining health & physical strength.2. Adjust to retirement & reduced income.3. Adjust to the death of a spouse or family
members.4. Adjust to living arrangements different from
what they are accustomed.5. Adjust to pleasures of aging i.e. increased
leisure & playing with grandchildren
Hanighurst stated that for older people to progress they must meet the following tasks
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Psycho-Social Theories of Aging
Disengagement Theory
Activity Theory
Continuity Theory
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Disengagement Theory
developed by Cummings and Henry in late 1950’s.
“aging is an inevitable, mutual withdrawal or disengagement, resulting in decreased interaction between the aging person and others in the social system he/she belongs to.”
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Activity Theory
developed by Robert Havighurst in the 1960’s. supports the maintenance of regular activities, roles,
and social pursuits. persons who achieve optimal age are those who stay
active. as roles change, the individual finds substitute
activities for these roles.
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Continuity Theory
proposed by Havighurst and co-workers in reaction to the disengagement theory
“basic personality, attitudes, and behaviors remain constant throughout the life span”
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Psychopathology
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Developing psychopathology(Psychodynamic models)
Busse & Pfeiffer 1969: Loss people, roles, physical capacity, opportunity. (nb depression is no greater in elderly)
Gutmann 1992: losses in later life re-enact losses in childhood
Vaillant 1993:Immature defence mechanisms provide insufficient defence against problems of old age
Gutmann 1992: loss of physical, cognitive, emotional strengths undermine functioning of ego.
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• Stressors faced by older people
• Mediators shaping a person’s response to stress
• Moderators that act on the stressor to lessen its intensity or buffer its effect
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Demands that call forth a physiologic, behavioral, or emotional response
TYPES OF STRESSORS: Chronic
May be health-related (eg, the pain and mobility limitation of arthritis)
May be psychologic (eg, the prolonged worry over a chronically ill spouse)
Acute May be health-related (eg, a newly diagnosed medical condition)
May be psychologic (eg, experiencing the unexpected death of a close friend
Stressors
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Caregiving Loss and Grief Role Loss ( spouse , friends, work) and Acquisition
(Grandparenthood and great-grandparenthood) provide both new demands and opportunities.
Social Status Changes in social identity: due to role loss in
retirement Losses in physical capacity and reserve Functional losses may place older persons in help-
seeking rather than help-providing roles
Examples OF STRESSORS
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The internal and external resources a person can
bring to bear to:
Assess and interpret a stressor
Assess his or her capacities for addressing it
Formulate a coping response
Often modifiable through interventions such as psychoeducation and family counseling
Mediators
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SELF-EFFICACY BELIEFS: Sense of one’s own ability to manage situations.
Strong self-efficacy beliefs: Contribute to good choice-making, good performance, and persistence of effort (especially
in women)
Contribute to increased productivity
COPING STRATEGIESCommon coping strategy: selection, optimization, compensation
Elderly select activities based on what they already do well
They do the selected activities more often and derive optimal credit for doing them
As performance diminishes, they employ compensatory strategies to put remaining capacities in the best light possible
SOCIAL INVOLVEMENT: there is an association between lack of social involvement and affective disorders such as depression.
Types of Mediators
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Behaviors or components of a person’s life that affect
the demands of stressors
May be in place before the onset of a stressor or may be developed in response to it
Three major types: Social involvement
Spiritual or religious activity
Engaging in healthy lifestyle behaviors
MODERATORS (Buffer)
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Coping with Psychosocial Changes & Developmental
Crises
Support System Community Resources Counseling Prayer/Religion
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Spirituality and Religiosity
These concepts are frequently confused.
Studies have found that nurses tend to avoid addressing spiritual needs of patients.
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Spirituality is the:
“totality of man’s inner resources, the ultimate concerns around which all
other values are focused, the central philosophy of life that guides
conduct, and the meaning-giving center of human
life which influences all individual and social behavior” (Moberg, 1979)
“trust & faith in a power greater than oneself”
(levin &
Taylor, 1997)
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Religion is:
only one aspect of spirituality; an organized practice of beliefs; may or may not fill an individual’s spiritual
needs eg. spiritual needs are much broader & more personal than any particular religious persuasion
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THANK YOU
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Ageing and mental disorder
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Ageing and mental disorder
Mental illness is not a manifestation of ageing
Approximately 88% of people over the age of 65 do not suffer from mental disorder
Excluding cognitive impairment means that people over the age of 65 have the lowest prevalence of mental disorder by age group.
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Mood disordersAnxiety disordersPsychotic disordersPersonality disorders
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Depression
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Is depression a
normal response to the aging process?
NO
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EPIDEMIOLOGY
Prevalence over 65▫1.4% ♀▫0.4% ♂▫1% overall▫Higher in institutional setting: Up to 25-40% in a general hospital setting and in long term care
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Depression is under-reported: WHY?
Communication issues (eg. hearing impairment) Presence of dementia
Symptom overlap Stigma of aging
Depression is “normal” Symptoms “masked” by co-morbid illness
THEREFORE YOU MUST SCREEN IN THOSE AT HIGHER RISK!
Geriatric Depression Rating Scale
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What are risk factors for depression in
the elderly?
Recently bereaved Female gender Single/widowed (recently) Stressful life events (eg. prolonged hospitalization,
recent move to nursing home) Social isolation Persistent complaints of memory difficulties, diagnosis
of dementia Chronic disabling illness or recent major physical illness
(eg. Parkinson’s disease, stroke) Chronic sleep problems or anxiety
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Does depression look different in the elderly?
• “Depressed mood” may be less prominent• More anxiety• More likely to express somatic complaints▫ 65% have hypochondriacal symptoms• Less likely to report guilt feelings• Cognitive impairment more common• Psychosis more common▫ Typical delusions – more common Somatic, persecution, nihilism, poverty
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•5 or more symptoms lasting >2 wk, change from previous functioning:▫ Depressed mood and/or loss of interest▫ Altered sleep, loss of energy, appetite
change or weight loss, feelings of worthlessness/guilt,psychomotor changes, loss of concentration and focus, recurrent thoughts of death
DSM-IV DIAGNOSTIC CRITERIA
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• Autoimmune• Cerebrovascular • Chronic pain• Degenerative Disease• Endocrine• Metabolic• Neoplasms• Infections
Medical Conditions Mask or Cause Depression
• DRUGS▫ Propranolol▫ Cimetidine▫ Clonidine▫ Benzodiazepines▫ Steroids▫ Tamoxifen▫ Many more...
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About 50% of patients develop depression Useful treatment includes TCA’s ECT helps depression and PD sx’s:
tremors, rigidity, & bradykinesia improved with 3-4 sessions
depression improved after 7-9 sessions
Depression &Parkinson’s Disease
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Presents with:
insomnia fatigue agitation psychomotor retardation decreased interest & energy concentration problems
50% of AD pt’s have depressive sx’s (15-20% with major depression)
Depression in Early Alzheimer’s
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Cerebrovascular disease can precipitate or
perpetuate depression Caused by ischemia (“silent strokes”) in
prefrontal cortex and basal ganglia; motor & sensory deficits usu. not found.
Marked apathy Lack of insight into depression Less depressed ideation Executive dysfunction Treatment resistance
Vascular Depression
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“dementia of depression” cognitive decline that clears if depression is
treated however, dementia rate in these patients is
still 20%/year even after full recovery of intellectual function.
Pseudodementia
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25% of all completed suicides are > 65 Suicide rate for depressed men over 65 is 5
times higher than for younger men 20% of older people who committed suicide
saw a physician that day Increased risk: financial problems, physical
illness, recent loss, abuse, isolation
SUICIDE IS A REAL RISK
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1-History: Recent symptom profile Recent changes/ how long? Past psychiatric history Past medical history Current medications Any recent medication changes
ASSESSMENT
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Social history/ Personal history(include interests
and hobbies) Functional ability/level of care Any recent changes in ADL’s / IADL’s Any stressors (past/new)2-Screening tool: Geriatric Depression Rating Scale Mini- Mental Status Exam3-medical work-up (includes blood work, urines,
CT Scan, X-Rays etc..)
ASSESSMENT
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Seek out medical illness Recognize medical side effects Rehab services to maximize remaining
function and retrain impaired iADL’s Involve family and caretakers Counselling: role transitions, grief,
dependency Medications / ECT
INTERVENTIONS
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Select based on symptoms, prior response,
concurrent illness, side effect profile Reassess after 4-6 weeks:
Increase dose, augment with second agent, add psychotherapy
Consider psychiatric consult/referral
MEDICAL THERAPY IN GERIATRIC DEPRESSION
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Start at half the dose of younger people Aim to reach an average dose at one month
Guidelines for Starting Antidepressants:
“Start low, go slow”
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Change if: No improvement in symptoms after at least 4 weeks at
maximum tolerated or recommended dose Insufficient improvement after 8 weeks at maximum
tolerated or recommended dose
When recovery is incomplete after an adequate trial, consider: Further 4 weeks of treatment, with or without
augmentation (meds or psychotherapy) Switching to another antidepressant
When switching, it is safe to reduce the first medication while starting the alternate (cross-over titration)
Consider specific interaction profiles
Guidelines for Switching Antidepressants
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Long-term Treatment Guidelines:
After 1st episode continue to treat for at least a year Monitor for recurrence up to 2 years Medication discontinuation should be slow (over months) Patients with partial resolution of symptoms, more than 2
episodes, severe or difficult to treat depression, or treatment requiring ECT, should receive indefinite treatment
Treatment response in nursing home patients should be evaluated monthly after initial improvement, and at quarterly care conferences and annual assessment once remission is achieved
Consider tolerance of treatment versus risks of discontinuation
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Too many side effects: Older TCA’s:
amitriptyline, clomipramine, doxepin, imipramine, protriptyline, trimipramine
MAOI’s: phenelzine, tranylcypromine
ANTIDEPRESSANTS TO AVIOD IN THE ELDERLY
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PROGNOSIS?
Similar response rates to younger patients
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Counseling Electro-convulsive therapy (ECT) Support Groups Day Hospital Treatment programs Social/ Community groups Combination of medications and above items Volunteer work Hobbies Pet therapy
Other Treatments
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Music therapy Humor therapy Reminiscence Depression education Bereavement therapy
Other Treatments
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Relatively safe (complication rate 1 in 1400
treatments, mortality rate 1 in 10,000) Effective - about 80% respond, although this drops
to 50% if all other modalities have been tried Particularly useful for active suicidal ideation,
psychotic depression, Parkinson’s-related depression, and for medication failures
Very effective short term, but with high relapse rates over next 6-12 months.
Drug therapy can reduce relapse
Electroconvulsive Therapy
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Cognitive-behavioral therapy (CBT), problem-
solving therapy (PST), and interpersonal psychotherapy (IPT) are effective treatments for major depression either alone or in combination with pharmacotherapy.
PSYCHOTHERAPY
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Personality disorders
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There is no clear answer to the question of whether or not
personality changes with age. Several studies have demonstrated remarkable stability of
personality factors with aging. Others have shown age-related changes in certain personality traits, including decreases in extraversion and an increase in harm-avoidance.
It is possible that the apparent stability of personality with age relates to genetic factors and environmental stability. The changes reported in some studies may reflect adaptations to changing life-roles, medical co-morbidity and social circumstances. The issue is complex, as changes in behavior do not necessarily reflect shifts in personality.
Ageing & Personality
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personality disorders as persistent, pervasive
patterns of inner experience and behaviour that begin in childhood or adolescence, continue into adulthood and are stable over time.
These disorders manifest in cognitive, affective and behavioural patterns that deviate markedly from cultural norms and lead to distress or impairment.
None of the instruments for assessment of personality disorder have been validated for use in elderly.
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Cross-sectional studies of personality disorder in old age suggest that there is a lower prevalence of cluster B disorders and a higher prevalence of cluster C disorders.
However, some suggest that features of borderline personality disorder are relatively dormant in middle life and re-emerge in old age.
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Anxiety disorder
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Determining the epidemiology and prevalence of
anxiety disorders in old age is complicated by the fact that anxiety is a symptom of most psychiatric and many medical conditions in old age.
Classes of Anxiety Disorders Panic Disorder Phobic Disorders Obsessive-Compulsive Disorder Posttraumatic Stress Disorder Generalized Anxiety Disorder
Anxiety disorder
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Medical comorbidity
Difficulty in differentiating anxiety from depression
Falsely high scores on anxiety rating scales due to cardiac and respiratory problems
Tendency of older patients to resist psychiatric evaluation
ASSESSMENT DIFFICULTIES
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Slide 93
PANIC DISORDER Panic attack:
Acute, discrete episode of intense anxiety
Reaction to some perceived threat
Lasts between a few minutes and a half hour
Symptoms may include:
Trembling, dizziness, sweating, nausea
Accelerated heart rate, chest pain, shortness of breath
Sense of detachment from surroundings
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Slide 94
DIAGNOSIS OF PANIC DISORDER Recurrent and unpredictable panic attacks
Have occurred for at least 1 month
Patient spends time in worried anticipation of possible recurrence
Onset after age 55: Fewer panic symptoms Less avoidance Lower score on somatization measures Less likely to persist into old age
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Slide 95
SPECIFIC PHOBIA Involves a distinct trigger, such as a specific person,
animal, place, object, event, or situation that results in symptoms of anxiety
Commonly, the patient’s anxiety level increases instantly when the feared trigger is encountered
Patient is able to identify this fear as unrealistic and unsupported, even though the cognitive and physiologic responses persist
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Slide 96
SOCIAL PHOBIA Fear of reactions that are embarrassing in social
situations, such as:
Trembling, Blushing, Sweating profusely
Feared situations include:
Giving public speeches, Socializing with others at a function or party
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Slide 97
OBSESSIVE-COMPULSIVE DISORDER
Obsessions: persistent thoughts or ideas that come to mind in a particular situation
Compulsions: behaviors performed in an effort to decrease the anxiety experienced as a result of the obsessions
Chronic and often disabling
New onset in late life is unlikelycommonly associated with a depressive syndrome or early dementia
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Slide 98
POSTTRAUMATIC STRESS DISORDER
Common symptoms:
Re-experiencing of the traumatic event
Avoidance of associated stimuli (both cognitively and behaviorally)
Hyperarousal (eg, difficulty falling or staying asleep,
Often comorbid with depression, panic disorder, and substance abuse
Diagnosis requires presence of symptoms for 1 month and clinically significant distress or functional impairment
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Slide 99
GENERALIZED ANXIETY DISORDER
Distinctive symptoms: Feeling easily tired Muscle tension Trouble sleeping through the night Difficulty concentrating on a task Feeling irritable or on edge
Diagnosis requires: Presence of symptoms for at least 6 months Sense that one cannot control the anxiety
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Slide 100
COMORBIDITY
Mixed Anxiety and Depression
Anxiety and Agitation in Dementia
Anxiety and Medical Disorders
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Pharmacological Antidepressants are probably the treatment of choice. Studies in older adults are
limited but citalopram and venlafaxine have been shown to be effective and well tolerated.
Benzodiazepines are effective in treating the symptoms of anxiety but at the cost of confusion, sedation, falls, tolerance and dependence. Use of benzodiazepines is limited to low doses for short periods and is generally avoided.
Buspirone has been shown to be effective in the treatment of GAD and does not cause sedation or dependence. It may be less effective than antidepressants in the treatment of anxiety. Response delayed for 2-4 wks.
Beta-blockers are sometimes prescribed to treat the physiological symptoms of anxiety.but in elderly patients the benefit is likely to be outweighed by the risk of side effects.
Management
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CBT is effective in elderly patients. but less so
than in younger adults. Nondirective supportive therapy may be as
effective as CBT in the elderly.
Non-pharmacological
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Psychotic disorders
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Hallucinations are abnormal perceptions that
can affect any of the 5 sensory modalities (auditory, visual, tactile, olfactory, gustatory)
Delusions are false fixed believes that can be: Suspicious (paranoid) Grandiose Somatic Self-blaming Hopeless
PSYCHOTIC SYMPTOMS
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Delirium Dementia Delusional disorder Primary mood disorder and Schizoaffective disorder Schizophrenia Temporal lobe epilepsy Medications Isolated Suspiciousness Syndromes of Isolated Hallucinations
Charles Bonnet Syndrome Organic Hallucinations
Differential diagnosis PERSON WITH PSYCHOTIC SYMPTOMS
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Only after other causes are excluded should the
diagnosis of a schizophrenia-like state be made
Delirium, most often superimposed on an underlying dementia, is the most common cause of new-onset psychosis in late life
• Next, consider a primary mood disorder
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Hallucinations, particularly visual
hallucinations, can be a symptom of delirium, even when it is mild
Onset is usually acute, and there is often an identifiable metabolic or infectious cause
Mental status examination reveals: Multiple cognitive impairments
Diminished or waxing and waning level of consciousness
PSYCHOTIC SYMPTOMS IN DELIRIUM
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Delusions are “mood congruent”
In patients with depression: Delusional content usually reflects self-
deprecation, self-blame, hopelessness, or the conviction of ill health
In patients with mania: Delusions are grandiose.
PSYCHOTIC SYMPTOMS IN
MOOD DISORDER
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Patients with dementia experience both
hallucinations and delusions Usually less complex than the delusions seen in
schizophrenia or mood disorder
Common delusions in dementia: Belief that one’s belongings have been stolen
Conviction that one is being persecuted
Belief that one’s spouse is unfaithful
PSYCHOTIC SYMPTOMS IN DEMENTIA
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Suspiciousness is a personality trait (common
to all humans but varying in its prominence)
May become more common in those 65
Distinguished from psychotic disorders by: The understandable nature of the ideas (for
example, excessive worry about safety)
The absence of other psychotic symptoms
ISOLATED SUSPICIOUSNESS
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The criteria for this syndrome are:
Visual impairment
Visual hallucinations
Partially or fully intact insight (the patient is aware that the perceptions cannot be real but still reports that they appear absolutely real and vivid)
Lack of evidence of brain disease or other psychiatric disorder
Affects 10%–13% of patients w/ bilateral acuity <20/60
Reassure the patient that the hallucinations are a sign of eye disease, not mental illness
CHARLES BONNET SYNDROME
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Chronic psychiatric disorder characterized by both
positive and negative symptoms
Examples of positive symptoms: Hallucinations
Delusions
Thought disorder
Examples of negative symptoms: Social dilapidation
Apathy
Exclude mood disorder and cognitive disorder
SCHIZOPHRENIA
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Onset after age 44
Female:male ratio ranges from 5:1 to 10:1
Prominent persecutory (paranoid) delusions and multimodal hallucinations
Differences from early-onset schizophrenia: Much lower incidence of thought disorder
Personality often intact
SCHIZOPHRENIA-LIKESYNDROMES OF LATE LIFE
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Unlike individuals with early-onset schizophrenia,
many persons with late-onset schizophrenia-like psychosis have been able to: hold responsible jobs work efficiently
But premorbid symptoms are common: Isolation “Schizoid” (socially isolated personality) traits
For that reason, can be confused with frontotemporal dementia (formerly called Pick’s disease)
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Establish trusting therapeutic relationship
Empathize with distress caused by symptoms
Encourage patient to maintain important relationships
Ask permission to discuss source of symptoms with close family members or friends
NONPHARMACOLOGIC TREATMENT OF LATE-ONSET SCHIZOPHRENIA
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Antipsychotic drugs are as effective in late-onset
schizophrenia as in early-onset cases
Increase dose semiweekly or weekly, as needed Responders should continue for at least 6 months
For patients who relapse on treatment or when the dose is lowered, maintain treatment for at least 1 to 2 years
Monitor for extrapyramidal side effects (EPS), such as tremor, dystonic reactions, and bradykinesia Avoid polypharmacy by reducing or switching medication
rather than adding a medication for EPS
PHARMACOLOGIC TREATMENT OF LATE-ONSET SCHIZOPHRENIA
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