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Geriatric Psychiatry
Anita S. Kablinger MD
Associate Professor
Psychiatry and
Pharmacology
Objectives:
Differentiate between the various
cognitive disorders
Know aspects of normal aging
Gain knowledge of the best treatment
options for geriatric psychiatric illnesses
Why is it a subspecialty?
Mental disorders may have different
manifestations, pathogenesis, and
pathophysiology from younger adults
Coexisting chronic medical illness
More medicines
Cognitive impairments
Increased risk for social stressors,
including retirement and widowhood
Geriatric population
increasing
2000, estimated that 1 in 5 Americans
were over 55 years of age, and 13% over
65 years of age
By 2050, estimates are that 22% will be
over the age of 65, and 5% over age 85.
Aging and the Life Cycle
(Erickson)
Young adulthood--intimacy versus
isolation
Middle-aged--generativity versus selfabsorption
Elderly--Integrity versus despair
(Acceptance of mortality, satisfaction with
one’s meaning in the world)
Fear of death is usually a mid-life issue
Other tasks of elderly
Reminiscence is normative
Loss
On-time normative incidents do not
usually result in crisis
Fears are usually pain, disability,
abandonment, and dependency
Cognition and aging
Cognition includes learning, memory, &
intelligence
Learning is the ability to gain new skills
and information. It may be slower in
elderly, especially verbal learning.
Cognition and aging
(continued)
 Memory is divided into immediate, shortand long- term memory. Immediate
memory remains intact.
Short-term memory is also intact,
however, it is affected by concentration
which may be less in older adults.
Long-term memory is most affected by
aging. Retrieval is less efficient; the
elderly need more cues
Intelligence
Ability to use information in an adaptive
way or to apply knowledge to specific
circumstances
Crystallized intelligence includes
vocabulary, verbal skills, and general
information can continue to increase
throughout life.
Fluid intelligence consists of recognizing
new patterns and creative problem
solving. This peaks in adolescence.
Benign senescent
forgetfulness
Age associated mild memory problems.
May also have cognitive problems due to
anxiety.
Examples are forgetting names,
misplacing items, and experiencing
difficulty with complex problem-solving.
(aging-associated cognitive decline)
Psychiatric Evaluation
See patient alone to assess for
suicidal/homicidal ideation even if
cognitively impaired
May need info from caretaker
May take extended time due to slower
response time
Other important aspects of
history
Family history--Alzheimer’s disease is
transmitted as an autosomal dominant
trait in 10-30% of the offspring of parents
with Alzheimer’s disease
Review of all meds, over the counter,
prescribed, herbal
Alcohol and substance abuse history
MSE
General description
mood, feelings, affect
witzelsucht is caused by frontal lobe
dysfunction and is the tendency to make
puns and jokes and laugh aloud at them
MSE (continued)
perceptual disturbances
may be transitory resulting from decreased
sensory acuity
types of agnosia (the inability to recognize
and interpret the significance of sensory
impressions: the denial of illness
(anosognosia), the denial of a body part
(atopognosia); or the inability to recognize
objects (visual agnosia) or faces
(prosopagnosia)
MSE (continued)
Language output
nonfluent or Broca’s aphasia--understanding
intact but can not speak, speech may be
telegraphic
fluent or Wernicke’s aphasia
global aphasia
ideomotor apraxia--can not demonstrate use
of simple objects
Visuospatial functioning--some decline is
normal with age
MMSE affected by
educational level
median score for 9-12 yrs of school is 26,
high school diploma 28
less sensitive in those with high
intelligence, and less specific with those
below average intelligence
Neuropsychological
Assessment
MMSE is not used to make a formal diagnosis
WAIS-R vocabulary holds up with age.
Performance part is a more sensitive indicator of
brain damage than the verbal part.
Depression can impair psychomotor
performance, especially visuospatial functioning
and timed motor performance. The Geriatric
Depression Scale is a useful screening
instrument that excludes somatic complaints
from its list of items.
Mental Disorders of old
age
Most common: depressive disorders,
cognitive disorders, phobias, and alcohol
use.
High risk of suicide
Risk factors include loss of social roles,
loss of autonomy, deaths, declining
health, increased isolation, financial
constraints, and decreased cognitive
functioning.
Cognitive Disorders
Include:
Delirium
Dementia
Amnestic Disorders
Psychiatric disorders due to a Medical
Condition
Postconcussion Syndrome
Replaces the term “organic disorders”
Note that major psychiatric illnesses may
also have changes in cognition, but they
are not called cognitive disorders
Delirium
Usually acute and fluctuating
Altered state of consciousness (reduced
awareness of and ability to respond to the
environment)
Cognitive deficits in attention,
concentration, thinking, memory, and
goal-directed behavior are almost always
present
Features of delirium
May be accompanied by hallucinations,
illusions, emotional lability, alterations in
the sleep-wake cycle, psychomotor
slowing or hyperactivity
Usually abrupt
Causes of Delirium—
I WATCH DEATH
Infectious
Withdrawal
Acute metabolic
Trauma
CNS Pathology
Hypoxia
Deficiencies
Endocrinopathies
Acute vascular
Toxins/drugs
Heavy Metals
Note that prescribed medicines may cause
delirium
Treatment of delirium
Look for underlying cause “always be
suspicious”
Close supervision, especially by family
Reorient frequently
Adequate lighting
Treatment of delirium
(continued)
Use consistent personnel
Try not to use restraints, as it can worsen
confusion.
Medication only if behavioral attempts fail
Avoid polypharmacy
Low dose neuroleptic is treatment of choice,
unless the delirium is due to withdrawal. If
due to withdrawal, use a short-acting
benzodiazepine.
ICU Syndrome
May be multifactorial
Postcardiotomy delirium occurs 3 or 4
days after surgery
Changes in dementia
Cognition, memory, language
Personality change, abstract thinking,
aphasias
Visuospatial functioning
However, level of awareness and alertness
usually intact in early stages
(differentiates dementia from delirium)
Chronic, versus acute
Amnestic Disorders
Differs from delirium and dementia
because major problem is short-term
memory only.
Impairment may be due to hemorrhage in
mamillary bodies, or degenerative
changes in the dorsal medial nucleus of
the thalamus
Most common cause is alcoholism
Transient global amnesia
Transient inability to learn new info
Variable retrograde amnesia that “shrinks”
following recovery
Level of conscousness and personal identity
intact
Due to transient vascular insufficiency of the
mesial temporal lobe, or medicines, tumors,
arrhythmias, cerebral embolism
Also have risk problems for stroke
Postconcussion syndrome
Follows a history of head trauma resulting in
cerebral concussion
LOC, posttraumatic amnesia, less commonly,
post-traumatic seizures
Impairment in attention, concentration,
performing simultaneous cognitive tasks, and in
learning new information, or recalling
information shortly after the injury
Not a form of dementia
Dementing Disorders
Only arthritis more common in geriatric
population
5% have severe dementia, and 15% mild
dementia in those over 65
Over 80, 20% have severe dementia
Most common causes: Alzheimer’s
disease, vascular dementia, alcoholism,
and a combination of these 3
Risk factors are age, family history, and
female sex
Noncognitive symptoms
accompanying dementia
Mood disorders--dementia and depressive
symptoms can coexist and the depression
responds to treatment
Pathological laughter and crying occurs
Irritability and explosiveness
Other noncognitive
symptoms in dementia
Excessive emotional outbursts that occur
after task failure are “catastrophic
reactions” and can be avoided by
educating family members to avoid
confrontation
Delusions or hallucinations occur during
the course of dementias in nearly 75%
Behavior problems in
dementia
Agitation, restlessness, wandering,
violence, shouting
Social and sexual disinhibition,
impulsiveness
Sleep disturbances
Dementia and treatable
conditions
10-15% from:
heart disease, renal disease, and congestive
heart failure
endocrine disorder, vitamin deficiency,
medication misuse
primary mental disorders
Subcortical dementia
Subcortical dementias are associated with
movement disorders, gait apraxia,
psychomotor retardation, apathy, akinetic
mutism.
Alert, but slowly responsive and inactive
Not fluent in language, but comprehends
Often dysarthric, difficulty with forming
complex sentences
Difficulty with executive function
Subcortical dementia
Causes:
Huntington’s disease, Parkinson’s disease,
NPH, multi-infarct dementia, Wilson’s
disease
Cortical dementias-Ex: Alzheimer’s, CJD, and Pick’s disease
Involve aphasia, agnosia, apraxia
Fluent, moderately attentive, normally
responsive to questions, and normally
active in his environment
Human prion disease
 result from dicing mutations of the prion
protein gene and may be inherited,
acquired, or sporadic.
They include familial CJD, GerstmannStraussler-Scheinder syndrome, and fatal
familial insomnia.
Autosomal dominant
Sporadic CJD
Accounts for 85% of human prion
diseases
Occurs world-wide with a uniform
distribution and incidence of around 1 in 1
million per annum
A mean age of onset of 65
Rare in those less than 30
Dementia of the Alzheimer’s
Type (DAT)
50-60% of patients with dementia
5% of those who reach 65 have DAT
15-25% of those 85 or older
More common in women
Occupy 50% of all NH beds
DAT
General sequence is memory, language,
then visuospatial functions
Death occurs in about 7 yrs
On autopsy: neurofibrillary tangles and
neuritic plaques with an amyloid core and
deposition of amyloid in blood vessels
Involves cholinergic system arising in
basal forebrain, nucleus basalis of
Meynert--reductions in brain acetylcholine,
and the adrenergic system
DAT (Genetics)
Chromosome 21
Most severe form associated with
chromosome 14
Genetically heterogeneous disease caused
by 2 or more genes located on 2 or more
chromosomes (14, 19, 21)
Slow virus?
Deposition of aluminum
PET Scans of DAT
Decreased metabolic rate of glucose in
temporoparietal area, and in frontal
regions in more severe cases
Pick’s Disease
Slowly progressive
Focal cortical lesions, primarily frontal that
produce aphasia, apraxia, and agnosia.
Lasts 2-10 yrs., average duration 5 yrs
CJD
Usual course one year
Not associated with aging
Incidence decreases after age 60
Terminal stage: severe dementia,
generalized hypertonicity, and profound
speech disturbance
Typical burst pattern on EEG
Vascular Dementia
Second most common type
Can reduce known risk factors:
hypertension, diabetes, cigarette smoking,
and arrhythmias
Huntington’s
Basal ganglia and cerebral cortex
Progressive dementia, muscular
hypertonicity, and bizarre choreiform
movements
Death in 15-20 yrs
On the G8 fragment of chromosome 4
Screening test available
NPH
Dementia
Ataxia
Incontinence
Dementia due to
Parkinson’s Disease
Motor dysfunction, frontal lobe symptoms,
and memory deficit
Nearly 1/2 are depressed, and depression
is most common mental disturbance in
Parkinson’s
Increased risk for anxiety
Levodopa, amantadine, and bromocriptine
can cause psychosis and delirium
HIV (AIDS)-Related
Dementia
Involvement of CNS is a primary symptom
of the illness and may occur before signs
of systemic infection
In later stages may be result of fungal,
parasitic, viral, or neoplastic disease
Initial infection involves the brain-headache, bells palsy, seizures, flu
symptoms, or aseptic meningitis
Later stages may show abnormal reflexes
Other types of dementia
Multiple sclerosis is characterized by
multifocal lesions in the white matter.
May show early mood lability
Vitamin B12 deficiency--neurologic
changes may occur before megaloblastic
changes
Hypothyroidism
Wilson’s disease
Diagnostic evaluation of
dementia
B12 and folate
VDRL and FTA
CT/MRI
EEG is sensitive for delirium
Consent and counseling for HIV
Treatment of behavior
problems
Neuroleptics should not be first choice,
unless the patient is psychotic and should
be on a “prn” basis
Consider the likelihood of depression and
anxiety first
Consider using behavioral methods if at all
possible
Medicines for behavioral
problems
Valproic acid, trazodone, and buspirone
may be of benefit
BZD’s may aggravate confusion
Social Recommendations
Refer to Alzheimer’s group or other
support groups
Continue preventive care--vision, dental,
etc.
Consider caregiver stress
Drug treatment for DAT
Most current ones affect acetylcholine
Tacrine
Aricept
Exelon
Reminyl
Early intervention may prevent or slow
decline
Depression
15% of all older adult community
residences and nursing home patients
Accounts for 50% of older adult
admissions to a psychiatric facility
Age is not a risk factor, but widowhood
and chronic medical illness are
Depression
May have more somatic complaints such
as decreased energy, sleep problems,
pain, weakness, GI disturbances
Increases use of primary care medical
resources
For those with a medical condition,
depressive symptoms significantly reduce
survival
Increases risk of suicide
Depression in medical
illness
Medicines or the medical illness may
cause depression
Rule out medical causes
Use psychological symptoms such as
hopelessness, worthlessness, guilt
Pseudodementia occurs in about 15% of
depressed older patients, and 25 to 50%
of patients with dementia are depressed
Depression in older adults
May have delusions which are usually
persecutory or hypochondriacal in nature
Need treatment with both an
antidepressant and an antipsychotic
ECT may be treatment of choice
Bereavement
Normal grief starts with shock, proceeds
to preoccupation, then to resolution
May be prolonged in elderly, but consider
major depression if there is marked
psychomotor retardation, lasts over 2
months, marked impairment, or if suicidal
ideation
Bipolar Disorder
Episodes persist into old age
Do organic workup if onset is over 65
Usually more irritable than euphoric, and
paranoid rather than grandiose
May have dysphoric mania, with
pressured speech, flight of ideas, and
hyperactivity, but thought content is
morbid and pessimistic
Treatment of bipolar
Lithium is an effective treatment, but
decreased renal clearance and neurotoxic
effects may be more common
Valproic acid is also helpful for behavioral
disturbances
Schizophrenia
Usually before 45, but there is a late
onset type beginning after age 65
More likely in women
Paranoid type more common
Psychopathology less marked with age
Residual type occurs in 30% of those
affected: Emotional blunting, social
withdrawal, eccentric behavior, and
illogical thinking predominate
Delusional Disorder
Onset between 40 and 55
Persecutory or somatic delusions most
common
In one study of people older than 65, 4%
had pervasive persecutory ideation
May be precipitated by stress, loss, social
isolation , visual impairment, deafness,
immigrant status
Anxiety Disorders
Very common in elderly
May occur first time after age 60, but not
usually
Most common are phobias, especially
agoraphobia
Elderly more likely to use anxiolytics
May be due to medical causes or
depression
Somatoform Disorders
More than 30% over age 65 have at least
one chronic disease. After 75, 20% have
diabetes mellitus and an average of 4
diagnosable chronic illnesses
Hypochondriasis
Hypochondriases peak incidence in 40-50
yr range. Repeat exams, but not invasive
and high risk tests
Hypochondriasis may be a secondary
symptom of depression
Alcohol and substance
abuse
20% of nursing home patients have
alcohol dependence
Sudden onset delirium in hospitalized
patients usually from withdrawal
Consider in patients with GI problems
May misuse OTC
35% use analgesics, and 30% use
laxatives
Alcohol
Brain more sensitive as ages
Due to changes in metabolism, a given
amount may produce a higher blood
alcohol level than in a younger individual
May worsen normal changes in sleep and
sexual functioning
Interacts with other medicines
Alcohol detoxification
Use lorazepam and oxazepam if needed
for detox in elderly because of rapid
metabolism
Personality disorders
Borderline, narcissistic, and histrionic
personality disorders may become less
intense
Before diagnosing a personality disorder,
verify that it is not an improperly treated
Axis I disorder
Some personality traits may become more
pronounced
Sleep disorders
Advanced age is single most important factor
associated with increased prevalence of sleep
disorders
REM sleep behavior disorder occurs almost
exclusively among elderly men
Advanced sleep phase--go to sleep early, and
awaken during night
Alcohol can interfere with sleep
Dementia associated with more arousals,
increased stage I sleep; decreased stages 3/4
Other disorders of old age
Vertigo--antivert may be of benefit.
Usually has psychological component
Syncope
Elder abuse--about 10% over age 65
abused
Psychopharmacology
Evaluate physically first, including EKG
Bring in all meds
Should give meds 3-4 times over 24 hrs.
Washout of psychotropic meds sometimes
beneficial
Major goals are to improve quality of life,
maintain in community, and delay or avoid
nursing home placement
start at lower doses
Psychopharmacology
Watch for all drug interactions
Compliance may be a problem
Cognitive dysfunction may require help
with medication regimen
Metabolism changes
Decrease in lean body mass and total
body water
Increase in body fat, prolongs half life
Hepatic metabolism decreases, as well as
production of albumin
Decreased renal function
25% of all prescriptions
are for people over 65
40% of all hypnotics are for over 65
75% of older people use OTC
Psychostimulants
May be of benefit in depressed older
patients
Amphetamines may augment analgesia
for patients on pain meds
Antipsychotics
Used for psychosis and behavioral
disturbances
Can have side effects at lower doses
Give a 4 week trial at least
No need to use prophylactic
antiparkinsonian agents, but the risk of
EPS increases with age
Antipsychotics
Low potency agents (mellaril, thorazine)
have increased effects such as orthostatic
hypotension, sedation, cognitive
impairment
Atypicals may be of most benefit
(clozapine, olanzapine, risperidone,
quetiapine, ziprasidone, aripiprazole)
Anxiolytics
Rate of use high
May cause anterograde amnesia
May accumulate in tissues if long acting
so may increase ataxia, insomnia, and
confusion
If necessary, oxazepam and lorazepam
are drugs of choice
Buspirone may be of benefit. Takes
several weeks to work
Geriatric psychotherapy
Goals are to have minimal complaints,
make and keep friends of both sexes,
have sex if interested and capable
Grief and loss are central issues
Example: retirement and self-esteem
Group therapy directly lessens the elder’s
sense of isolation
Family support is crucial
Institutional Care
50% stay less than 3 months
Skilled nursing facilities vs. intermediatecare facilities
70% proprietary, 30% governmental
State hospitals now exclude people with
dementia
Restraints
40% nursing home patients placed in
restraints last year
Without restraints, have better muscle
tone, less rage, greater sense of mastery
Competence
Legal decision
May be competent for some procedures,
and incompetent for others
Pearls
Evaluate any change in cognition. It is
not normal
Rule out drug interactions, alcohol abuse,
or medical problems if depressed or
anxious
The dose of antidepressant that gets the
patient well is the dose that keeps the
patient well
Pearls
The elderly generally require less
medication for the same symptoms--start
low, and go slow