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Mental health and Aging
Vineeth John MD MBA
Case of a new onset Bipolar Disorder
• A 60-year-old, right-handed, previously successful and
psychiatrically healthy businessman was brought by his family
to a university hospital neuropsychiatry service for
consultation regarding behavioral and personality changes.
• When he was age 55 years, his customarily excellent financial
and social judgment began to decline. Over the next 4 years,
his attention to personal hygiene deteriorated, his business
decisions became financially and ethically unsound, his range
of social interests narrowed dramatically, and he developed
an insatiable "sweet tooth."
Case of a new onset Bipolar Disorder
In the year preceding the consultation, his ability to maintain
sleep diminished, he began spending money recklessly and
impulsively and became unable to appreciate the feelings and
concerns of others, and his speech and behavior took on a
perseverative quality. Concurrently, he developed
unprovoked, brief, frequent, and excessively intense episodes
of tearfulness and laughing. These episodes lasted minutes at
most, after which he would return to his usual euthymic
emotional state.
Case of a new onset Bipolar Disorder
One month before the neuropsychiatric consultation, he had
received a diagnosis of late-onset bipolar disorder and had
begun treatment with lithium carbonate. When his serum
lithium level reached the therapeutic range, his cognitive,
behavioral, and motor function declined precipitously,
prompting the consultation for a second diagnostic opinion.
Late onset psychosis
Psychosis of Alzheimer's disease
Late onset Schizophrenia
Late life delusional disorder
Psychotic disorders secondary to General Medical
Conditions
Psychosis in AD
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Increased risk of agitation
Increase in aggression
Poor self care
Disruptive behavior
Wandering
High rate of institutionalization
Psychosis in AD
• Between 30 to 50 % of AD patients have
psychotic symptoms
• Psychotic symptoms are more prevalent as the
disease progresses but are more common in the
middle stages.
• Visual hallucinations are more common than
auditory hallucinations.
Common themes of delusions in AD
• Stealing
• Stranger in the house
• Spying
• Impersonating the spouse or loved one
Psychosis in other dementias
• Dementia of Lewy bodies -VH and Delusions
• Parkinson's Disease - Delusions and
hallucinations
• Vascular Dementia
Treatment of Psychotic Symptoms in
Dementia
• Low dose antipsychotics are the norm.
• Careful balancing of the risks and benefits
need to be performed.
Delusions in Dementia
Hallucinations in Dementia
Agitation in Dementia
Depressed Mood in Dementia
Devanand et al. Archives of General Psychiatry 1997;54(3) 257-63
Agitation in Dementia
• Treat reversible causes of agitation-UTI,
medications, alterations in renal functions,
pain and discomfort
• Behavioral Interventions
• Antipsychotic medications
• Anticonvulsants
• Acetyl Cholinesterase Inhibitors/Memantine
• SSRIs and antidepressant therapy
Factors affecting Psychosocial interventions
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Individual biography
Individual’s personality
Coexisting physical and mental health problems
Person’s social relationships
Physical environment in which the person is living
Community and cultural understandings of
tolerance for confusion and frailty
• Extent and location of the disease
Psychotherapeutic Interventions
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Behavior management training
Caregiver training
Scheduled toileting
Reminiscence therapy
Validation therapy
Supportive therapy
Reality orientation
Art therapy
Late onset Schizophrenia
• Schizophrenia is characterized by it's onset in youth
and subsequent deterioration of functionality.
• Schizophrenia after 45 years of age was considered late
onset by APA DSM III R, 1987. International consensus
panel chose 40 years as the cut off point.
• No such distinction is elaborated in DSM IV TR version.
What are the distinct features of late onset
schizophrenia?
• Lack of negative symptoms
• Lack of thought disorder
• More paranoid schizophrenia subtype
• Presence of the features of neurodegeneration –CVAs.
• More in women than in men
• Patients who develop late onset schizophrenia were also noted to
have sensory deficits - visual and hearing
Differential diagnosis of late onset schizophrenia
• Psychotic disorders secondary to general medical
conditions
• Psychotic symptoms which might be part of delirium
• Early onset schizophrenia undetected
• Mood disorders with psychotic features
• Delusional disorders
PDGMC vs Schizophrenia
INDICATORS
PDGMC
SCHIZOPHRENIA
ONSET
SUDDEN
GRADUAL
DRUG/ALCOHOL HISTORY
TEMPORALLY RELATED
COMORBIDITY
MEDICAL HISTORY
COMMON
INFREQUENT
CONCOMITANT MEDS
FREQUENT
INFREQUENT
FAMILY HISTORY
NOT FOR PSYCHOSIS
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HALLUCINATIONS
MULTIMODAL
AUDITORY USUALLY
Treatment of late onset schizophrenia
• Atypical antipsychotics
• Psychosocial treatments-social skills, CBT
• Family interventions for relapse prevention
Aging and Early onset Schizophrenia
• Around 30% could show evidence for
improvement and remission.
• Cognitive deterioration is reasonably steady
and do deteriorate significantly
John Nash Jr- “ A beautiful mind”
John Nash, Jr- In his own words
“But after my return to the dream-like delusional
hypotheses in the later 60's I became a person of
delusionally influenced thinking but of relatively
moderate behavior and thus tended to avoid
hospitalization and the direct attention of psychiatrists.
Thus further time passed. Then gradually I began to
intellectually reject some of the delusionally influenced
lines of thinking which had been characteristic of my
orientation. This began, most recognizably, with the
rejection of politically-oriented thinking as essentially a
hopeless waste of intellectual effort.”
Psychotic disorders due to general medical
conditions in the elderly
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Stroke
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Parkinson's disease
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Epilepsy
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Herpes Encephalitis
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Thyroid and adrenal disorders
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Folate, B12 deficiencies
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Systemic lupus erythematosus
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Alcoholic hallucinosis
Medications causing psychotic symptoms
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Levadopa
Bromicriptine
Amantadine
Isoniazid
Corticosteroids
Amphetamines
Methylphenidate
Lidocaine
Cimetidine
Mood disorders secondary to general medical
conditions
• Rate of depression in the medical population
is 12 to 20%.
• Many physical illnesses and medications can
cause symptoms mimicking depression.
Common medical conditions causing depression
• Strokes
• Parkinson's Disease
• Hypothyroidism
• Addison's Disease
• Occult carcinoma of the Pancreas
• Collagen vascular disease
• Multiple sclerosis
Most common medications causing
depression
• Antihypertensives - reserpine and methyl
dopa
• Steroids
Secondary Mania
• Stroke
• Right hemisphere cerebral neoplasms
• Multiple sclerosis
• Encephalitis
• Syphilis
• Head injury
• Uremia
Secondary Mania
• Corticosteroids
• Thyroxin
• Levodopa
• Bromocriptine
• Amphetamines
• Cimetidine
Dimensions of Grief and Bereavement
• Emotional and cognitive experiences
• Coping strategies
• Continuing relationship with the deceased
• Health, occupational and social functioning
• Relationships
• Social identity and Self esteem
Complications of Grief and
Bereavement
• Morbidity
• Increased somatic complaints
• Worsening of pre existing illnesses
• Increased use of medical services
• Mortality
• Widowers: highest risk in the first six months
• Widows: period of risk delayed by 1or 2 years.
Psychiatric complications of grief
• Substance use
• Anxiety symptoms
• PTSD
• Depression
Risk factors leading to Depression in the
Grieving process
• Unnatural sudden unexpected death
• Preexisting mood disorder
• Early, intense depressive reaction after the loss
• Poor physical health
• Increased alcohol consumption
• Family history of major depression
• Poor social support system
Geriatric depression
• Prevalence of geriatric depression is much higher
in medical settings than in the community -30%.
• 50% of nursing home residents are at risk to
develop depression.
• Cognitive impairment is an expected complication
in elderly patients who develop depression
Under diagnosis of depression in the
elderly
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Under reporting of symptoms
More focus on physical symptoms
More anhedonia than sadnesss
Subsyndromal depression not meeting criteria
Medical illness detection overshadow the
diagnosis of depression
Co-morbidity and complications of late life
depression
• Depression worsens outcomes and prognosis of medical illnesses
• Depression lengthens hospital stay
• Depression increases perception of ill health
• Depression increases economic burden on the health care system
• Depression worsens disability
• Depression also results in increased suicide risk
-White men over the age of 65 has the highest suicide rate
Risk factors for suicide in the elderly
• Loneliness and poor social support
• Presence of psychiatric disorder
• Presence of fire arm
• Impaired ability with IADLs
• Medical co-morbidity
Treatment options for Depression in
the elderly
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SSRIs
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TCAs
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MAOIs
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Bupropion
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Mirtazapine
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Augmenting agents
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ECT
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Psychotherapy
Characteristics of Delirium
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Disturbance of consciousness
Abnormal cognition
Acute onset and fluctuating in course
Multifactorial etiology
Hyperactive, hypoactive, and mixed forms
Characteristics of delirium
• Misdiagnosis is frequent – confused with
depression and mania
• May develop over hours to days.
– Abrupt onset more common.
– The line between dementia and delirium is often
unclear.
Etiology of delirium
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Etiology - Multifactorial
Infections
Toxins, including drugs
Substance withdrawal
Organ failure: heart, liver, kidney, etc
Metabolic derangements
Primary brain disorders
Pathogenesis of Delirium
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No specific structural brain lesion identified:
EEG showing slow waves but nonspecific
Depleted acetylcholine
Dopamine, GABA, serotonin, acetylcholine imbalance
Cytokine activation (sepsis)
Risk Factors
• Dementia is the strongest risk factor – 25 to 75% of
patients have dementia.
• Other predisposing brain diseases: stroke,
Parkinson’s
• Advanced age
• Severe medical illness
• Hyponatremia, dehydration, other metabolic
problems
• Anticholinergic drugs, sedative hypnotics, narcotics
Clinical Presentation
• Disorientation to place, time, situation
• Impaired consciousness
– Reduced awareness
– Reduced or clouded consciousness with or
without overt hallucinations
Clinical Presentation
• Decreased ability to focus, sustain, or shift attention
– Decreased selective attention
– Distractibility
• Cognition is made worse by inattention.
• Speech:
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Tangential
Poorly organized
Slowed, slurred
Word finding difficulties
Clinical Presentation
• Impaired registration, recent/remote memory
with associated confabulation
• Perceptual abnormalities:
– May be agitated in response to hallucinations
Diagnosis
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History from family and/or caregivers
Bedside observations
DSM-IV diagnostic criteria
Reliable diagnostic instruments:
– Confusion Assessment Method
– The Delirium Rating Scale
– Delirium Symptom Review
• Diagnostic errors are common in:
– Hypoactive form
– The setting of rapid fluctuations of cognition.
Differential Diagnosis
• Dementia
– Alzheimer dementia
– Lewy body dementia
• Depressive states
• Psychotic disorders