ADULTHOOD PSYCHIATRY  brief sexual encounters in short-lived relationships no longer

significantly boost self-esteem

Adults  considered finished products in whom the ultimate developmental  young adult who fails to develop the capacity for intimate
states had been reached. relationships runs the risk of living in isolation and self-absorption
in midlife
Adulthood  always the result of the interaction among body, mind, and
environment, never exclusively the result of any one of the three variables. Interracial Marriage
 Most persons are more likely to marry someone from the same racial
Adulthood can be divided into three main parts: young or early adulthood and ethnic background.
(ages 20 to 40), middle adulthood (ages 40 to 65), and late adulthood or
old age. Parenthood
 intensifies the relationship between the new parents
YOUNG ADULTHOOD  expands their internal images of each other to include thoughts and
(20 TO 40 YEARS OF AGE) feelings emanating from the role of parent

 considered to begin at the end of adolescence (about age 20) and to end Alternative Lifestyle Parenting
at age 40  Both single and marred homosexual men and women are choosing
 characterized by peaking biological development, the assumption of to raise children.
major social roles, and the evolution of an adult self and life structure  Children are obtained through:
A. Adoption
Transition from Adolescence to Young Adulthood B. Born to a lesbian woman through artificial insemination
 characterized by real and intrapsychic separation from the family of C. Obtained from a willing mother surrogate
origin and the engagement of new, phase-specific tasks
 establish self-reliance and begins to formulate new, young-adult goals
that eventually result in creation of new life structures that promote MIDDLE ADULTHOOD
stability and continuity (40 TO 65 YEARS OF AGE)

Work Identity  golden age of adulthood

 The transition from learning and play to work may be gradual or abrupt.  experience the gap between early aspirations and current
achievements
 Depending in the choice of career, and opportunity, work may become a
source of ongoing frustration or an activity that enhances self-esteem. Transition from Young to Middle Adulthood
 slow and gradual, with no sharp physical or psychological
Developing Adult Friendships demarcation
 In late adolescence and young adulthood, before marriage and  aging process picks up speed and becomes a powerful organizing
parenthood, friendships are often the primary source of emotional influence on intrapsychic life
sustenance.  widening concern for the larger social system and differentiation of
one's own social, political, and historical system nfrom others
Sexuality and Marriage
 developmental shift from sexual experimentation to the desire for Erik Erikson
intimacy  described middle adulthood as characterized either by generativity
or by stagnation.
  defined generativity as the process by which persons guide the  Spouses often grow, develop, and change at different rates; one
oncoming generation or improve society. spouse may discover at the other is not the same as when they first
 A childless person can be generative by: married.
A. Helping others
B. Being creative Types of Separation
C. Contributing to society 1. Psychic Divorce
 the love object is given up, and a grief reaction about the death of the
George Vaillant relationship occurs
 found a strong correlation between physical and emotional health in 2. Legal Divorce
middle age  involves going through the courts so that each of the parties is
 those with the poorest psychological adjustment during college remarriageable.
years had a high incidence of physical illness in middle age 3. Economic Divorce
 involves major concerns to the division of the couple's property
Reappraising Relationships between them and economic support for the wife
 midlife is a time of serious reappraisal of marriage and committed 4. Community Divorce
relationships  the social network of the divorced couple changes markedly
 individuals struggle with question of whether to settle for what they  a few relatives and friends are retained from the community, and
have or to search for greater perfection with a new partner new ones are added.
5. Coparental Divorce
Climacterium  the separation of a parent from the child's other parent.
 the period in life characterized by decreased biological and
physiological functioning Custody
 the menopausal period is considered the female climacterium  The parental right doctrine is a legal concept that awards custody to
 male climacterium has no clear demarcation the more fit natural parent and attempts to ensure that the best
interests of the child are served.
Midlife Transition and Crisis
 defined as an intense reappraisal of all aspects of life precipitated by Types of Custody
the growing recognition that life is finite and approaching an end 1. Joint Custody
 characterized by mental turmoil, not action  a child spends equal time with each parent
 an increasingly common practice
Empty-Nest Syndrome 2. Split Custody
 a depression that occurs in some men and women when their  siblings are separated and each parent has custody of one or more
youngest child is about to leave home of the children
 most parents perceive the departure of the youngest child as a relief 3. Single Custody
rather than a stress  the children live solely with one parent and the other parent has
 if no compensating activities have been developed, particularly by rights of visitation that may be limited in some way by the court
the mother, some parents become depressed
Reasons for Divorce
Divorce  Divorce tends to run in families and rates are highest in couples who
 Divorce is a major crisis of life. marry as teenagers or come from different socioeconomic
backgrounds.
  If a person's parents were divorced, he or she may choose to resolve GERIATRIC PSYCHIATRY
a marital problem in the same way, through divorce.
“The passage from youth to old age is mirrored by a shift from the pursuit of
Intercourse Outside of Marriage wealth to the maintenance of health.”
 Adultery is defined as voluntary sexual intercourse between a Late adulthood
married person and someone other than his or her spouse.  the aging body increasingly becomes a central concern, replacing the
 For men, the first extramarital affair is often associated with the midlife preoccupations with career and relationships.
wife's pregnancy, when coitus may be interdicted. Most of these
 this is because of normal decline in function, altered physical
incidents are kept secret from the spouse and, if known, rarely
appearance, and the increased incidence of physical illness
account for divorce.
Adult Maturity
 mental state found in healthy adults that is characterized by detailed Despite these occurrences, the body in late adulthood can still be a source of
knowledge of the parameter of human existence, a sophisticated considerable happiness and can convey a sense of accomplishment particularly
level of self-awareness based on an honest appraisal of one's own if attention is paid to:
experience within those basic parameters, and the ability to use this  regular exercise
intellectual and emotional knowledge and insight caringly in  healthy diet
relation to one's self and others.  adequate rest
 preventive maintenance medical care

Physical and mental health – is the normal state in the aged and not illness and
debilitation

The developmental tasks of late adulthood that lead to mental health:

 To maintain the body image and physical integrity
 To conduct the life review
 To maintain sexual interests and activities
 To deal with the death of significant loved ones
 To accept the implications of retirement
 To accept the genetically programmed failure of organ systems
 To divest oneself of the attachment to possessions
 To accept changes in the relationship with grandchildren

Old age or late adulthood – stage of life cycle that begins at age 65

Gerontologists - those who study the aging process

 divide older adults into two groups:
o Young old - ages 65 to 74
o Old-old - ages 75 and beyond
And some gerontologist use the term oldest old to refer to those over 85.
OLDER ADULTS pod ang organ system na vulnerable in each person
Older adults can also be described as: 2. Exogenous – excessive exposure to UV, smoking and alcohol use
▫ Well-old - persons who are healthy
▫ Sick-old - persons who have an infirmity that interferes with If an organ system starts to deteriorate in geriatric patients then it leads to
functioning and requires medical or psychiatric attention illness or worst death
As the population ages, the health needs of older adults have grown
enormously, and geriatric physicians and psychiatrists play major roles in Aging generally means the aging of cells.
treating this population.
In the central nervous system, age-related cell changes occur in neurons, which
 Geriatric psychiatry show signs of degeneration.
o emphasizes the biological and psychological aspects of normal
aging, the psychiatric effect of acute and chronic physical In senility (characterized by severe memory loss and a loss of intellectual
illness, and the biological and psychosocial aspects of the functioning), signs of degeneration are much more severe. An example of this is
pathology of primary psychiatric disturbances of older age. the
 Neurofibrillary degeneration - seen most commonly in dementia of
 Geriatric psychiatrists the Alzheimer's type
o focus on prevention, evaluation, diagnosis and treatment of
mental and emotional disorders in the elderly and Genetic factors have been implicated in disorders that commonly occur in older
improvement of psychiatric care for healthy and ill elderly persons, such as hypertension, coronary artery disease, arteriosclerosis, and
patients. neoplastic disease.

BIOLOGY OF AGING Inheritance factors for breast and stomach cancer, colon polyps, and certain
Aging process or senescence mental disorders is involve in the old age population.
 from the Latin senescere, "to grow old"
 characterized by a gradual decline in the functioning of all of the body's Huntington's disease
systems (cardiovascular, respiratory, genitourinary, endocrine, and - associated with the development of dementia, specifically the subcortical type
immune system) of dementia, which is characterized by more motor abnormalities and fewer
language abnormalities than in the cortical type of dementia
Even with the aging process, many older persons retain their cognitive abilities - shows an autosomal dominant mode of inheritance with complete penetrance
and physical capacities to a remarkable degree. - average age of onset is between 35 and 40 years, but cases have occurred as
late as 70 years
“The belief that old age is always associated with profound intellectual and
physical infirmity is a MYTH” LONGEVITY
Family history of longevity is the best indicator of a long life
Not all organ systems deteriorate at the same rate, nor do they follow a similar
pattern of decline for all persons. PREDICTORS OF LONGEVITY THAT ARE WITHIN A PERSON'S CONTROL:
 regular medical check-ups
2 Factors  minimal or no caffeine or alcohol consumption
1. Genetic – because each person have different genetic make-up so different  work gratification
  a perceived sense of the self as being socially useful in an altruistic
role, such as spouse, teacher, mentor, parent, or grandparent ETHNICITY AND RACE
Healthy eating and adequate exercise are also associated with health and The proportion of older persons in the black, Hispanic, and Asian populations is
longevity. smaller than that in the white population, but it is increasing rapidly

LIFE EXPECTANCY SEX RATIOS

With the improvements in sanitation, housing, education and health care On average, women live longer than men and are more likely than men to live
system, the average life expectancy of both sexes has increased in every decade alone. The number of men per 100 women decreases sharply from age 65 to 85

Over the years, there are a great percentage of declines that has occurred in GEOGRAPHIC DISTRIBUTION
mortality from cerebrovascular disease and coronary artery disease so in The most populous states have the largest number of older persons.
contrast to this mortality from cancer, which rises with age, has also increased
especially cancer of the lung, colon, stomach, skin, and prostate. EXERCISE, DIET, AND HEALTH
Diet and exercise play a role in preventing or ameliorating chronic diseases of
The leading causes of death among older persons: older persons, such as arteriosclerosis and hypertension.
 heart disease
 cancer Hyperlipidemia, which correlates with coronary artery disease, can be
 stroke controlled by reducing body weight, decreasing the intake of saturated fat, and
limiting the intake of cholesterol.
Accidents - are the leading causes of death of persons over the age of 65.
Increasing the daily intake of dietary fiber can also help decrease serum
Most fatal accidents are caused by falls, pedestrian incidents, and burns. lipoprotein levels

Falls are most commonly the result of cardiac arrhythmias and hypotensive A daily intake of 1 ounce (about 30 mL) of alcohol has been correlated with
episodes. longevity and elevated high-density lipoproteins (HDL).

Some gerontologists consider death in very old persons (over 85) to result from Statin drugs that reduce cholesterol have a dramatic effect on reducing
an aging syndrome cardiovascular disease in persons with diet-resistant or exercise-resistant
hyperlipidemia.
Aging Syndrome
– characterized by diminished elastic-mechanical properties of the heart, Low salt intake (less than 3 g a day) is associated with a lowered risk of
arteries, lungs, and other organs hypertension.
- some gerontologists consider death in very old persons (over 85) to result
from this syndrome Hypertensive geriatric patients can often correct their condition by moderate
exercise and decreased salt intake without the addition of drugs
Death results from trivial tissue injuries that would not be fatal to a younger
person A regimen of daily moderate exercise (walking for 30 minutes a day) has been
associated with:
Senescence (the condition or process of deterioration with age) is viewed as the  a reduction in cardiovascular disease
cause of death.  decreased incidence of osteoporosis
  improved respiratory function
 the maintenance of ideal weight
 a general sense of well-being

Exercise has been shown to improve strength and function even among the very
old.

In many cases, a disease process has been reversed and even cured by diet and
exercise, without additional medical or surgical intervention.

This table reveals that almost every biological change associated with aging is
positively affected by diet and exercise.

STAGE THEORIES OF PERSONALITY DEVELOPMENT

Early personality theorists proposed that development was completed by the
end of childhood or adolescence

Erik Erikson is one of the first development theorists to propose that

personality continues to develop and grow over the life span

- He believed that development proceeded through a series of

psychosocial stages, each with its own conflict that is resolved
by the individual with greater or lesser success.
PERSONALITY OVER THE LIFE SPAN: STABI LITY OR CHANGE?
- termed the crisis of the last epoch of life integrity versus
despair and believed that successful resolution of this crisis - focuses on defining the core personality traits within the
involved a process of life review and achieving a sense of peace individual and determining their course over the life span
and wisdom through coming to terms with how one's life was For example, do those who are gregarious or extroverted (sociable person)
lived during early childhood and adolescence remain extroverted through midlife and
old age? Several well-designed longitudinal studies that have followed
- The integrity versus despair stage begins as the aging adult individuals over periods ranging from 10 to 50 years have found strong
begins to tackle the problem of his or her mortality. The onset evidence for
of this stage is often triggered by life events such as retirement,
the loss of a spouse, the loss of friends and acquaintances, Stability In Five Basic Personality Traits :
facing a terminal illness, and other changes to major roles in 1. Extroversion
life. 2. Neuroticism (negative person or anxious emotional state)
3. Agreeableness
4. Openness to experience
5. Conscientiousness
PSYCHOSOCIAL ASPECTS OF AGING IV. Countertransference:
 Sources of countertransference:
I. Social Activity: ▫ Older individuals are dealing with illness and signs of aging, the loss of
 Healthy older persons usually maintain na level of social activity that is only spouses and friends, and the constant awareness of time limitation
slightly changed from that of earlier years. and the nearness of death
 Old age is a a period of continued intellectual, emotional, and psychological ▫ responses center on the older patient's sexuality
growth.
 Physical illness of the death of friends and relatives may preclude continued V. Socioeconomics:
social interaction.  economics of old age is of paramount importance to older persons themselves
 Increased sense of isolation makes them vulnerable to depression. and to society at large
 Maintaining social activities is valuable for physical and emotional well’being.
VI. Retirement
II. Ageism  retirement is a time for the pursuit of leisure and for freedom from the
 Coined by Robert Butler responsibility of previous working commitments
 Refers to discrimination toward old persons and to the negative stereotypes  For others, it is a time of stress, especially when retirement results in economic
about old old age that are held by younger adults. problems or a loss of self-esteem
 Persons often associate old age with loneliness, poor health, senility, and
general weakness of infirmity. VII. Sexual Activity
 More than four of five persons over the age of 65 have at least one chronic
 frequency of orgasm, from coitus or masturbation, decreases with age in men
condition.
and women
 Good health is not the sole determinant of a good quality of life in old age.
 most important factors in determining the level of sexual activity with age
 Factors affecting good aging appear to be multidimensional.
1. Health and survival of the spouse
 Aging ¨robustly¨means considering aging in terms of productive involvement,
2. One's own health
affective status, functional status, and cognitive status
3. Level of past sexual activity
III. Transference  social and cultural factors appear to be more responsible for the sexual changes
 Parental transference observed than for the psychological changes of aging per se
▫ patient reacts to the therapist as a child to a parent  The widely held notion that the elderly are essentially asexual is often a self-
 Peer or Sibling Transferrence fulfilling prophecy
▫ expressions of experiences from a variety of nonparental
relationships VIII. Long-Term Care
▫ Patient looks to the therapist to share experiences with siblings,  Many older persons who are infirm require institutional care
spòuses, friends, and associates  only 5 percent are institutionalized in nursing homes at any one time, about 35
 Son or Daugther transference percent of older persons require care in a long-term facility at some time
▫ quite common in middleaged individuals and the elderly during their lives
▫ therapist is cast in the role of the patient's child, grandchild, or son-in-
law or daughterinlaw PYSCHIATRIC PROBLEMS OF OLDER PERSONS
▫ themes expressed in this form of transference are multiple and often  prevalence of major depressive disorder and dysthymia is actually less than in
center on defenses against dependency feelings, activity and younger age groups
dominance versus passivity and submission, and attempts to rework  Depression in old persons is often accompanied by physical symptoms or
unsatisfying aspects of relationships with children before time runs cognitive changes that may mimic dementia
out  incidence of suicide among older persons is high ( 40 per 1 00,000 population)
 Sexual transference and is highest for older white men
▫ in older individuals are frequent and intense  suicide of older persons is perceived differently by surviving friends and family
▫ therapist needs to be able to accept them and manage his or her members on the basis of gender
countertransference responses ▫ Men are thought to have been physically ill
▫ Women are thought to have been mentally ill
PSYCHIATRIC EXAMINATION OF THE OLDER PATIENT ▫ Tearfulness and overt crying occur in depressive and cognitive
 Psychiatric history taking and the mental status examination of older adults disorders, especially if the patient feels frustrated about being
follow the same format as for younger adults unable to answer one of the examiner's questions
 When a patient is cognitively impaired, an independent history should be ▫ Presence of a hearing aid or another indication that the patient has
obtained from a family member or caretaker a hearing problem should be noted
▫ patient's attitude toward the examiner can give clues about
 Psychiatric History possible transference reactions
▫ complete psychiatric history includes preliminary identification (name,
age, sex, marital status), chief complaint, history of the present illness, B. Functional Assessment
history of previous illnesses, personal history, and family history ▫ Patients older than 65 years of age should be evaluated for their
▫ review of medications (including over-the-counter medications) that the capacity to maintain independence and to perform the activities of
patient is currently using or has used in the recent past is also important daily life, which include toileting, preparing meals, dressing,
▫ Benign senescent forgetfulness: minor memory impairments, such as grooming, and eating
forgetting persons' names and misplacing objects ▫ Degree of functional competence in their everyday behaviors is an
▫ patient's childhood and adolescent history can provide information important consideration in formulating a treatment plan for these
about personality organization and give important clues about coping patients
strategies and defense mechanisms used under stress
▫ history of learning disability or minimal cerebral dysfunction is significant C. Mood, Feelings, and Affect
▫ occupational history should include the patient's feelings about work, ▫ Suicide is a leading cause of death of older persons
relationships with peers, problems with authority, and attitudes toward ▫ Loneliness is the most common reason cited by older adults who
retirement consider suicide
▫ family history should include a patient's description of parents' attitudes ▫ Feelings of loneliness, worthlessness, helplessness, and
and adaptation to their old age and, if applicable, information about the hopelessness are symptoms of depression
causes of their deaths ▫ Nearly 75% of all suicide victims suffer from depression, alcohol
▫ patient's current social situation should be evaluated abuse, or both
▫ financial history helps the psychiatrist evaluate the role of economic ▫ Disturbances in mood states, most notably depression and anxiety,
hardship in the patient's illness and to make realistic treatment can interfere with memory functioning
recommendations ▫ expansive or euphoric mood may indicate a manic episode or may
▫ marital history includes a description of the spouse and the signal a dementing disorder
characteristics of the relationship ▫ Frontal lobe dysfunction often produces witzelsucht, which is the
▫ patient's sexual history includes sexual activity, orientation, libido, tendency to make puns and jokes and then laugh aloud at them
masturbation, extramarital affairs, and sexual symptoms (e.g., impotence ▫ Patient's affect may be flat, blunted, constricted, shallow, or
and anorgasmia) inappropriate, all of which can indicate a depressive disorder,
schizophrenia, or brain dysfunction
 Mental Status Examination ▫ Dominant lobe dysfunction causes dysprosody, an inability to
▫ offers a cross-sectional view of how a patient thinks, feels, and behaves express emotional feelings through speech intonation
during the examination
D. Perceptual Disturbances
A. General Description ▫ Hallucinations and illusions by older adults can be transitory
▫ includes appearance, psychomotor activity, attitude toward the phenomena resulting from decreased sensory acuity
examiner, and speech activity ▫ Confusion about time or place during hallucinations points to an
▫ Motor disturbances (e.g., shuffling gait, stooped posture, "pill organic condition
rolling" movements of the fingers, tremors, and body asymmetry) ▫ Hallucinations can be caused by brain tumors and other focal
should be noted pathology
▫ Involuntary movements of the mouth or tongue may be adverse ▫ Brain diseases cause perceptive impairments
effects of phenothiazine medication ▫ Agnosia, the inability to recognize and interpret the significance of
▫ Depressed patients seem to be slow in speech and movement sensory impressions, is associated with organic brain diseases
▫ Mask-like facies occurs in Parkinson's disease ▫ Types of Agnosia:
▫ Patient's speech may be pressured in agitated, manic, and anxious  Anosignosia - denial of illness
states  Atopognosia - denial of a body part
  Visual agnosia - inability to recognize objects  Immediate retention and recall are tested by giving the
 Prosopagnosia - inability to recognize faces patient six digits to repeat forward and backward
 Remote memory can be tested by asking for the patient's
E. Language Output place and date of birth, the patient's mother's name before
▫ Covers the aphasias, which are disorders of language output she was married, and names and birthdays of the patient's
related to organic lesions of the brain children
▫ Nonfluent or Broca's aphasia, the patient's understanding  In cognitive disorders, recent memory deteriorates first
remains intact, but the ability to speak is impaired  Recent memory assessment can be done by giving the
▫ Simple test for Wenicke's aphasia is to point to some common patient the names of three items early in the interview and
objects-such as a pen or a pencil, a doorknob, and a light switch- ask for recall later while Others prefer to tell a brief story
and ask the patient to name them and ask the patient to repeat it verbatim.
▫ Ideomotor apraxia - patient also may be unable to demonstrate  Memory of the recent past also can be tested by asking for
the use of simple objects, such as a key and a match the patient's place of residence, including the street
number, the method of transportation to the hospital, and
F. Visuospatial Functioning some current events
▫ Some decline in visuospatial capability is normal with aging  Careful assessment should be done in retrograde amnesia
(loss of memory before an event) or anterograde amnesia
G. Thought (loss of memory after the event)
▫ Disturbances in thinking include neologisms, word salad,
circumstantiality, tangentiality, loosening of associations, flight of 4. Intellectual Tasks, Information, and Intelligence
ideas, clang associations, and blocking  patient's fund of general knowledge is related to
▫ Loss of the ability to appreciate nuances of meaning (abstract intelligence
thinking) may be an early sign of dementia  examiner must take into account the patient's educational
▫ Thinking is then described as concrete or literal level, socioeconomic status, and general life experience in
assessing the results of some of these tests
H. Sensorium and Cognition
▫ Sensorium concerns the functioning of the special senses 5. Reading and writing
▫ cognition concerns information processing and intellect  determine whether the patient has a specific speech
▫ neuropsychiatric examination is the survery of boath areas and deficit
consists of the clinician's assessment and a comprehensive battery
of psychological tests 6. Judgment
 Judgment is the capacity to act appropriately in various
1. Consciousness situations
 Sensitive indicator of brain dysfunction is an altered state
of consciousness  Neuropsychological evaluation
 Patient does not seem to be alert, shows fluctuations in ▫ thorough neuropsychological examination includes a comprehensive
levels of awareness, or seems to be lethargic battery of tests that can be replicated by various examiners and can be
 In severe cases, the patient is somnolescent or stuporous repeated over time to assess the course of a specific illness
▫ most widely used test of current cognitive functioning is the Mini-
2. Orientation Mental State Examination (MMSE), which assesses orientation,
 Impairment in orientation to time, place, and person is attention, calculation, immediate and short-term recall, language, and
associated with cognitive disorders the ability to follow simple commands
 Cognitive impairment often is observed in mood disorders, ▫ MMSE is used to detect impairments, follow the course of an illness, and
anxiety disorders, factitious disorders, conversion disorder, monitor the patient's treatment responses, but it is not used to make a
and personality disorders, especially during periods of formal diagnosis
severe physical or environmental stress ▫ Maximal MMSE score is 30
▫ Age and educational level influence cognitive performance as measured
3. Memory by the MMSE
 Memory usually is evaluated in terms of immediate, recent, ▫ The Bender Gestalt Test is one of a large number of instruments used to
and remote memory test visuospatial functions
 ▫ Halstead-Reitan Battery, which is the most complex battery of tests • Ex: reversible causes of delirium and dementia needs accurate diagnosis
covering the entire spectrum of information processing and cognition and treatment; if not, becomes irreversible
▫ Depression, even in the absence of dementia, often impairs psychomotor  Use of comprehensive battery is preferable for confident determination of
performance, especially visuospatial functioning and timed motor presence and type of cognitive disorders
performance  Predisposing factors of mental disorders:
▫ The Geriatric Depression Scale is a useful screening instrument that
• Loss of social roles, loss of autonomy, Death of friends and relatives,
excludes somatic complaints from its list of items
▫ presence of somatic complaints on a rating scale tends to confound the Declining health, Increased isolation, Financial constraints, Decreased
diagnosis of a depressive disorder cognitive functioning
 Many drugs can cause psychiatric symptoms in older adults
▫ Medical History
 includes all major illnesses, trauma, hospitalizations, and Dementing Disorders
treatment interventions  Dementia (the second most common cause of disability among >65 y/o) is a
 Elderly patients have more concomitant, chronic, and multiple generally progressive and irreversible impairment of the intellect
medical problems and take more medications than younger adults  Risk factors: age, family history, female sex
and many of these medications can influence their mental status  Develops over time, with previously achieved mental functions are lost gradually
 Depressed mood, delusions, and hallucinations may precede other o Cognition, memory, language, visuospatial functions, behavioral
symptoms of Parkinson's disease by many months
disturbances
 Psychiatric disorder can also cause such somatic symptoms as
weight loss, malnutrition, and inanition of severe depression  Can be caused by Primary Degenerative CNS disease, Vascular disease, mixed
 Drug effects can be long lasting and may induce depression (e.g., causes
antihypertensives), cognitive impairment (e.g., sedatives),  Subcortical dementia: associated with movement disorders, gait apraxia,
delirium (e.g., anticholinergics ), and seizures (e.g., neuroleptics) psychomotor retardation, apathy, akinetic mutism
 Cortical Dementia: manifest aphasia, agnosia, apraxia
EARLY DETECTION AND PREVENTION STRATEGIES
 Age-related illnesses develop insidiously and gradually progress over years
• Ex: Alzheimer's Disease – gradual accumulation of neuritic plaques and
neurofibrillary tangles in brain
 To prevent neural damage = development of strategies for early detection and
prevention
 Detection (to detect and follow brain changes over time)
▫ Positron Emission Tomography
▫ Functional Magnetic Resonance Imaging
▫ Genetic Risk Measures
 Clinical Trials of possible treatments to delay onset of AD:
▫ Cholinesterase inhibitor drugs
▫ Anticholesterol drugs
▫ Anti-inflammatory drugs
▫ Vitamin E
 Novel Approaches to measuring the physical evidence of AD, the plaques and
tangles in cerebral cortex, might be used to facilitate testing of innovative
treatments to rid of pathognomonic lesions.

MENTAL DISORDERS OF OLD AGE

 Most common are depressive disorders, cognitive disorders, phobias, and
alcohol use disorders
 They are at high risk of suicide and drug-induced psychiatric symptoms
 Many can be prevented, ameliorated and even reversed.
Depressive Disorders Delusional Disorder
 Present in 15% of older adult community residents and nursing home patients  Age of onset is usually 40-55, but can occur during geriatric period
 Risk factor: being widowed, chronic medical illness  Most common form = persecutory (believed they are being spied, followed,
 SSx: reduced energy and concentration, sleep problems, decreased appetite, poisoned, harassed)
weight loss, somatic complaints o Lock themselves in room, live reclusive lives
 Vulnerable to Major Depressive episodes with melancholic features:  Somatic delusion (believe having fatal illness) can also occur
depression, hypochondriasis, low self-esteem, feeling of worthlessness, self-  Risk factors: physical/psychological stress, death of spouse, loss of job,
accusatory trends retirement, social isolation, financial problems, debilitating medical illness,
 Cognitive impairment in depressed geriatric patients = dementia syndrome of visual impairment, deafness
depression (pseudodementia)  Late-onset delusional disorder called paraphrenia is characterized by
o Deficits in attention and concentration are variable, less likely to have persecutory delusions [not associated with dementia]
language impairment
Anxiety Disorders
 Some appear for the first time after 60
 Most common disorder are phobias
o Less severe than in younger px, but more debilitating
 The person may deal with the thought of death with a sense of despair and
anxiety
 Fragility of autonomic nervous system may account for development of anxiety

Obsessive-Compulsive Disorders
 Obsession and compulsions may appear for the first time
o But demonstrated evidence of the disorder when younger
 Ssx: excessive desire for orderliness, rituals and sameness, inflexible and rigid,
compulsions to check things again and again

Somatic Symptom Disorder

 Physical symptoms resembling medical disease are relevant in geriatrics
because somatic complaints are common
 Hypochondriasis is common in persons over 60; disorder is chronic, and
prognosis guarded
o Regular PE help reassure patients they do not have fatal disease
o Clinicians should acknowledge the complaint is real
Schizophrenia
 First episodes diagnosed after 65 is rare Alcohol and Other Substance Use Disorder
 Women are more likely to have late-onset type (age >45)  Older adults with alcohol dependence have history of excessive drinking
 Greater prevalence of paranoid schizophrenia in late-onset type  Usually medically ill, with liver disease, widowed, divorced, or never married
 About 20% of people with schizophrenia shows no active symptoms by age 65  Many have arrest records, homeless
(psychopathology becomes less marked as patient age)  Most have chronic dementing illness
 Residual type occurs in 30% of schizophrenics: emotional blunting, social  Alcohol and substance abuse = 10% of all emotional problems in older adults
withdrawal, eccentric behavior, illogical thinking o Dependence on hypnotics (to ensure sleep), anxiolytics (to allay
 Older persons with schizophrenic symptoms respond well to antipsychotic chronic anxiety), narcotics (pain relief for ill cancer patients)
drugs  Ssx: confusion, poor personal hygiene, depression, malnutrition, effects of
exposure and falls
o Sudden onset of delirium in hospitalized = most often caused by alcohol
withdrawal
  Misuse of OTC substances like nicotine, caffeine, analgesics, laxatives  Needs medical workup to rule out potential causes

Sleep Disorders
 Advanced age = most important factor associated with increased prevalence of
sleep disorders
o Sleeping problems, daytime sleepiness, daytime napping, use of
hypnotic drugs
 Has higher rates of breathing-related disorders and medication-induced
movement disorders
 Dysomnias are the most frequent (primary insomnia, nocturnal myoclonus,
restless leg syndrome, sleep apnea)
 REM sleep behavior disorder occurs almost exclusively in men
 Conditions that interfere with sleep: pain, nocturia, dyspnea, heartburn
 Patients in nursing homes (without daily routines) may experience an advance
sleep phase (sleep early, awaken during night) because of decreased length of
their daily sleep-wake cycle

Suicide Risk
 Elderlies have higher risk for suicide that any other population (5x higher)
 Principal reason = loneliness ☹
o Other reasons for suicidal thoughts: financial problems, poor medical
health, depression
 60% who commit suicide = MEN; 75% who attempted = WOMEN
 Suicide victims use guns or hang themselves; those who attempted take drug
overdose
 Autopsies suggest that elderlies who committed suicide had psychiatric disorder
(depression)
 Most common precipitants: physical illness and loss
 Most who committed suicide communicate their suicidal thoughts to family or Hearing Loss
friends before  30% of >65 yrs old have significant hearing loss (prebycusis)
 50% at age 75
 Some complain they can hear but can’t understand what is being said
OTHER CONDITIONS OF OLD AGE
 Can be treated with hearing aids

Vertigo
Elder Abuse
 Feeling of vertigo or dizziness is common
 An act or omission which results in harm or threatened harm to the health or
 May cause elderlies to become inactive because of fear of falling welfare of an elderly
 Causes: anemia, hypotension, cardiac arrythmia, CVD, basilar artery o Includes abuse and neglect - physically, psychologically, financially,
insufficiency, middle ear disease, acoustic neuroma, benign postural vertigo, materially
Meniere’s disease o Possible sexual abuse
 Overuse of anxiolytics can cause dizziness and daytime somnolence o Omission – withholding food, medicine, clothing, other necessities
 Tx: Meclizine (Antivert) 25 to 100 mg daily  10% of >65 yrs old are abused
 Family conflicts and other problems often underlie elder abuse
Syncope  Victims, old and frail, live often with their assailants
 Sudden loss of consciousness
 Results from reduction of cerebral blood flow and brain hypoxia
SPOUSAL BEREAVEMENT  Issues: need to adapt to recurrent and diverse losses, need to assume new roles,
 One of the most stressful of all life experiences need to accept mortality
 51% of women and 14% of men over 65 will be widowed at least once o Psychotherapy helps to deal with these issues and the emotional
 Depressive symptoms peak within first few months after death problems surrounding them
 A relationship exists between spousal loss and subsequent mortality  Psychotherapy increases self-esteem and self-confidence, decrease feelings of
hopelessness and anger, and improves quality of life
PSYCHOPHARMACOLOGICAL TREATMENT OF GERIATRIC DISORDERS o Relieve tensions of biological and cultural origin, helps older people
 Pretreatment medical evaluation is important, including EDG work and play within the limits of their functional status
 Let patient/family members bring all currently used medications o A study showed that px showed less urinary incontinence, improved
 Psychotropic drugs are given equally divided doses 3 to 4 times over 24-hour gait, greater mental alertness, improved memory, better hearing
period  Therapist must be more active, supportive and flexible to geriatric patients
o Older patients may not tolerate sudden rise in drug blood level from o They usually seek therapy for a therapist’s unqualified and unlimited
one large dose support, reassurance and approval
o Changes in BP and PR, and other side effects should be watched o They expect therapist to be all powerful, all knowing, and can effect a
 For px with insomnia: major portion of antidepressant/antipsychotic given at magical cure
bedtime o Most patients eventually recognize that the therapist is human; but
 Liquid preparations for those who can’t, or won’t swallow tablets some may have to assume the idealized role
 Need to frequently reassess px to determine need for maintenance meds, change
in dosage, development of adverse effects
 Psychotropic drugs are the among the most prescribed, together with
cardiovascular and diuretic meds

Principles
 Major Goals: improve quality of life, maintain persons in the community, delay
or avoid their placement in nursing homes
 Individualization of dosage = basic tenet of geriatric psychopharmacology
 Alterations in dosage are required:
o Renal disease – decrease renal clearance
o Liver disease – decrease metabolism of drug
o Cardiovascular disease – affect renal and hepatic clearance
o GI disease – decrease gastric acid secretion – influence drug absorption
o Changes in lean to fat body mass – many lipid-soluble drugs action
prolonged
o RULE: lowest possible dose that achieves desired therapeutic response
o Start low, go slow

PSYCHOTHERAPY FOR GERIATRIC PATIENTS

 Standard psychotherapeutic interventions – insight-oriented psychotherapy,
supportive psychotherapy, cognitive therapy, group therapy, family therapy
 Freud says that psychoanalysis is not suited for geriatric patients (limitation of
plasticity of personality); but there is no general rule given
 Insight-Oriented Psychotherapy – may remove a specific symptom
o Benefit when px have possibility for libidinal and narcissistic
gratification
o Contraindicated when it would bring only insight that life is a failure