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

significantly boost self-esteem

Adults  considered finished products in whom the ultimate developmental
states had been reached.
Adulthood  always the result of the interaction among body, mind, and
environment, never exclusively the result of any one of the three variables.
Adulthood can be divided into three main parts: young or early adulthood
(ages 20 to 40), middle adulthood (ages 40 to 65), and late adulthood or
old age.
YOUNG ADULTHOOD
(20 TO 40 YEARS OF AGE)
 young adult who fails to develop the capacity for intimate
relationships runs the risk of living in isolation and self-absorption
in midlife
Interracial Marriage
 Most persons are more likely to marry someone from the same racial
and ethnic background.
Parenthood
 intensifies the relationship between the new parents
 expands their internal images of each other to include thoughts and
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.
 Depending in the choice of career, and opportunity, work may become a
source of ongoing frustration or an activity that enhances self-esteem.
Developing Adult Friendships
 In late adolescence and young adulthood, before marriage and
parenthood, friendships are often the primary source of emotional
sustenance.
Sexuality and Marriage
 developmental shift from sexual experimentation to the desire for
intimacy
 experience the gap between early aspirations and current
achievements
Transition from Young to Middle Adulthood
 slow and gradual, with no sharp physical or psychological
demarcation
 aging process picks up speed and becomes a powerful organizing
influence on intrapsychic life
 widening concern for the larger social system and differentiation of
one's own social, political, and historical system nfrom others
Erik Erikson
 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
a marital problem in the same way, through divorce.
Intercourse Outside of Marriage
 Adultery is defined as voluntary sexual intercourse between a
married person and someone other than his or her spouse.
 For men, the first extramarital affair is often associated with the
wife's pregnancy, when coitus may be interdicted. Most of these
incidents are kept secret from the spouse and, if known, rarely
account for divorce.
Adult Maturity
 mental state found in healthy adults that is characterized by detailed
knowledge of the parameter of human existence, a sophisticated
level of self-awareness based on an honest appraisal of one's own
experience within those basic parameters, and the ability to use this
intellectual and emotional knowledge and insight caringly in
relation to one's self and others.
GERIATRIC PSYCHIATRY
“The passage from youth to old age is mirrored by a shift from the pursuit of
wealth to the maintenance of health.”
Late adulthood
 the aging body increasingly becomes a central concern, replacing the
midlife preoccupations with career and relationships.
 this is because of normal decline in function, altered physical
appearance, and the increased incidence of physical illness
Despite these occurrences, the body in late adulthood can still be a source of
considerable happiness and can convey a sense of accomplishment particularly
if attention is paid to:
 regular exercise
 healthy diet
 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
Older adults can also be described as:
▫ Well-old - persons who are healthy
▫ Sick-old - persons who have an infirmity that interferes with
functioning and requires medical or psychiatric attention
As the population ages, the health needs of older adults have grown
enormously, and geriatric physicians and psychiatrists play major roles in
treating this population.
 Geriatric psychiatry
o emphasizes the biological and psychological aspects of normal
aging, the psychiatric effect of acute and chronic physical
illness, and the biological and psychosocial aspects of the
pathology of primary psychiatric disturbances of older age.
 Geriatric psychiatrists
o focus on prevention, evaluation, diagnosis and treatment of
mental and emotional disorders in the elderly and
improvement of psychiatric care for healthy and ill elderly
patients.
BIOLOGY OF AGING
Aging process or senescence
 from the Latin senescere, "to grow old"
 characterized by a gradual decline in the functioning of all of the body's
systems (cardiovascular, respiratory, genitourinary, endocrine, and
immune system)
Even with the aging process, many older persons retain their cognitive abilities
and physical capacities to a remarkable degree.
“The belief that old age is always associated with profound intellectual and
physical infirmity is a MYTH”
Not all organ systems deteriorate at the same rate, nor do they follow a similar
pattern of decline for all persons.
2 Factors
1. Genetic – because each person have different genetic make-up so different
pod ang organ system na vulnerable in each person
2. Exogenous – excessive exposure to UV, smoking and alcohol use
If an organ system starts to deteriorate in geriatric patients then it leads to
illness or worst death
Aging generally means the aging of cells.
In the central nervous system, age-related cell changes occur in neurons, which
show signs of degeneration.
In senility (characterized by severe memory loss and a loss of intellectual
functioning), signs of degeneration are much more severe. An example of this is
the
 Neurofibrillary degeneration - seen most commonly in dementia of
the Alzheimer's type
Genetic factors have been implicated in disorders that commonly occur in older
persons, such as hypertension, coronary artery disease, arteriosclerosis, and
neoplastic disease.
Inheritance factors for breast and stomach cancer, colon polyps, and certain
mental disorders is involve in the old age population.
Huntington's disease
- associated with the development of dementia, specifically the subcortical type
of dementia, which is characterized by more motor abnormalities and fewer
language abnormalities than in the cortical type of dementia
- shows an autosomal dominant mode of inheritance with complete penetrance
- average age of onset is between 35 and 40 years, but cases have occurred as
late as 70 years
LONGEVITY
Family history of longevity is the best indicator of a long life
PREDICTORS OF LONGEVITY THAT ARE WITHIN A PERSON'S CONTROL:
 regular medical check-ups
 minimal or no caffeine or alcohol consumption
 work gratification
  a perceived sense of the self as being socially useful in an altruistic
role, such as spouse, teacher, mentor, parent, or grandparent
Healthy eating and adequate exercise are also associated with health and
longevity.
LIFE EXPECTANCY
With the improvements in sanitation, housing, education and health care
system, the average life expectancy of both sexes has increased in every decade
Over the years, there are a great percentage of declines that has occurred in
mortality from cerebrovascular disease and coronary artery disease so in
contrast to this mortality from cancer, which rises with age, has also increased
especially cancer of the lung, colon, stomach, skin, and prostate.
The leading causes of death among older persons:
 heart disease
 cancer
 stroke
Accidents - are the leading causes of death of persons over the age of 65.
Most fatal accidents are caused by falls, pedestrian incidents, and burns.
Falls are most commonly the result of cardiac arrhythmias and hypotensive
episodes.
Some gerontologists consider death in very old persons (over 85) to result from
an aging syndrome
Aging Syndrome
– characterized by diminished elastic-mechanical properties of the heart,
arteries, lungs, and other organs
- some gerontologists consider death in very old persons (over 85) to result
from this syndrome
Death results from trivial tissue injuries that would not be fatal to a younger
person
Senescence (the condition or process of deterioration with age) is viewed as the
cause of death.
ETHNICITY AND RACE
The proportion of older persons in the black, Hispanic, and Asian populations is
smaller than that in the white population, but it is increasing rapidly
SEX RATIOS
On average, women live longer than men and are more likely than men to live
alone. The number of men per 100 women decreases sharply from age 65 to 85
GEOGRAPHIC DISTRIBUTION
The most populous states have the largest number of older persons.
EXERCISE, DIET, AND HEALTH
Diet and exercise play a role in preventing or ameliorating chronic diseases of
older persons, such as arteriosclerosis and hypertension.
Hyperlipidemia, which correlates with coronary artery disease, can be
controlled by reducing body weight, decreasing the intake of saturated fat, and
limiting the intake of cholesterol.
Increasing the daily intake of dietary fiber can also help decrease serum
lipoprotein levels
A daily intake of 1 ounce (about 30 mL) of alcohol has been correlated with
longevity and elevated high-density lipoproteins (HDL).
Statin drugs that reduce cholesterol have a dramatic effect on reducing
cardiovascular disease in persons with diet-resistant or exercise-resistant
hyperlipidemia.
Low salt intake (less than 3 g a day) is associated with a lowered risk of
hypertension.
Hypertensive geriatric patients can often correct their condition by moderate
exercise and decreased salt intake without the addition of drugs
A regimen of daily moderate exercise (walking for 30 minutes a day) has been
associated with:
 a reduction in cardiovascular disease
 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.
- termed the crisis of the last epoch of life integrity versus
despair and believed that successful resolution of this crisis
involved a process of life review and achieving a sense of peace
and wisdom through coming to terms with how one's life was
lived
- The integrity versus despair stage begins as the aging adult
begins to tackle the problem of his or her mortality. The onset
of this stage is often triggered by life events such as retirement,
the loss of a spouse, the loss of friends and acquaintances,
facing a terminal illness, and other changes to major roles in
life.
PERSONALITY OVER THE LIFE SPAN: STABI LITY OR CHANGE?
- focuses on defining the core personality traits within the
individual and determining their course over the life span
For example, do those who are gregarious or extroverted (sociable person)
during early childhood and adolescence remain extroverted through midlife and
old age? Several well-designed longitudinal studies that have followed
individuals over periods ranging from 10 to 50 years have found strong
evidence for
Stability In Five Basic Personality Traits :
1. Extroversion
2. Neuroticism (negative person or anxious emotional state)
3. Agreeableness
4. Openness to experience
5. Conscientiousness
PSYCHOSOCIAL ASPECTS OF AGING
I. Social Activity:
 Healthy older persons usually maintain na level of social activity that is only
slightly changed from that of earlier years.
 Old age is a a period of continued intellectual, emotional, and psychological
growth.
 Physical illness of the death of friends and relatives may preclude continued
social interaction.
 Increased sense of isolation makes them vulnerable to depression.
 Maintaining social activities is valuable for physical and emotional well’being.
II. Ageism
 Coined by Robert Butler
 Refers to discrimination toward old persons and to the negative stereotypes
about old old age that are held by younger adults.
 Persons often associate old age with loneliness, poor health, senility, and
general weakness of infirmity.
 More than four of five persons over the age of 65 have at least one chronic
condition.
 Good health is not the sole determinant of a good quality of life in old age.
 Factors affecting good aging appear to be multidimensional.
 Aging ¨robustly¨means considering aging in terms of productive involvement,
affective status, functional status, and cognitive status
III. Transference
 Parental transference
▫ patient reacts to the therapist as a child to a parent
 Peer or Sibling Transferrence
▫ expressions of experiences from a variety of nonparental
relationships
▫ Patient looks to the therapist to share experiences with siblings,
spòuses, friends, and associates
 Son or Daugther transference
▫ quite common in middleaged individuals and the elderly
▫ therapist is cast in the role of the patient's child, grandchild, or son-in-
law or daughterinlaw
▫ themes expressed in this form of transference are multiple and often
center on defenses against dependency feelings, activity and
dominance versus passivity and submission, and attempts to rework
unsatisfying aspects of relationships with children before time runs
out
 Sexual transference
▫ in older individuals are frequent and intense
▫ therapist needs to be able to accept them and manage his or her
countertransference responses
IV. Countertransference:
 Sources of countertransference:
▫ Older individuals are dealing with illness and signs of aging, the loss of
spouses and friends, and the constant awareness of time limitation
and the nearness of death
▫ responses center on the older patient's sexuality
V. Socioeconomics:
 economics of old age is of paramount importance to older persons themselves
and to society at large
VI. Retirement
 retirement is a time for the pursuit of leisure and for freedom from the
responsibility of previous working commitments
 For others, it is a time of stress, especially when retirement results in economic
problems or a loss of self-esteem
VII. Sexual Activity
 frequency of orgasm, from coitus or masturbation, decreases with age in men
and women
 most important factors in determining the level of sexual activity with age
1. Health and survival of the spouse
2. One's own health
3. Level of past sexual activity
 social and cultural factors appear to be more responsible for the sexual changes
observed than for the psychological changes of aging per se
 The widely held notion that the elderly are essentially asexual is often a self-
fulfilling prophecy
VIII. Long-Term Care
 Many older persons who are infirm require institutional care
 only 5 percent are institutionalized in nursing homes at any one time, about 35
percent of older persons require care in a long-term facility at some time
during their lives
PYSCHIATRIC PROBLEMS OF OLDER PERSONS
 prevalence of major depressive disorder and dysthymia is actually less than in
younger age groups
 Depression in old persons is often accompanied by physical symptoms or
cognitive changes that may mimic dementia
 incidence of suicide among older persons is high ( 40 per 1 00,000 population)
and is highest for older white men
 suicide of older persons is perceived differently by surviving friends and family
members on the basis of gender
▫ Men are thought to have been physically ill
▫ Women are thought to have been mentally ill
PSYCHIATRIC EXAMINATION OF THE OLDER PATIENT
 Psychiatric history taking and the mental status examination of older adults
follow the same format as for younger adults
 When a patient is cognitively impaired, an independent history should be
obtained from a family member or caretaker
 Psychiatric History
▫ complete psychiatric history includes preliminary identification (name,
age, sex, marital status), chief complaint, history of the present illness,
history of previous illnesses, personal history, and family history
▫ review of medications (including over-the-counter medications) that the
patient is currently using or has used in the recent past is also important
▫ Benign senescent forgetfulness: minor memory impairments, such as
forgetting persons' names and misplacing objects
▫ patient's childhood and adolescent history can provide information
about personality organization and give important clues about coping
strategies and defense mechanisms used under stress
▫ history of learning disability or minimal cerebral dysfunction is significant
▫ occupational history should include the patient's feelings about work,
relationships with peers, problems with authority, and attitudes toward
retirement
▫ family history should include a patient's description of parents' attitudes
and adaptation to their old age and, if applicable, information about the
causes of their deaths
▫ patient's current social situation should be evaluated
▫ financial history helps the psychiatrist evaluate the role of economic
hardship in the patient's illness and to make realistic treatment
recommendations
▫ marital history includes a description of the spouse and the
characteristics of the relationship
▫ patient's sexual history includes sexual activity, orientation, libido,
masturbation, extramarital affairs, and sexual symptoms (e.g., impotence
and anorgasmia)
 Mental Status Examination
▫ offers a cross-sectional view of how a patient thinks, feels, and behaves
during the examination
A. General Description
▫ includes appearance, psychomotor activity, attitude toward the
examiner, and speech activity
▫ Motor disturbances (e.g., shuffling gait, stooped posture, "pill
rolling" movements of the fingers, tremors, and body asymmetry)
should be noted
▫ Involuntary movements of the mouth or tongue may be adverse
effects of phenothiazine medication
▫ Depressed patients seem to be slow in speech and movement
▫ Mask-like facies occurs in Parkinson's disease
▫ Patient's speech may be pressured in agitated, manic, and anxious
states
▫ Tearfulness and overt crying occur in depressive and cognitive
disorders, especially if the patient feels frustrated about being
unable to answer one of the examiner's questions
▫ Presence of a hearing aid or another indication that the patient has
a hearing problem should be noted
▫ patient's attitude toward the examiner can give clues about
possible transference reactions
B. Functional Assessment
▫ Patients older than 65 years of age should be evaluated for their
capacity to maintain independence and to perform the activities of
daily life, which include toileting, preparing meals, dressing,
grooming, and eating
▫ Degree of functional competence in their everyday behaviors is an
important consideration in formulating a treatment plan for these
patients
C. Mood, Feelings, and Affect
▫ Suicide is a leading cause of death of older persons
▫ Loneliness is the most common reason cited by older adults who
consider suicide
▫ Feelings of loneliness, worthlessness, helplessness, and
hopelessness are symptoms of depression
▫ Nearly 75% of all suicide victims suffer from depression, alcohol
abuse, or both
▫ Disturbances in mood states, most notably depression and anxiety,
can interfere with memory functioning
▫ expansive or euphoric mood may indicate a manic episode or may
signal a dementing disorder
▫ Frontal lobe dysfunction often produces witzelsucht, which is the
tendency to make puns and jokes and then laugh aloud at them
▫ Patient's affect may be flat, blunted, constricted, shallow, or
inappropriate, all of which can indicate a depressive disorder,
schizophrenia, or brain dysfunction
▫ Dominant lobe dysfunction causes dysprosody, an inability to
express emotional feelings through speech intonation
D. Perceptual Disturbances
▫ Hallucinations and illusions by older adults can be transitory
phenomena resulting from decreased sensory acuity
▫ Confusion about time or place during hallucinations points to an
organic condition
▫ Hallucinations can be caused by brain tumors and other focal
pathology
▫ Brain diseases cause perceptive impairments
▫ Agnosia, the inability to recognize and interpret the significance of
sensory impressions, is associated with organic brain diseases
▫ Types of Agnosia:
 Anosignosia - denial of illness
 Atopognosia - denial of a body part
  Visual agnosia - inability to recognize objects
 Prosopagnosia - inability to recognize faces
E. Language Output
▫ Covers the aphasias, which are disorders of language output
related to organic lesions of the brain
▫ Nonfluent or Broca's aphasia, the patient's understanding
remains intact, but the ability to speak is impaired
▫ Simple test for Wenicke's aphasia is to point to some common
objects-such as a pen or a pencil, a doorknob, and a light switch-
and ask the patient to name them
▫ Ideomotor apraxia - patient also may be unable to demonstrate
the use of simple objects, such as a key and a match
F. Visuospatial Functioning
▫ Some decline in visuospatial capability is normal with aging
G. Thought
▫ Disturbances in thinking include neologisms, word salad,
circumstantiality, tangentiality, loosening of associations, flight of
ideas, clang associations, and blocking
▫ Loss of the ability to appreciate nuances of meaning (abstract
thinking) may be an early sign of dementia
▫ Thinking is then described as concrete or literal
H. Sensorium and Cognition
▫ Sensorium concerns the functioning of the special senses
▫ cognition concerns information processing and intellect
▫ neuropsychiatric examination is the survery of boath areas and
consists of the clinician's assessment and a comprehensive battery
of psychological tests
1. Consciousness
 Sensitive indicator of brain dysfunction is an altered state
of consciousness
 Patient does not seem to be alert, shows fluctuations in
levels of awareness, or seems to be lethargic
 In severe cases, the patient is somnolescent or stuporous
2. Orientation
 Impairment in orientation to time, place, and person is
associated with cognitive disorders
 Cognitive impairment often is observed in mood disorders,
anxiety disorders, factitious disorders, conversion disorder,
and personality disorders, especially during periods of
severe physical or environmental stress
3. Memory
 Memory usually is evaluated in terms of immediate, recent,
and remote memory
 Immediate retention and recall are tested by giving the
patient six digits to repeat forward and backward
 Remote memory can be tested by asking for the patient's
place and date of birth, the patient's mother's name before
she was married, and names and birthdays of the patient's
children
 In cognitive disorders, recent memory deteriorates first
 Recent memory assessment can be done by giving the
patient the names of three items early in the interview and
ask for recall later while Others prefer to tell a brief story
and ask the patient to repeat it verbatim.
 Memory of the recent past also can be tested by asking for
the patient's place of residence, including the street
number, the method of transportation to the hospital, and
some current events
 Careful assessment should be done in retrograde amnesia
(loss of memory before an event) or anterograde amnesia
(loss of memory after the event)
4. Intellectual Tasks, Information, and Intelligence
 patient's fund of general knowledge is related to
intelligence
 examiner must take into account the patient's educational
level, socioeconomic status, and general life experience in
assessing the results of some of these tests
5. Reading and writing
 determine whether the patient has a specific speech
deficit
6. Judgment
 Judgment is the capacity to act appropriately in various
situations
 Neuropsychological evaluation
▫ thorough neuropsychological examination includes a comprehensive
battery of tests that can be replicated by various examiners and can be
repeated over time to assess the course of a specific illness
▫ most widely used test of current cognitive functioning is the Mini-
Mental State Examination (MMSE), which assesses orientation,
attention, calculation, immediate and short-term recall, language, and
the ability to follow simple commands
▫ MMSE is used to detect impairments, follow the course of an illness, and
monitor the patient's treatment responses, but it is not used to make a
formal diagnosis
▫ Maximal MMSE score is 30
▫ Age and educational level influence cognitive performance as measured
by the MMSE
▫ The Bender Gestalt Test is one of a large number of instruments used to
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
 Present in 15% of older adult community residents and nursing home patients
 Risk factor: being widowed, chronic medical illness
 SSx: reduced energy and concentration, sleep problems, decreased appetite,
weight loss, somatic complaints
 Vulnerable to Major Depressive episodes with melancholic features:
depression, hypochondriasis, low self-esteem, feeling of worthlessness, self-
accusatory trends
 Cognitive impairment in depressed geriatric patients = dementia syndrome of
depression (pseudodementia)
o Deficits in attention and concentration are variable, less likely to have
language impairment
Schizophrenia
 First episodes diagnosed after 65 is rare
 Women are more likely to have late-onset type (age >45)
 Greater prevalence of paranoid schizophrenia in late-onset type
 About 20% of people with schizophrenia shows no active symptoms by age 65
(psychopathology becomes less marked as patient age)
 Residual type occurs in 30% of schizophrenics: emotional blunting, social
withdrawal, eccentric behavior, illogical thinking
 Older persons with schizophrenic symptoms respond well to antipsychotic
drugs
Delusional Disorder
 Age of onset is usually 40-55, but can occur during geriatric period
 Most common form = persecutory (believed they are being spied, followed,
poisoned, harassed)
o Lock themselves in room, live reclusive lives
 Somatic delusion (believe having fatal illness) can also occur
 Risk factors: physical/psychological stress, death of spouse, loss of job,
retirement, social isolation, financial problems, debilitating medical illness,
visual impairment, deafness
 Late-onset delusional disorder called paraphrenia is characterized by
persecutory delusions [not associated with dementia]
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
Alcohol and Other Substance Use Disorder
 Older adults with alcohol dependence have history of excessive drinking
 Usually medically ill, with liver disease, widowed, divorced, or never married
 Many have arrest records, homeless
 Most have chronic dementing illness
 Alcohol and substance abuse = 10% of all emotional problems in older adults
o Dependence on hypnotics (to ensure sleep), anxiolytics (to allay
chronic anxiety), narcotics (pain relief for ill cancer patients)
 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
 May cause elderlies to become inactive because of fear of falling
 Causes: anemia, hypotension, cardiac arrythmia, CVD, basilar artery
insufficiency, middle ear disease, acoustic neuroma, benign postural vertigo,
Meniere’s disease
 Overuse of anxiolytics can cause dizziness and daytime somnolence
 Tx: Meclizine (Antivert) 25 to 100 mg daily
Syncope
 Sudden loss of consciousness
 Results from reduction of cerebral blood flow and brain hypoxia
 An act or omission which results in harm or threatened harm to the health or
welfare of an elderly
o Includes abuse and neglect - physically, psychologically, financially,
materially
o Possible sexual abuse
o Omission – withholding food, medicine, clothing, other necessities
 10% of >65 yrs old are abused
 Family conflicts and other problems often underlie elder abuse
 Victims, old and frail, live often with their assailants
SPOUSAL BEREAVEMENT
 One of the most stressful of all life experiences
 51% of women and 14% of men over 65 will be widowed at least once
 Depressive symptoms peak within first few months after death
 A relationship exists between spousal loss and subsequent mortality
PSYCHOPHARMACOLOGICAL TREATMENT OF GERIATRIC DISORDERS
 Pretreatment medical evaluation is important, including EDG
 Let patient/family members bring all currently used medications
 Psychotropic drugs are given equally divided doses 3 to 4 times over 24-hour
period
o Older patients may not tolerate sudden rise in drug blood level from
one large dose
o Changes in BP and PR, and other side effects should be watched
 For px with insomnia: major portion of antidepressant/antipsychotic given at
bedtime
 Liquid preparations for those who can’t, or won’t swallow tablets
 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
 Issues: need to adapt to recurrent and diverse losses, need to assume new roles,
need to accept mortality
o Psychotherapy helps to deal with these issues and the emotional
problems surrounding them
 Psychotherapy increases self-esteem and self-confidence, decrease feelings of
hopelessness and anger, and improves quality of life
o Relieve tensions of biological and cultural origin, helps older people
work and play within the limits of their functional status
o A study showed that px showed less urinary incontinence, improved
gait, greater mental alertness, improved memory, better hearing
 Therapist must be more active, supportive and flexible to geriatric patients
o They usually seek therapy for a therapist’s unqualified and unlimited
support, reassurance and approval
o They expect therapist to be all powerful, all knowing, and can effect a
magical cure
o Most patients eventually recognize that the therapist is human; but
some may have to assume the idealized role

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