Geriatric psychiatry

Geriatric psychiatry, also known as geropsychiatry, psychogeriatrics or psychiatry of old age, is a branch of medicine and a subspecialty of psychiatry dealing with the study, prevention, and treatment of neurodegenerative, cognitive impairment, and mental disorders in people of old age.

Geriatric psychiatry is a specialty focused on preventing, evaluating, diagnosing, and treating emotional and mental disorders in adults who are 55 years of age and older.

Aging is inevitable, but that doesn’t make it any easier. With old age comes normal biological and psychological changes, as well as the development of certain health and mental health conditions like chronic illnesses, physical disabilities, psychiatric syndromes, and comorbid diseases.

When it comes to treating geriatric patients, there are some key differences from treating younger people. Geriatric patients may or may not be able to take an active role in their mental health treatment. They may require differing amounts of support or assistance from other people in their life, which might include members of their family or medical staff.

Older individuals could need a particular form of treatment that addresses their mental health, physical, emotional, and social needs. By addressing all of these things together, a geriatric psychiatrist can provide the best support.

WHEN TO VISIT A GERIATRIC PSYCHIATRIST?

There are some unique reasons to see a geriatric psychiatrist. Some of these are age related issues or could be the result of a physical problem, such as a stroke, chronic pain, Parkinson’s disease, diabetes, or other medical conditions or cognitive problems. The patient may struggle with expressing emotions. Elder people experience a setback as a result of a different mental health disorder as they may suffer memory impairment. Each of these could be a reason that a patient would seek mental health support.Patients may be experiencing family problems or issues with financial reasons. No matter what reason the geriatric patient has for seeking mental health treatment, they deserve to get help. That is why geriatric psychiatry is considered a separate specialty.

WARNING SIGNS OF MENTAL HEALTH ISSUES IN GERIATRIC AGE GROUP:

• Withdrawn behaviour & dullness
• Excitation and irritability
• Mood swings
• Increased or reduced psychomotor activity
• Increased or reduced appetite
• Sleep changes or insomnia
• Changes in bowel or bladder habits or INCONTINANCE
• Loss of memory gradual or Rapid
• Altered sensorium, Disorientation
• Change in personality
• Change in gait or walk
• Tremors stiffness of body or rigidity
• Suspicious behaviour
• hallucinations

COMMON DISEASES TREATED UNDER GERIATRIC PSYCHIATRY

Diseases and disorders diagnosed or managed by geriatric psychiatrists include:

Dementia

• Mild cognitive impairment
• Alzheimer’s disease
• Vascular dementia
• Dementia with Lewy bodies

Dementia or Major neurocognitive disorder is a disease commonly seen with advancing age characterised by progressive decline in cognitive abilities and thus causing significant impairment in functioning and activities of daily living. The most common type of Demetria is Alzheimer’s dementia followed by vascular Dementia. Diffuse Lewy body dementia (DLBD), Frontotemporal dementia (FTD) and Mixed dementia are some of the other important types of dementia.

Due to increasing prevalence, Dementia is emerging as a major public health priority leading to increased risk for mortality, high level of disability, caregiver burden and cost burden. With an alarming incident rate of alarming with one new case every three seconds, the global prevalence of dementia is estimated to increase to 131 million in the year 2050. The global economic cost for care of persons with dementia is estimated to increase from 818 billion USD to 2 trillion USD by the year 2050. In INDIA Current estimates of global prevalence of dementia is nearly 47 million with nearly 4.1 million patients with dementia.

Besides cognitive impairment there is increased prevalence of neuropsychiatric manifestations or BPSDs behavioural &and psychological symptoms). BPSDs could manifest as hyperactivity like aggression, irritability, affective symptoms and apathy, psychotic symptoms like delusions and hallucinations and changes with sleep and appetite. It is observed that almost 90% of patient of dementia can have BPSDs over the course of illness. This can further increase the emotional and financial burden to family, increase rate of hospitalisation amounting to significant distress to caregiver.

Parkinson’s disease:

In Parkinson’s disease, certain nerve cells (neurons) in the brain gradually break down or die. Many of the symptoms are due to a loss of neurons that produce a chemical messenger in your brain called dopamine. When dopamine levels decrease, it causes abnormal brain activity, leading to impaired movement and other symptoms of Parkinson’s disease .The cause of Parkinson’s disease is unknown, but several factors appear to play a role, including Age, genes hereditary etc.

Parkinson’s disease signs and symptoms can be different for everyone. Early signs may be mild and go unnoticed. Symptoms often begin on one side of your body and usually remain worse on that side, even after symptoms begin to affect both sides. Symptoms including following Tremor. A tremor, or shaking, usually begins in a limb, often your hand or fingers. You may rub your thumb and forefinger back and forth, known as a pill-rolling tremor. Your hand may tremble when it’s at rest.

Slowed movement (bradykinesia). Over time, Parkinson’s disease may slow your movement, making simple tasks difficult and time-consuming. Your steps may become shorter when you walk. It may be difficult to get out of a chair. You may drag your feet as you try to walk. Rigid muscles. Muscle stiffness may occur in any part of your body. The stiff muscles can be painful and limit your range of motion.

Impaired posture and balance. Your posture may become stooped, or you may have balance problems as a result of Parkinson’s disease. Loss of automatic movements. You may have a decreased ability to perform unconscious movements, including blinking, smiling or swinging your arms when you walk.

Speech changes. You may speak softly, quickly, slur or hesitate before talking. Your speech may be more of a monotone rather than have the usual inflections.

Writing changes. It may become hard to write, and your writing may appear small.

Neuropsychiatric complications from stroke and multiple sclerosis.

Late-life presentations of psychiatric disorders:

Late life Depression:

Late-life depression is one of the most common neuropsychiatric disorders in the elderly. Late life depression is a significant public health problem as well as a burden on patients, their families, and caregivers. There are significant associations of late life depression with medical disorders and cognitive impairment, the latter due to effects of the depression itself or association with dementia. Accurate diagnosis and treatment are of utmost importance to improve quality of life, alleviate suffering, and prevent suicide. A number of effective antidepressant medications are available; combination therapy with these medications and cognitive behavioural therapy appears most efficacious, and maintenance therapy can decrease the chances of remission.

Delirium:

Delirium is a state of heightened mental confusion that commonly affects older people admitted to hospital. Ninety six percent of cases are experienced by older people. When older people with dementia experience severe illness or trauma such as a hip fracture they are more at risk of delirium.

Delirium causes great distress to patients, families and carers and has potentially serious consequences such as increased likelihood of admission to long term care and increased mortality.

People who have delirium may need to stay longer in hospital or in critical care; have an increased incidence of dementia and have more hospital-acquired complications such as falls and pressure ulcers.

There are many causes that may bring on a state of delirium. Most common causes in elderly.

Dementia: If a person already has dementia, then a relatively minor injury or upset may bring on delirium. This can include things like a single dose of a new medication or a change in residence. In fact, dementia is the most common risk factor for delirium, and two-thirds of cases of delirium occur in people who already have dementia.

Drugs, including any new medications, increased dosages, drug interactions, over-the-counter drugs, alcohol, etc.

Electrolyte disturbances, especially dehydration and thyroid problems.

Withdrawal effects such as when long-term sedatives (including alcohol and sleeping pills) are stopped, or when pain drugs are not being given adequately.

Infection, commonly urinary or respiratory tract infection.

Reduced sensory input, which happens when vision or hearing are poor.

Intracranial (referring to processes within the skull) such as a brain infection, haemorrhage, stroke, or tumor (rare).

Urinary problems or intestinal problems, such as constipation or inability to urinate.

Myocardial (heart) and lungs, such as heart attack, problems with heart rhythm (arrhythmia), worsening of heart failure, or chronic obstructive lung disease.

In other people who aren’t as vulnerable, delirium may develop when several factors occur together, such as general anaesthesia, major surgery, and change in psychiatric medications.

Other common psychiatric disorders in late life are:

• Anxiety disorders
• Bipolar disorder
• Schizophrenia
• Personalitydisorders
• Catatonia,
• Substance use disorders etc.

GERIATRIC PSYCHIATRY ASSESMENT:

The geriatric assessment is a multidimensional, multidisciplinary assessment designed to evaluate an older person’s functional ability, physical health, cognition and mental health, and social and environmental circumstances.

As the patient enters a geriatric clinic a detailed evaluation by trained psychiatrist is done including interview of patient and history from family member or caregiver followed by detailed physical and neurological examination. A proper psychological assessment including memory and neurocognitive assessment with help of standardised tests and tools is done based on the symptoms and presentation of the clinical presentation.

Necessary blood investigations and brain imaging like CT brain and MRI Brain can be advised depending on the symptoms and clinical presentation of patient.

Based on the clinical evaluation examination and assessment a treatment and long-term care plan is decided for individual patient including support to caregivers and family members.