Chapter 22
Psychiatry of the Elderly
167
, Chapter 22: Psychiatry of the Elderly
Introduction
Patients suitable for referral to a Psychiatry of the Elderly Service include:
o Patients aged 65 years and over with a new onset of mental illness (no past history of mental illness). Those
individuals with a past history of mental illness remain under the care of general adult psychiatry.
o Patients suffering from cognitive impairment with associated psychological or behavioural problems.
Services include:
o Domiciliary assessment (i.e. an assessment in the home of a patient)
Assessment at home is beneficial as people are most likely to behave and communicate in their normal
way in familiar surroundings.
It also provides a more accurate picture of a patient’s needs and enables learning from the views of
carers.
Professionals can observe whether patients can make themselves a hot drink and whether there are any
likely risks from poor hygiene or fire hazards.
Looking in the fridge and the food cupboards provides a quick and informative check on food intake
and a patient’s ability to monitor when food is no longer safe to eat.
o Day hospital
Provides an alternative to acute hospital admission for both dementia sufferers who have behavioural
or psychiatric symptoms and people with functional illness such as depression.
Active psychiatric treatment involving biological, psychological and social approaches take place in
day hospitals.
o Day centre
Provides socialisation for older people.
Provides carer relief (i.e. a break for carers while the elderly person attends the day centre).
o Outpatient clinic
Outpatient clinics are particularly useful for follow up of elderly patients with functional psychiatric
disorders such as depression who do not require the intensive treatment modalities available in the day
hospital setting.
o Inpatient care
Acute inpatient beds: required for acute psychiatric illness.
Long-stay inpatient beds: maybe required for -
People with dementia who have severe behavioural problems unnameable to treatment.
People with dementia who are immobile and may also have severe physical problems.
People with dementia who are mobile and who do not have severe psychiatric or physical
problems but undertake such activities as wandering. The needs of this group of people are for
care in a safe, supervised environment which allows them to move around but under supervision
and also provides personal care.
Changes associated with normal aging
Brain changes
o Ventricle volume and sulci increase.
o Brain volume and weight decreases (the decrease in brain volume is not uniform. Occipital cortex is least
affected).
o Cellular metabolism decreases.
o Grey matter volume decreases between adulthood and old age.
o White matter volume increases from age 19-40 years and then declines.
o All the following increase with age and have been related to memory loss: neurofibrillary tangles, senile
amyloid plaques, lewy bodies, hirano bodies, lipofuscin accumulation.
Intellectual functioning
o IQ peaks at 25 years, plateaus until 60-70 years and then declines.
o Performance IQ declines after the age of 30 years and drops markedly after age 65 years.
o Verbal IQ is less affected.
o Short-term memory does not alter with age but working memory declines.
o Long-term memory declines, except for remote events of personal significance which may be recalled with
great clarity.
o Verbal comprehension shows little or no decline.
o Scientific creativity peaks in the 30s.
o Artistic creativity peaks in the 50s.
Note: dementia is not part of normal aging.
168
, Body changes
o Decreased
Total body mass, body water, body muscle, rate of gastric emptying, blood flow in splanchnic
circulation, gastrointestinal absorptive surface, metabolically active tissue, liver volume and blood flow,
hepatic biotransformation, renal blood flow and renal function, renal tubular function.
o ncreased
Body fat, gastric pH (i.e. less acidic).
Dementia
Introduction
Dementia is a syndrome due to disease of the brain, usually of chronic or progressive nature in which there
is a disturbance of higher cortical functions, including memory, thinking, orientation, comprehension,
calculation, learning capacity, language and judgement.
The impairment of memory typically affects the registration, storage and retrieval of new information.
Previously learned and familiar material may also be lost, particularly in the later stages.
Consciousness is not clouded (versus delirium where it is clouded).
Many people with dementia experience periods of confusion and wandering which are worse at night. This
is referred to as ‘sundowning’.
The ‘four As’ of dementia:
o Amnesia: loss of recent rather than remote memory.
o Agnosia: inability to recognise objects, a family member or even one’s own reflection in the mirror.
o Apraxia: inability to carry out simple tasks (e.g. dressing, eating).
o Aphasia: inability to speak, which can be receptive or expressive.
Epidemiology
Prevalence 5% of people > 65 years.
20% of people > 80 years.
Gender Alzheimer’s disease: females > males.
Vascular dementia: males > females.
Race Caucasian race is a risk factor for dementia.
Aetiology
Irreversible causes
o Alzheimer’s disease (the most common type of dementia).
o Vascular dementia (the second most common type of dementia).
Note: the boundary between Alzheimer’s disease and vascular dementia can be blurred. In such instances, the term
mixed dementia can be used. A lot of people with Alzheimer’s disease have neurovascular disease.
o Lewy body dementia.
o Dementia in Pick’s disease (frontotemporal dementia).
o Dementia in Creutzfeldt Jakob disease.
o Dementia in Huntington’s disease.
o Dementia in Parkinson’s disease.
o Dementia in human immunodeficiency virus (HIV) disease
Potentially treatable causes
o Head injury.
o Chronic alcohol use.
o Infections (e.g. meningitis or encephalitis).
o Normal pressure hydrocephalus.
o Brain tumours.
o Heavy metal exposure (e.g. lead, arsenic, mercury or manganese).
o Hypoxia.
o Endocrine disorders (e.g. Addison’s disease, Cushing’s disease, diabetes, hyperparathyroidism or
hypoparathyroidism, hypothyroidism or hyperthyroidism, phaeochromocytoma).
o Metabolic disorders (e.g. hypercalcaemia, hyponatremia, renal failure with uraemia, hepatic failure,
porphyria).
o Nutritional deficiencies (e.g. B1 [thiamine] deficiency, B12 [cobalamin] deficiency, pellagra [deficiency
of niacin or tryptophan], protein calorie malnutrition).
o Drug reactions or misuse (e.g. hypnotics, anticholinergic medications, illicit substances [especially heroin
and cocaine]).
169
Psychiatry of the Elderly
167
, Chapter 22: Psychiatry of the Elderly
Introduction
Patients suitable for referral to a Psychiatry of the Elderly Service include:
o Patients aged 65 years and over with a new onset of mental illness (no past history of mental illness). Those
individuals with a past history of mental illness remain under the care of general adult psychiatry.
o Patients suffering from cognitive impairment with associated psychological or behavioural problems.
Services include:
o Domiciliary assessment (i.e. an assessment in the home of a patient)
Assessment at home is beneficial as people are most likely to behave and communicate in their normal
way in familiar surroundings.
It also provides a more accurate picture of a patient’s needs and enables learning from the views of
carers.
Professionals can observe whether patients can make themselves a hot drink and whether there are any
likely risks from poor hygiene or fire hazards.
Looking in the fridge and the food cupboards provides a quick and informative check on food intake
and a patient’s ability to monitor when food is no longer safe to eat.
o Day hospital
Provides an alternative to acute hospital admission for both dementia sufferers who have behavioural
or psychiatric symptoms and people with functional illness such as depression.
Active psychiatric treatment involving biological, psychological and social approaches take place in
day hospitals.
o Day centre
Provides socialisation for older people.
Provides carer relief (i.e. a break for carers while the elderly person attends the day centre).
o Outpatient clinic
Outpatient clinics are particularly useful for follow up of elderly patients with functional psychiatric
disorders such as depression who do not require the intensive treatment modalities available in the day
hospital setting.
o Inpatient care
Acute inpatient beds: required for acute psychiatric illness.
Long-stay inpatient beds: maybe required for -
People with dementia who have severe behavioural problems unnameable to treatment.
People with dementia who are immobile and may also have severe physical problems.
People with dementia who are mobile and who do not have severe psychiatric or physical
problems but undertake such activities as wandering. The needs of this group of people are for
care in a safe, supervised environment which allows them to move around but under supervision
and also provides personal care.
Changes associated with normal aging
Brain changes
o Ventricle volume and sulci increase.
o Brain volume and weight decreases (the decrease in brain volume is not uniform. Occipital cortex is least
affected).
o Cellular metabolism decreases.
o Grey matter volume decreases between adulthood and old age.
o White matter volume increases from age 19-40 years and then declines.
o All the following increase with age and have been related to memory loss: neurofibrillary tangles, senile
amyloid plaques, lewy bodies, hirano bodies, lipofuscin accumulation.
Intellectual functioning
o IQ peaks at 25 years, plateaus until 60-70 years and then declines.
o Performance IQ declines after the age of 30 years and drops markedly after age 65 years.
o Verbal IQ is less affected.
o Short-term memory does not alter with age but working memory declines.
o Long-term memory declines, except for remote events of personal significance which may be recalled with
great clarity.
o Verbal comprehension shows little or no decline.
o Scientific creativity peaks in the 30s.
o Artistic creativity peaks in the 50s.
Note: dementia is not part of normal aging.
168
, Body changes
o Decreased
Total body mass, body water, body muscle, rate of gastric emptying, blood flow in splanchnic
circulation, gastrointestinal absorptive surface, metabolically active tissue, liver volume and blood flow,
hepatic biotransformation, renal blood flow and renal function, renal tubular function.
o ncreased
Body fat, gastric pH (i.e. less acidic).
Dementia
Introduction
Dementia is a syndrome due to disease of the brain, usually of chronic or progressive nature in which there
is a disturbance of higher cortical functions, including memory, thinking, orientation, comprehension,
calculation, learning capacity, language and judgement.
The impairment of memory typically affects the registration, storage and retrieval of new information.
Previously learned and familiar material may also be lost, particularly in the later stages.
Consciousness is not clouded (versus delirium where it is clouded).
Many people with dementia experience periods of confusion and wandering which are worse at night. This
is referred to as ‘sundowning’.
The ‘four As’ of dementia:
o Amnesia: loss of recent rather than remote memory.
o Agnosia: inability to recognise objects, a family member or even one’s own reflection in the mirror.
o Apraxia: inability to carry out simple tasks (e.g. dressing, eating).
o Aphasia: inability to speak, which can be receptive or expressive.
Epidemiology
Prevalence 5% of people > 65 years.
20% of people > 80 years.
Gender Alzheimer’s disease: females > males.
Vascular dementia: males > females.
Race Caucasian race is a risk factor for dementia.
Aetiology
Irreversible causes
o Alzheimer’s disease (the most common type of dementia).
o Vascular dementia (the second most common type of dementia).
Note: the boundary between Alzheimer’s disease and vascular dementia can be blurred. In such instances, the term
mixed dementia can be used. A lot of people with Alzheimer’s disease have neurovascular disease.
o Lewy body dementia.
o Dementia in Pick’s disease (frontotemporal dementia).
o Dementia in Creutzfeldt Jakob disease.
o Dementia in Huntington’s disease.
o Dementia in Parkinson’s disease.
o Dementia in human immunodeficiency virus (HIV) disease
Potentially treatable causes
o Head injury.
o Chronic alcohol use.
o Infections (e.g. meningitis or encephalitis).
o Normal pressure hydrocephalus.
o Brain tumours.
o Heavy metal exposure (e.g. lead, arsenic, mercury or manganese).
o Hypoxia.
o Endocrine disorders (e.g. Addison’s disease, Cushing’s disease, diabetes, hyperparathyroidism or
hypoparathyroidism, hypothyroidism or hyperthyroidism, phaeochromocytoma).
o Metabolic disorders (e.g. hypercalcaemia, hyponatremia, renal failure with uraemia, hepatic failure,
porphyria).
o Nutritional deficiencies (e.g. B1 [thiamine] deficiency, B12 [cobalamin] deficiency, pellagra [deficiency
of niacin or tryptophan], protein calorie malnutrition).
o Drug reactions or misuse (e.g. hypnotics, anticholinergic medications, illicit substances [especially heroin
and cocaine]).
169
