Management of Psycho geriatric Problems

Ronny T Wirasto Program Studi Pendidikan Dokter FMIPA Universitas Tadulako 2011

Topik
Definisi Gangguan Diagnosis Terapi

Normal Aging
Factors associated with normal aging include:
-Decreased muscle mass/ increase fat -Decrease brain wt/ enlarged ventricles & sulci -Impaired vision & hearing -Minor forgetfulness (benign senescent forgetfulness)

PROGRESSIVE DEVELOPT

REGRESSION AGING INVOLUTION

INFANT

ADULT
Social activity Ageism Counter transference Socio economic Retirement Sexual activity Long tem care

ELDERLY

What Kinds Of Changes

Learn slowly To adapt with difficulty to new situations To persevere with old habit of thought fail to remember recent event

Old People Suffer From

Nutritive deficiencies that result chiefly from economic psychological or physical problems

What reversible - irreversible

Why - Biological - Sociocultur - Physiological - Psychosocial

How - to manage - to prevent many kind of elderly

Emotional Cognitive behavior change in elderly

Where -they must seeking Who aware the condition doctor family

Stages of Dying
***Normal emotional response when facing death or loss of body part include: -Denial -Anger (blaming others for illness) -Bargaining(ex. Ill never smoke or drink again if my cancer is cured) -Depression -Acceptance ***May be experienced in any order or may occur simultaneously

Major Depression
-common in geriatric population -Elderly are twice as likely to commit suicide as general population -15% of nursing home residents -Symptoms of major depression in elderly often include problems with memory & cognitive functioning, termed Pseudo Dementia, so we have to work up an elderly patient for major depression when presents with memory loss

Depressive symptoms include:

-sleep disturbances (early morning awakening). -decrease appetite and weight loss. -feeling of worthlessness and suicidal ideation. -lack of energy and diminished interest in activities.

Pseudo Dementia
-The presence of apparent cognitive deficits in patients with major depression i.e. DEMENTIA + DEPRESSION

-Because of depression symptoms, patient may appear demented and it is not true!!

-Demented pts are more likely to confabulate ( guess) when they dont know an answer, whereas depressed pts will just say they dont know and when you pressed for an answer, depressed pts will often give the correct one.

Dementia Insidious onset Delights in accomplishments Sun downing Common (increase confusion at night)

Pseudo Dementia ( Depression ) More acute onset Emphasizes failure Uncommon

Guess at answer ( confabulate )

Pt unaware of problem

Often answer Dont Know

Pt is aware of problem

TREATMENT
-Supportive psychotherapy -Psychodynamic psychotherapy -Low dose antidepressant (SSRIs) -Electroconvulsive Therapy -Mirtazapine: Sedative (good for insomnia) -Methylphenidate: adjunct to antidepressant for psychomotor retardation (DONT give in late afternoon or evening, lead to insomnia)

Bereavement
-Elderly are more likely to experience losses of lovers, relatives & friends. -Its important to distinguish b/w normal grief rxn from pathological ones (depression).

Normal grief rxn

INVOLVES:
-Feeling of guilt and sadness -Mild sleep disturbance and wt loss -Illusions (seeing the deceased person or hearing his/her voice) -Attempts to resume daily activities & work -Symptoms resolve within 1 yr (worst symptoms within 2 months)

Abnormal grief (major depression)

INVOLVES:
-Feeling of sever guilt and worthlessness -Significant sleep disturbance and wt loss -Hallucinations and delusions -No attempt to resume activity -Suicidal ideation -Symptoms persist >1 yr (worst symptoms >2 months)

Sleep Disturbances
-Incidence increase with aging -Difficulty sleeping, Daytime drowsiness & Daytime napping -Causes: *medical conditions. *Environment. *Medications. *Normal changes associated with aging .

Changes in Sleep Structure

***REM Sleep:
-Increase no. of REM episodes at night -REM episodes are shorter than normal -Total amount of REM sleep not changed

***Non-REM Sleep:
-Increase awakening after sleep onset -Increase amount of stage 1 & 2 sleep -Decrease amount of stage 3 & 4 sleep

Tx of Sleep Disturbances
-Approaches should be tried first:
Alcohol cessation, Increased structure of daily routine, Elimination of daytime naps & treatment of underlying medical conditions

-Sedative Hypnotics
Hydroxyzine (Vistaril) & Zolpidem (Ambien) Important Note prefer not to be used due to their S/E in elderly like memory impairment, ataxia, paradoxical excitement & rebound insomnia

Elder Abuse
- -10% of all people >65 yrs underreported by victims -Perpetrator is usually caregiver who lives with the victim -Types: Physical, Sexual, Psychological, neglect (withholding of care) & exploitation (misuse of finance).

Care for the elderly

-Restraints:
-Often overused in nursing homes & hospitals -Always try alternatives such as closer monitoring & tilted chairs

-Nursing Homes:
-provide care and rehabilitation for chronically ill and impaired pts as well as for pts who are in need of short term care before returning to their prior living arrangement -50% stay permanently, 50% discharged after few months

Cont,,, Elder Care

-Old Age Home:
Elderly can live for the rest of their lives with no attempt to rehabilitate.

-medications:
Many older people on multiple medications, they suffer from more side effects because of decreased lean body mass and impaired liver and kidney function.

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