Indah Sandy Febryanti 030.05.113

WHO (1989) >60 years old Indonesian Health Ministry 60 69 years old Greater improvement on health care elder population >> Greater life expectancy Indonesia Today : World Estimation : 24 millions elder (9,77%) 2030 - 70 millions 2050 - 82 millions

old age is not a disease.Lifestyle Diet & Nutrition Environment etc. degrading/degenerating organ functions

physiological

new role in society

sociological

psychological

Integrity versus Despair (Erik Erikson)

Physical Examination Laboratory Examination

Psychiatric History

Mental State Examination

Neuropsychological Evaluation

Complete physical examination Supportive laboratory exams (kidney function, liver function, ct-scan, etc)

Due to aging process Diagnostics Exclude overlying diseases Psychiatry manifestation as side effect of general condition or medication Precaution before giving prescription

Minor memory impairmentsbenign senescent of forgetfulness

Childhood and adolescent historypersonality, defense mechanism, coping strategies

Occupational history (pension)Plans for future?

Current social situationchildren, financial, caregiver

Marital historyspouse, widow, grief

General Description Functional Assessment -- Activity Daily Living Mood, Feelings and Affectmood disturbances : early sign of dementia

Perceptual Disturbances (Hallucinations, Illusions) Language Output (Aphasia) Visuospatial FunctioningDecline in this function is normal w/ aging

Thought (Loss ability of abstract thinking early sign of dementia) Sensorium and Cognition Judgment

Mini Mental State Examination (MMSE)

Cognitive functions : orientation, attention, calculation, recall, etcWechsler Adult Intelligence Scale-Revised (WAIS R) Assessment of intellectual abilities. Verbal, performance, IQ scores Bender estalt est / alstead Reitan Batter

Visuospatial functions.eriatric Depression Scale

To assess depression

Estimation on mid 20th century Psychiatric Disorders : 20 millions. Indonesian National Prevalence Mental disorder at age > 15 yrs old 11,6% Psychotic disorder 4,6 % Highest prevalence : DKI Jakarta (20,3) Nangroe Aceh Darussalam (18,5), West Sumatera (16,7),

Mental disorder prevalence increases as the age. >75 yrs old : 33,7 %Other risk factors : Female, low education level, unemployed, and poverty.

Sleep Disorder

dementia

Bipolar I

depressive

MENTAL DISORDER OF OLD AGESomatoform

schizo-phrenia

Anxiety

delusional

A generally progressive and irreversible impairment of the intellect. Develops over time. Gradually. Characteristic Changescognition, memory, language, visuospatial functions behavioral disturbances : agitation, restlessness, wandering, rage, violence, shouting, social disinhibiton, sleep disturbances, delusions.

Causes of Cognitive ImpairmentBrain injuries, cerebral tumors, AIDS, alcohol, medications, infections, chronic pulmonary disease, inflammatory.

10-15% have potentially treatable Conditions.systemic disorder (heart disease, renal disease, endocrine, etc) primary mental disorders (mostly depressive)

ALZHEIMER DEMENTIA 50 -60 % female > male

Memory impairment with at least one of the following : aphasia, apraksia, agnosia, executive function impairment. Etiology unknown. Hypothetically : loss of selective colinergic neurons. Loss of volume in frontal and temporal lobe. Prevention, not useful Palliative Care To decrease agitation and agression : propanolol, pindolol, buspirone, valproate. Haloperidol for acute behavioral disorder.

VASCULAR DEMENTIA Cognitive deficit (as Alzheimer) but associated with focal neurological signs Sudden onset. Prevention useful. Diagnostic MRI Decreased cerebral blood flow causes dementia.

15 % Symptoms and Signs Reduced energy and concentration Sleep problems Decreased appetite, weight loss Somatic complaints. Age itself is not a risk factor But : widowed, chronic medical illness, etc Suicidal Ideation Pseudodementia The dementia syndrome of depression

1 % prevalence (all age category) Recurrence Symptoms and Signs expansive mood, irritability, decreased sleeping hours, impulsive, distracted easily. Deficit in consciousness, disorentation and cognitive impairment organic cause. Individualized dose of Lithium. Neurotoxicity in Elderly >>

First episode after age 65 : RARE 20 % : no active symptoms by age 65 80 % : varying degrees of impairment Greater prevalence of paranoid schizophrenia in the late-onset-type 30 % Residual Type emotional blunting, social withdrawal, eccentric behavior, illogical thinking, delusions, hallucinations

Age of onset : 40 55 yrs old Delusions Persecutory >> Somatic Paraphrenia late onset of delusional disorder persecutory delusions not associated with dementia Physical or Psychological stress.death of spouse, medical illnesses, surgery, visual impairment, deafness

Panic disorder, phobia, OCD, generalized anxiety disorder, acute stress disorder, PTSD. The thought of death with a sense of despair may cause anxiety Previous personality organization

Somatic complaints in older age is very COMMON. Hypochondriasis common in >60 yrs peak incidence : 40 50 yrs Repeated physical examinations Avoid invasive and high risk examinations. Clinicians should acknowledge that the complaint is real.

Altered regulatory and physiological systems in aging. CausesPrimary sleep disorderdysomnia >> (primary insomnia, restless legs syndrome, sleep apnea)

Mental disorder General medical disorder Social and environmental factors

Interfering ConditionsPain, nocturia, dyspnea, heartburn Lack of daily structure and of social or vocational responsibilites

REM Sleep : more and shorter REM episode, less total REM Sleep NREM Sleep

Psychopharmacological

A pretreatment medical evaluation Bring all currently used medications GOALS to improve quality of life maintain persons in the community delay or avoid placement in nursing home

Psychotropic drugsgiven in equally divided doses (3-4 times) over a 24-hour period.

Response monitoring Individualization of DosageDrug metabolism (liver) Drug clearance (kidney and liver) Drug absorption (GI) Drug distribution (fat body mass)

The lowest possible dose should be used to achieve the desired therapeutic response. Multiple drug interactions.

Psychotherapy Insight-oriented psychotherapy supportive psychotherapy cognitive therapy group therapy family therapy

Adapting to common age-related issues - recurrent and diverse losses (death of friends,etc) - the need to assume new roles - the need to accept mortality/death Psychotherapy - increases self-esteem and self-confidence - decreases feelings of helplessness and anger - improves the quality of life

Kaplan HI, Sadock BJ and Grebb JA. Kaplan-Sadock. Sinopsis Psikiatri. Jilid 1. Alih bahasa : Wijaya Kusuma. Jakarta : Bina Rupa Aksara. 2010. Hal 867-891. Busse EW and Blazer DG. Textbook of Geriatry Psychology. Edisi kedua. Washington : The American Psychiatric Press. 1997. Hal 155-263. Sadock BJ, Sadock VA. Concise Textbook of Clinical Psychiatry. Edisi kedua. Philadelphia : The William-Wilkins. 2004. Hal 599-602. Sadock BJ, Sadock VA. Synopsis of Psychiatry. Edisi kesepuluh. Philadelphia : The William-Wilkins. 2007. Hal 1348-1358. Kaplan HI, Sadock BJ and Grebb JA. Kaplan-Sadock Sinopsis Psikiatri jilid 1. Alih bahasa : Wijaya Kusuma. Jakarta : Bina Rupa Aksara. 2010. Hal 116-134. WebMD. Alzheimer's Disease and Other Forms of Dementia. Diunduh dari : http://www.webmd.com/alzheimers/guide/alzheimers-dementia. Diakses tanggal 10 Desember 2010. Alzheimer's Society. What is vascular dementia? Diunduh dari : http://alzheimers.org.uk/site/scripts/documents_info.php?categoryID=200137&docume ntID=161&pageNumber=1. Diakses tanggal 10 Desember 2010. Helpguide.org. Depression in Older Adults and Elderly. Diunduh dari : http://helpguide.org/mental/depression_elderly. Diakses tanggal 12 Desember 2010. Laporan Riset Kesehatan Dasar Tahun 2007. Departemen Kesehatan RI. Covino, Jennifer. Depression in Geriatric Patients. Diunduh dari : http://www.medscape.com/viewarticle/520534. Diakses tanggal 12 Desember 2010. Moran M, Lawlor B; Late-life Schizophrenia; PSYCHIATRY 4:11; 2005 The Medicine Publishing Company Ltd, 2005 (ebook).