Common giatric psychaitric disease converted

Common Psychological Disorder in Elderly
DR WAFA SHEIKH
CONSULTANT FAMILY MEDICINE
ABFM ,SBFM, MRCGP (INT)
1
9/5/2021 DR WAFA SHEIKH

Learning objectives
Clinical case scenario 1 Depression in Elderly
Geriatric Depression Scale
Mini-Cox Assessment for Dementia
Guideline for management of Depression in Elderly
Clinical case scenario 5- steps protocol for providing mental healthcare in primary health
care(WHO)
Clinical case scenario 3 Anxiety Disorder and Panic attack in Elderly
Drug side effect
Special issues Heart Disease , COPD , Parkinson’s Disease, Psychiatric co-morbidity
Clinical presentation and Management
2

• 68 years old female frequently visited to physician clinic she is not satisfied with her previous visits
every time she has a new complaint although she had been requested all investigation which is
requested for her complaints all investigation are normal .
• On this visit anxious and looks sad no eye to eye contact on further exploration it is revealed
that she is suffering from sleep disturbances . She is alone at home
• His husband died few years ago and she had a one daughter she lived for her study in another city.
• She is known case of Hypothyroidism , Gout and Osteoarthritis .
On further exploration of hidden agenda because her frequent visits and sleep disturbance she is
in STRESS .
SUSPECT ? Depression
Depression in older adults diagnosis and management BMJC vol 19
Case 1 scenario…………
3

Predisposing factors include previous clinical depression, physical and chronic disabling illnesses
(e.g., Cerebrovascular illness, multiple medications and persistent sleep difficulties.
Psychosocial predisposing risk factors include female gender, personality traits such as dependency,
being widowed or divorced, being socially disadvantaged, lacking social support, and having
caregiving responsibilities for others with significant illness.
Precipitating risk factors for LLD include recent bereavement, change of residence (e.g., from house
to nursing home), and adverse life events (e.g., loss, separation, financial crisis, declining health,
marital problems).
Recently bereaved patients should be screened for LLD and a clinical determination should be made
regarding depression based on the patient’s history and the cultural norms for the expression of
distress after loss.
4

A complete assessment for Late Life Depression :
5
Reviewing DSM-5 diagnostic criteria for late-life depression and assessing the patient for
depression using appropriate screening tools.
•Performing a physical examination and ordering laboratory investigations to identify (e.g.,
hypothyroidism, anemia).
• Determining severity of condition, including presence of psychosis or catatonia.
• Assessing suicide risk.
• Identifying any comorbid psychiatric and medical illnesses.
• Identifying any personal or family history of mood disorder.
• Reviewing current medications, allergies, and substance use.
• Reviewing current stresses and life situation.
• Assessing level of functioning/disability.
• Considering support system, family situation, and personal strengths.
• Reviewing results from Mini-Mental State Exam and any other tests for cognitive function.
• Reviewing collateral information.

DSM-5 Diagnosis criteria of LLD (Late Life Depression)
The criterion “markedly diminished interest or pleasure” may overlap with or be confused with the
apathy of dementia (classified as major neurocognitive disorder in DSM-5) .
Loss of weight or appetite
Sleep disturbance ( physical illness, chronic pain, or the use of substances such as opioids).
Psychomotor retardation, fatigue, and anergia
Feelings of worthlessness and suicidal ideation (to end-of-life issues. )
6

Help-seeking behaviors
Suggestive of LLD include persistent complaints of pain, headache, fatigue,
insomnia, gastrointestinal distress, weight loss, and multiple diffuse
symptoms.
There may be frequent calls and visits to the family practitioner and high
utilization of services
7

Depression Geriatric scale
Criteria: Questions (abnormal or positive answers in parentheses)
Yes
1 A
.re you basically satisfied with your life? (No)
2 D
.o you often get bored? (Yes)
3 D
.o you often feel helpless? (Yes)
4 D
.o you prefer to stay at home rather than going out and doing new things? (Yes)
5 D
.o you feel pretty worthless the way you are now? (Yes)
• III. Interpretation
Syeda score 4
1 Twopositive answers suggests depression
•IV. Efficacy
1 Test Sensitivity: 97%
2 Test Specificity: 85%
3 A
.s effective as the Fifteen-Item Geriatric Depression Scale
Fpin clinical evidenceHoyl (1999) J Am Geriatr Soc 47(7):
873-8 [PubMed]
8

Mini-Cog Assessment for
dementia
9

Case continue …..
10
• Syeda has help seeking behavior with frequent visits and has multiple
complaint predisposing and predisposing psychological risk factors
• Persistent sleep difficulties
• Geriatric depression score positive 4
• Mini-Cog screening for cognitive impairment 4-5 negative screen for
dementia
Diagnosed her Moderate depression Plan of
management
?

Management late-life Depression(depression in Elderly)
There is good evidence to support the use of Psychotherapy or Pharmacotherapy alone, and the
two in combination.
For Milder forms of LLD, psychotherapy may be recommended as a stand-alone treatment, with the
addition of pharmacotherapy if required.
For Moderate severity LLD, antidepressant treatment is recommended, with the addition of
psychotherapy if required.
For Severe LLD, antidepressant treatment and referral to mental health services are recommended.
11

12
Obesity smoking sexual dysfunction
pregnancy elderly
Chronic migraine headache

Pharmacotherapy
SSRIs best safety profile in the elderly (e.g., Citalopram, Escitalopram, Paroxetine,
Sertraline)
SNRI ((e.g., venlafaxine), bupropion, moclobemide, and mirtazapine are all
commonly used and well tolerated by older patients. 2014 guideline update from the Canadian
Coalition for Seniors’ Mental Health
In General, Drugs side effect constipation, diarrhea, nausea, insomnia,
somnolence, and sexual dysfunction
Depression in older adults diagnosis and management BCMJ vol 59 2019
13

While response rates to antidepressants are similar in younger and older patients, physiological
changes with aging, polypharmacy, and comorbidities all increase the risk of adverse drug
reactions occurring.
“start low, go slow” but go
with the understanding that older patients may require full adult doses in order to
Achieve Response (a 50% reduction in symptoms on a validated depression scale)
or
Remission (absence of depression on a validated depression scale) since many
older adults receive subtherapeutic doses or are treated for inadequately short
periods.
14
Guide line for Management late-lifeDepression

Guide line for Management late-life Depression
Antidepressant medications for LLD should be started at half the normal adult dose and then increased within 1 week
if tolerated.
Subsequently, doses should be titrated up regularly until there is a noticeable clinical response, maximum dose is
reached, or side effects limit further increases. The aim should be to reach average therapeutic dose within 4 weeks.
A change of medication should be considered if there is no response after 4 weeks on maximum dose.
Or only partial response after 8 weeks, options include switching to or adding on an alternative therapy.
Augmentation include lithium, methylphenidate, another antidepressant (preferably of a different class), an
atypical antipsychotic, or psychotherapy.
Physicians without comfort or experience using multiple agents should consider referral to a specialist or use the
strategy of switching.
When adding on a second serotonergic antidepressant, clinicians must monitor for serotonin syndrome.
15

Full remission of symptoms should be the goal of treatment.
Following remission of a first episode of LLD, patients should be maintained on a full therapeutic
dose of medication for at least 1 year.
If pharmacotherapy is discontinued, it should be done gradually over months with close monitoring.
Patients who respond but do not achieve full remission should be maintained on therapy indefinitely
with ongoing effort to achieve full resolution.
Patients who have had more than two episodes of LLD or had particularly severe episodes should
also continue on indefinite antidepressant treatment if tolerated.
16
Guide line for Management late-lifeDepression

Patient follow-up visit…….
• After the patient (education )agreement clarification
• Combination therapy CBT + Pharmacotherapy
• We start with Syeda Tab Escitalopram 5 mg po od at bed time for 2 week
• After 2 week patient came she is feeling better and her sleep has been improved .
She is giving good response follow up after one month
• Plan is to increase the dose Tab Escitalopram 10 mg po od for 8 weeks
• After 8 week patient came she is improved sleeping well feeling happy .
• Continue same dose for 6-9 month .
17

Clinical based 5- steps protocol for providing mental
healthcare in primary health care(WHO)
18

Case 2
58 years old female referred from general physician to Family Medicine clinic with complaint
of headache and sleep disturbances . As she has difficulty in sleep and unrefreshed sleep
and feeling tired after getting up in the morning . She has stopped all her social activities she
want to leave alone .
She is also complaining of generalized bodach and fatigue .She has daughter lives with her
along with 4 kids after her husband died in car accident (Depended on her financial crises )
Uncontrolled Diabetes and Hypertension
History of Analgesic prescribed frequently by physician Tab paracetamol
Other history is unremarkable
Examination : Stable
BP:160/90mmhg
FBS :250 mg/dl
19

5- steps protocol for providing mental healthcare in primary health
care(WHO)
20

5- steps protocol for providing mental healthcare in
primary health care(WHO)
Step 1 Suspecting Sleep disturbance and uncontrolled Diabetes and Hypertension
Step 2: Screening
ICE No Idea but want to improve her sleep
Abnormal thinking Hallucination , Delusion
Stress Sleep Pattern Severe late insomnia
Performance Marked Declined
Relation ship Isolation
22

5- steps protocol for providing mental healthcare in primary
health care(WHO)
• STEP 3 -Scoping some time she had an suicidal ideation but she never attempt or either
think to attempt .
• No history of hallucination or delusion
• No history of substance abuse
• No history of episode of high mood or low mood
• Reason for referral no
• STEP 4-Diagnosis based on m GAP version 2.0 (WHO 2016)
• Sad mood and loss of interest (screening depression positive)
• Level of disorder Moderate Severe Depression PHQ :9 16
insomnia
24

5- steps protocol for providing mental healthcare in primary
health care(WHO)
MMSE :
Behavior: no eye to eye contact , her eye brow were low shoulder were down
Mood : sad with tearing eyes
Speech low tone
Cognition normal
Memory intact Mini –Cog 5
Psychosis no hallucination or delusion
No suicidal ideation
25

Moderate Severe Depression with insomnia
How do you manage this case
?
26

STEP 5 : management
27
Non- pharmacological
Diet (Mediterranean ) and Exercise (BMJ, up to date )
Cognitive Behavioral Therapy , Supportive and Narrative therapy
Pharmacological
• After the patient agreement clarification
• Combination therapy CBT + Pharmacotherapy
• We start with Tab Escitalopram 5 mg po od at bed time (insomnia ) for 1st week from Next week 10
mg po od
After 2 weeks Patient came her response : No side effect Feeling better continue the same dose
Next follow up visit Patient came after 4 weeks she was happy no complaint of headache sleep is
improved her PHQ 9 was 0 (Remission period) now follow up every 2-3 month
Plan to continue same dose for 6-9 month (Maintenance therapy ) ….continued regular follow up

28
Case 3 Generalized Anxiety disorder and Panic Attack
Clinical case scenario 3 Anxiety Disorder and Panic attack in
Elderly
Types of Anxiety Disorder
Drug side effect
Special issues Heart Disease , COPD , Parkinson’s Disease, Psychiatric co-
morbidity
Clinical presentation and Management(Summery )

Case scenario…..
65 years old male came with excessive worries and anxiety 3 days ago after Maghrib
pray suddenly he started to have dyspnea palpitation and chest pain ,
No hope no activity all the time home bounded lack of interest in all activities , sadness ,
disturbed sleep
Unable to concentrate
He feels alone her wife has died last year now all the responsibilities on him .
He is only earning member of family soon he get retirement , worried for 2 daughters are
unmarried one son is studying in university .
Known case of type 2 Diabetes & IBS ,
Past history 30 years ago GAD and Social phobia was treated
No Family history of Psychiatric illness
Smoker 30 /Day
29

Case continue ….
MMSE :
Behavior Good Talk Coherent
Mood sad Anxious
Tone : low
Oriented Intact
Memory Mini-Cox Score 5
Insight : positive
No Hallucination And Delusion
No Suicidal Ideation
30

1
19
19
31

Severe Anxiety Disorder and Panic Attack
Moderate Severe Depression
32

Anxiety Disorders
33

WHAT LEADS TO ANXIETY DISORDER?
•Extreme stress or trauma
•Bereavement and complicated or chronic grief
•Alcohol, caffeine, drugs (prescription, over-the-counter, and illegal)
•A family history of anxiety disorders
•Other medical or mental illnesses or
•Neurodegenerative disorders (like Alzheimer’s or other dementias)
34

The stresses and changes that sometimes go along with aging—poor health, memory
problems, and losses—can cause an anxiety disorder.
Common fears : Many older adults are afraid of falling, being unable to afford living
expenses and medication, being victimized, being dependent on others, being left alone,
and death.
Older adults and their families should be aware that health changes can also bring on
anxiety.
Anxiety disorders commonly occur along with other physical or mental illnesses, including
alcohol or substance abuse, which may hide the symptoms or make them worse.
It’s also important to note that many older adults living with anxiety suffered an anxiety
disorder (possibly undiagnosed and untreated) when they were younger.
A stressful event, such as the death of a loved one, can cause a mild, brief anxiety, but
anxiety that lasts at least six months can get worse if not treated.
35

Anxiety disorder and Risk factors
36

Assessment
A comprehensive assessment of anxiety disorders includes interviewing the older adult
and her/his caregiver .
It is thus important to assess not only the severity of these symptoms; but also
impairment in functioning because of the symptoms. This can be achieved by interviewing
the patient and the caregiver, keeping the following in mind:
•Fears and concerns as a part of normal aging e. g. Limited mobility in an elderly leading to
avoidance of going out of the house)
•Anxiety associated with dementia
•Medical disorders which may mimic anxiety symptoms')
•Co-morbidities cardiac illness, depression, malignancy, Parkinson's disease, auto-immune
disorders, collagen vascular diseases, endocrine disorders etc.)
•Clinical presentation in young adults and elderly differs. For e.g., in elderly phobia is
experienced as a fear of situations or inanimate stimuli, such as lightening whereas among
young people phobia is usually of animals')
•The ‘worried well’ Worry as a symptom in older adults, independent of a diagnosable
disorder.
37

Medical conditions that mimic the Anxiety Disorder
SYSTEM
Neurological
CVS
GI disorder
Metabolic Disease
Deficiency state
SPECIFIC DISEASE
Stroke, parkinsonism , multiple sclerosis ,
Angina , cardiac arrythmias , acute asthmatic attack
Irritable bowl syndrome
Hypoglycemia, Hyperthyroidism, Pheochromocytoma
Vit B1 ,B6, B12, Folic acid
38

Sign Of Anxiety Disorder
•Excessive worry or fear
•Refusing to do routine activities or being overly preoccupied with routine
•Avoiding social situations
•Overly concerned about safety
•Racing heart, shallow breathing, trembling, nausea, sweating
•Poor sleep
•Muscle tension, feeling weak and shaky
•Hoarding/collecting
•Depression
•Self-medication with alcohol or other central nervous system depressants
40

Differences in symptoms in working age and older adults
Working age adults Older adults
Anxiety symptoms – muscle tension, worry, fatigue,
sleep disturbances
Anxiety symptoms - muscle tension, worry, fatigue,
sleep disturbances
Severe panic symptoms Lower level of cognitive and somatic distress
obsessive compulsive disorder - more obsessional
symptoms
More rituals - contamination and religious obsessions
PTSD - more severe psychological symptoms More severe physical symptoms and functional
impairment
GAD – worries related more to work, financial,
future, social
GAD – more health related worries
Panic disorder – severe panic attacks Panic disorder – more dizziness and faintness
42

Investigations
Investigations including considering blood tests, thyroid function tests, blood
sugar, ECG, blood calcium and potassium levels and sodium, kidney function tests,
urine analysis and drug screening
Review medications – some medications such as Parkinson’s disease treatment
can cause anxiety
Drug and alcohol use
Cognition
44

WHAT ARE THE TREATMENT OPTIONS?
Treatment can involve medication, therapy, stress reduction, coping skills, and family or other
social support.
A mental health care provider can determine what type of disorder or combination of
disorders the patient has, and if any other conditions, such as grief, depression, substance
abuse, or dementia, are present.
Those who have been treated before for an anxiety disorder should tell their provider about
previous treatment.
If they received medication, they should indicate what was used, dosage, side effects, and
whether the treatment was helpful.
If the patient attended therapy sessions, he or she should describe the type, how many
sessions, and whether it was helpful.
Sometimes individuals must try several different treatments or combinations of treatments
before they find the one that works best for them
45

Psychotherapy
Cognitive behavioral therapy is based on the theory that a patient’s interpretation of
situations affects mood and behavior. In treatment, the patient identifies maladaptive or
distorted cognitions and learns to challenge these to reduce the intensity of emotion and
problematic behavior.
Problem-solving therapy is a form of CBT that involves teaching the patient to identify
problems, brainstorm solutions, implement a solution, and evaluate its effectiveness. ST
also appeared to be effective for those with depression and executive dysfunction.
Interpersonal therapy is a structured, time-limited treatment based on the premise that
onset and recurrence of depression is related to interpersonal relationships. IPT focuses
on grief, interpersonal conflicts, role transitions, and interpersonal deficits. Patients use
techniques to explore, clarify, and express feelings, and to change behavior. 6-month
follow-up both studies found greater improvement in the IPT groups compared with the
treatment-as-usual groups
46

A Cochrane review showed that selective serotonin reuptake inhibitors (SSRIs) and
TCAs had similar efficacy, rates of withdrawal because of side effects were higher with
TCAs, suggesting that SSRIs may be a superior first choice for treatment of
nonpsychotic major depressive disorder
47

Case continue……..
Severe Anxiety Disorder Panic Attack Moderate Severe Depression
Combination therapy
CBT & Pharmacotherapy
Along diet and exercise and CBT
Tab Escitalopram 5 mg po od for first week and lorazepam 2mg po od for 2 weeks
Next week 10 mg po od
Follow up after 2 week He improve feeling better continue therapy one month
Next month he came still feeling anxious plan to increase the dose 15mg po od follow up after
6 week
Feeling good continue the same dose for six month.
He was going well with regular follow up .
After 9 month our plan to stop the drug gradually we stop drug after 3 month with tapering
dose patient was successfully treated .
49

Case continue …..
After 6 moth stopping medication on day patient came to the clinic under severe stress
anxious and complain of insomnia and panic attack
After asking he is now retired man suffering from financial crises, all the Burdon on his
shoulder
His son after finishing education still jobless
After reassuring with agreement of patient we restart the
Similar drug with same dose …… this time duration will be 2 years
Again with regular follow up till now patient is stable .
50

Case continue …..
On a routine visit he came with complain of dizziness , headache .
Blood pressure : 110/70 mmhg .
Pulse 80 /minutes
Investigation :
CBC : Hb 12 mg/dl
Blood glucose 110 mg/dl
Serum Na level < 135 mmol/l
Serum potassium: WNL
51

Hyponatremia
CAUSES HYPONATREMIA?
Nausea or vomiting.
Headache, confusion, or fatigue
Low blood pressure
Loss of energy
Muscle weakness, twitching, or cramps
Seizures or coma
Restlessness or bad temper
SYMPTOMS OF HYPONATREMIA?
Kidney failure - the kidneys cannot get rid of
extra fluid from the body
Congestive heart failure - excess fluid builds up
in the body
Diuretics (water pills) - makes the body get rid
of more sodium in the urine
Antidepressants and pain medication - may
cause more sweating or urinating than normal
Severe vomiting or diarrhea - the body loses a
lot of fluid and sodium
Excessive thirst (primary polydipsia) - causes
too much fluid intake
52

Hyponatremia (SIADH)
A risk exists for hyponatremia secondary to the syndrome of inappropriate
antidiuretic hormone secretion (SIADH), meaning that serum sodium levels should be
checked 1 month after treatment with an SSRI or a selective norepinephrine reuptake
inhibitor.
A review of antidepressant-induced SIADH showed greater risk from SSRIs and
venlafaxine than from mirtazapine and TCAs.
Clinicians should check sodium levels sooner if symptoms of hyponatremia develop or if
there are risk factors such as old age, female sex, diuretic use, low body mass
index, or low baseline plasma sodium level.
54

Mild cases serum sodium below 135 mmol/l may be
managed either by stopping the drug or by careful
observation if the drug is considered essential.
Moderate cases below 130mmol/l would lead to nausea
and malaise
More severe hyponatremia <120mmol/l. may require fluid
restriction in the short term as well as withdrawal of the causal
drug.
Referral may be required for <115 mmol/l can be life
threatening patients with acute illness and for those with
severe and/or refractory hyponatremia.
55

Anxiety Disorder Diagnosis and Management
Summery
56

Generalized Anxiety Disorder
Common in elderly
Sub –syndrome as compare to adult
May have associated memory problem
Illness anxiety and health anxiety is characteristic
Initiate with escitalopram or sertraline
Benzodiazepine may be added for only 2-4 weeks
If no response consider changing/or augment with velafexine or imipramine or buspirone or
pregabalin
Watch for cognitive decline
Clinical practice guidelines for Geriatric Anxiety Disorders Indian journal of Psychiatry 2018
57

Panic disorder
Not common in elderly
Differentiate from essential anxiety
usually panic attack rather than disorder seen
Strat with life style modification and non pharmacological measures
Initiate treatment with escitalopram or paroxetine
Benzodiazepine should be avoided due to rebound anxiety
In no response consider changing/ or augment with mirtazapine , venlafaxine or imipramine
58

Phobias
Common in elderly
Fear of falling is common
Initiate treatment with escitalopram or paroxetine
Benzodiazepine may be added for only 2-4 week
In no response consider changing /or augment with venlafaxine
Watch for cognitive decline
59

Obsessive Compulsive Disorder
Not Common in elderly .
Watch foe BPSD/FTD or Substance abuse
Illness anxiety and health anxiety is characteristic
Initiate with escitalopram ,Fluoxetine , Fluvoxamine
If no response consider changing /or augment with clomipramine
60

Post Traumatic Stress Disorder
Common war veterans
Re-experience phenomena is rare
Can chronic and debilitating
Initiate with paroxetine and sertraline
In no response consider changing /or augment with Mirtazapine or venlafaxine or low
doses of Olanzapine or Risperidone
61

Special issues Heart Disease , COPD , Parkinson’s Disease, Psychiatric
co-morbidity
Clinical presentation and Management
62

THANK YOU
68

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