Psych Exam 3 Elder

• Co-morbidities
• Other Sx mask psychiatric d/o
• More likely to report physical sx before psychiatric sx

• Sleep
• Anxiety
• Somatoform (psychiatric d/o with physical sx)
• Thought
• Substance Use
• Cognitive
• Mood/ Major Depression/ Suicide

• Late onset (after 65 years)
• Dellusional d/o
• Persucatory dellusions and schizo

• Don't tell their physican about non-prescription drugs
• Inc depression and dec quality of life (pt perception of too many drugs)
• 10 meds... 100% chance of drug-drug interaction

• Avoids polypharmacy
• Effective for depression
• Safe
• Reccommended for Elderly

• Start w/ low dose
• Predisposed to more adverse drug rxns
• Benzos have long half-life, not appropriate
• Account or 85% of pt falls

• Acetylcholine is responsible for memory and dec w/ age
• Meds with acetylcholine may cause: acute cognitive impairment, confusion, chronic cognitive defects
• ACE inhibitors dec effectiveness of enzyme breaking down acetylcholine

• Tricycline Antidepressants
• Paxil
• GI anti-spasmodics
• First gen antipsychotics
• Lithium
• Antihistamines
• Anti-Parkinsonian
• Muscle relaxants
• Zantac
• Calcium channel blockers
• SSRIs help depression b/c they dec anticholinergic effects

Cognitive fxn intactRxn time slowsLearning is importantMemory loss is not part of agingGerotranscendence: continued growth in dimensions such as spirtuality and inner strengthRelationship strains

• Functional status may decrease
• Retirement: most are successful
• Cultural impact
• Social activities change
• Community strains: Residential care, Assisted living

• Changes in family roles: loss of spouse, poverty, sexuality
• Retirement: Affects social roles, income, use of health services, and participation in leisure
• Widowed women more impacted
• Restrictions from health conditions

• In 2 wks: have others said they care about you, have you provided help to others
• Could you call on someone if needed
• Besides children, do you have family you talk to 1x/mo

• Dec renal clearance
• Dec blood flow to liver
• Neuronal cell loss
• Sexuality maintained (check adverse effects of psychotropic meds)

• Changes in organs
• Slow neurologic
• Brain changes
• Neuroplasticity- less able to make new pathways
• All 5 senses decline w/ age

• Dev task of adjusting to changes
• Growth in spirituality, generativity, and inner strength

• Chronic illnesses: Arthritis, hypertension, heart disease, respiratory disorders, substance abuse
• Polypharmacy
• Bereavement and loss
• Poverty
• Lack of social support
• Psychiatric Disorders: Depression
• Shared living arrangements and
• elder mistreatment

• Reduce stigma
• Access to services
• Monitor meds SE to inc adherence
• Avoid premature institutionalization
• Prevent depression and suicide- counseling

• Social support
• Lifestyle support
• Self-care
• Spiritual support
• Community services

• A disruption or deficit in cognitive function
• Affecting orientation, attention, memory, vocabulary, calculation ability, and abstract thinking
• APA defines 3 distinct categories:
• 1. Delerium, dementia, and amnestic disorders
• 2. Mental disorders resulting from a general medical condition.
• 3. Substance –related disorders

• Acute cognitive impairment with rapid onset caused by medical condition
• Ex- “ICU psychosis”; Acute Brain Syndrome (ABS); Acute confusion; Acute psychosis

• Chronic cognitive impairment
• Differentiated by cause, not symptoms

• Children: can be related to medications or fever
• Elderly: most commonly occurs in
• this population group, often mistaken for dementia- (caregiver prejudice)

• Medications
• Infections
• Fluid and electrolyte imbalances
• Hypoxia/ischemia

• Reduction in cerebral functioning
• Damage to enzyme systems, blood–brain barrier, or cell membranes
• Reduced brain metabolism
• Imbalance of neurotransmitters
• Raised plasma cortisol level

• 1. Cognitive changes with rapid onset(several scales i.e. MMSE) disordered cognition
• 2. attention deficit: difficulty focusing, sustaining, or shifting attention
• 3. disturbed Consciousness: reduced level of consciousness
• May be disoriented to time and place, but rarely to person
• *Develops over a short period of time
• Usually reversible if underlying medical cause is identified
• Serious, should be treated as an emergency

• –Hyperkinetic delirium
• Psychomotor hyperactivity
• Excitability
• Hallucinations
• –Hypokinetic delirium
• Lethargic
• Somnolent
• Apathetic

• DILATED PUPILS
• ELEVATED PULSE
• DIAPHORESIS

• Id nml
• Health status
• Physical exam and Sx
• Labs
• Physical fxn
• Substance abuse hx
• Rx Meds and OTC

• Acute confusion
• Disturbed thought processes
• Disturbed sensory perception
• Hyperthermia
• Acute pain
• Risk for infection
• Disturbed sleep pattern
• Interrupted family processes
• Ineffective protection
• Ineffective role performance
• Risk for injury

• Safety- from self
• r/o life-threatening illness
• stop suspected meds
• monitor VS, behavior, mental status
• correct underlying cause
• supportive measures- hydrate, pain

• Antipsychotics
• Atypical antipsychotics (cardiac SE)
• Benzos (use before antip for hepatic problems)
• Manage SE

• Avoid
• Unless pt in danger to self or others
• Inc agitation- causes rhabdomyolysis

• Frequent brief interaction
• Support for confusion or hallucinations
• Encouraged to express fears and discomforts
• Adequate lighting
• Easy-to-read calendars and clocks
• Reasonable noise level: decrease stimulation
• Frequent verbal orientation
• Devices available: eyeglasses and hearing aids
• Comfort measures to instill trust

• Correction of underlying physiologic alteration
• Resolution of confusion
• Family member verbalization of understanding
• Prevention of injury

• Sudden onset
• Fluctuating course
• dec consciousness
• dec attention
• dec cognition
• Hallucinations
• dec activity ( hypokinetic v. hyperkinetic delirium)
• Incoherent speech
• Involuntary motor movement
• Illness, toxicity

• Insidious onset
• Stable course
• Clear
• dec cognition
• Hallucinations may be present
• Activity baseline Normal
• Speech baseline Normal
• Normal motor movement
• No underlying illness or abnormal lab findings
• depends on stage of illness

• Beta-amyloid plaques
• Neurofibrillary tangles
• Cell death and neurotransmitters
• Genetic factors
• Oxidative stress and free radicals
• Inflammation

• A syndrome with cognitive deficits resulting from a general medical condition, use of a substance, or multiple biologic etiologies. ..severe enough to compromise social or occupational function, and decline from previous functioning.
• All forms affect memory and cognition
• Degenerative, progressive neuropsychiatric disorder that results in cognitive impairment, emotional and behavioral changes, physical and functional decline, and ultimately death

• Essential feature: multiple cognitive deficits
• One or more of the following:
• Aphasia (alterations in language)
• Apraxia (impaired ability to execute movement)
• Agnosia (failure to recognize or identify objects)
• Disturbance of executive functioning- i.e. making decisions

• Early-onset (65 years and younger) Rapid progression
• Late-onset (over 65)

Forgetfulness, misplace articles, decreased recall, social withdrawal, frustrated with self, changes may not be apparent to others

decreased ability for self-care; way-finding; disoriented to time and place; wandering, pacing, possible hallucinations or delusions begin, decreased visual perception leading to accidents; needs supervision; emotional lability-big swings; symptoms noticeable

cannot care for self; loss use of language; minimal long term memory; constant complete care

• Priorities will change throughout the course of the disorder
• Initially, delay cognitive decline
• Moderate level: protect patient from hurting self
• Late stages: physical needs become the focus of care

• Health Status
• Physical Exam
• Physical Fxns: self-care, sleep-wake disturbance, activity and exercise, nutrition, pain

• Responses to mental health problems: personality changes
• Cognitive status (MMSE and others)
• Memory
• Language
• Visuospatial impairment
• Executive functioning

• Suspiciousness, delusions, and illusions
• Hallucinations
• Mood changes
• Anxiety
• Catastrophic reactions

• Apathy and withdrawal
• Restlessness, agitation, and aggression
• Aberrant motor behavior
• Disinhibition
• Hypersexuality
• Stress and coping skills

• Functional status, social systems, spiritual assessment, legal status, and quality of life
• Extent of primary caregiver’s personal, informal, and formal support systems

• Confirm Dx
• Establish baseline
• Therapeutic relationship
• Tx efforts: mgt of cognitive sx, delay in cognitive decline, tx of noncognitive sx, support caregiver

• Self-care
• Nutiriton
• Support elimination
• Sleep
• Activity and exercise
• Pain and comfort
• Relaxation

• ACE Inhibitors
• Antipsychotics
• SSRIs
• Anti-anxiety (caution)
• Avoid meds with Anticholinergic effects

• Cognitive Impairment
• Psychosis
• Alterations in Mood

• Patient safety interventions adjusted for progression through stages of dementia
• Environmental interventions
• Socialization activities
• Home visits
• Community actions

• Speak clearly, slowly, directly
• Don’t approach from behind
• Face patient
• Use of para-verbal and nonverbal communication techniques

• Vascular dementia
• Dementia caused by other conditions:
• AIDS
• Head trauma
• Parkinson’s disease
• Huntington’s disease
• Pick’s disease
• Creutzfeldt-Jakob disease
• Substance-induced persisting dementia

• Impairment in memory caused by medical condition or persisting effects of a substance
• Severe memory impairment without other significant cognitive symptoms
• Can be caused by a variety of pathologic processes