Geriatric Psychiatry
I. Introduction
Old age is not a disease. It is a phase of the life cycle characterized by its own developmental issues, many of which are concerned with loss of physical agility and mental acuity, friends and loved ones, and status and power. However, there are elderly persons with mental or physical disorders, or both, that impair their ability to function or even survive, known as the sick-old. Geriatric psychiatry is concerned with preventing, diagnosing, and treating psychological disorders in older adults and promoting longevity. Persons with a healthy mental adaptation to life have been found to live longer than those stressed with emotional problems.
II. Demographics
Late adulthood or old age is considered to begin at age 65. Divided into young-old, ages 65 to 74; old-old, ages 75 to 84; and oldest-old, age 85 and beyond. Also divided into well-old (those who are healthy) and sick-old (persons with an infirmity that interferes with daily functioning and that requires medical or psychiatric care).
The life expectancy in the United States is approaching 80 years, with an average of 74 for men and 81 for women. Women outlive men by about 7 years. People at least 85 years old now constitute 10% of those 65 and older and is the most rapidly growing segment of the older population.
III. Biology of Aging
The aging process (senescence) is characterized by a gradual decline in the functioning of all the body’s systems—cardiovascular, respiratory, endocrine, and immune, among others. An overview of all the biological changes is given in Table 27-1.
Cognition
Mild memory loss common—called benign senescent forgetfulness. New material can be learned; however, it requires more repetition and practice than in younger persons. IQ does not decrease.
Persons of low socioeconomic status are at a higher risk for cognitive decline than persons in higher groups. Cognitive decline slowed in persons who are involved in continual learning and stimulation.
IV. Medical Illness
The leading five causes of death in the elderly are heart disease, cancer, stroke, Alzheimer’s disease, and pneumonia. Central nervous system (CNS) changes and psychopathology are frequent causes of morbidity, as are arthritis and related symptoms. Benign prostatic hyperplasia affects three fourths of men over age 75. Urinary incontinence is believed to occur in as many as one fifth of
the elderly, sometimes in association with dementia. These common disorders result in behavior modification. Arthritis, for example, may restrict activity and alter lifestyle. The elderly, like other adults, are profoundly embarrassed by urinary difficulties and will restrict activities and hide or deny their disability to maintain self-esteem. Cardiovascular disease is a prominent cause of morbidity and mortality in the elderly. Hypertension may be present in 40% of the elderly, many of whom are receiving diuretics or antihypertensive medications. Hypertension itself can result in CNS effects ranging from headaches to stroke, and pharmacotherapy for this condition can result in mood and cognitive disorders (e.g., electrolyte disturbances due to diuretic treatment). Atherosclerosis, associated with both cardiovascular disease and hypertension, has been related to the occurrence of the major forms of dementia—not only vascular dementia but also Alzheimer’s disease. Sensory changes also accompany the aging process. One third of the aged have some degree of auditory disability. In one study, nearly one half of persons 75 to 85 years of age had lens cataracts, and more than 70% had glaucoma. Difficulties with convergence, accommodation, and macular degeneration also are sources of visual disability in the aged. These sensory changes frequently interact with psychopathological disabilities, serving to magnify psychopathological deficit and color symptoms.
the elderly, sometimes in association with dementia. These common disorders result in behavior modification. Arthritis, for example, may restrict activity and alter lifestyle. The elderly, like other adults, are profoundly embarrassed by urinary difficulties and will restrict activities and hide or deny their disability to maintain self-esteem. Cardiovascular disease is a prominent cause of morbidity and mortality in the elderly. Hypertension may be present in 40% of the elderly, many of whom are receiving diuretics or antihypertensive medications. Hypertension itself can result in CNS effects ranging from headaches to stroke, and pharmacotherapy for this condition can result in mood and cognitive disorders (e.g., electrolyte disturbances due to diuretic treatment). Atherosclerosis, associated with both cardiovascular disease and hypertension, has been related to the occurrence of the major forms of dementia—not only vascular dementia but also Alzheimer’s disease. Sensory changes also accompany the aging process. One third of the aged have some degree of auditory disability. In one study, nearly one half of persons 75 to 85 years of age had lens cataracts, and more than 70% had glaucoma. Difficulties with convergence, accommodation, and macular degeneration also are sources of visual disability in the aged. These sensory changes frequently interact with psychopathological disabilities, serving to magnify psychopathological deficit and color symptoms.
Table 27-1 Biological Changes Associated with Aging | |
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