Points of Geriatric Psychiatry Epidemiology
Prevalence of mental disorder Barriers to mental health service utilization
Normal aging Psychiatry disorders or problems commonly seen
Dementia, depression, delirium, sleep problems, anxiety, suicide
Treatment Pharmacotherapy, Psychotherapy Treatment models
Mental disorders among older adults--ECA
community inpatients
Cognitive impairment 4.9 30.2
Affective disorders 2.5 18.5
Anxiety disorders 5.5 5.2
Alcoholism 0.9 2.6
Schizophrenia 0.1 0
Somatization 0.1 0
Personality disorders 0 8.3
Others 0 7.9
Normal aging -- neuropsychiatry
Brain structure Decrease in gross brain weight
Widened sulci, gyral atrophy, Ventricles enlarge
Increased transport across BBB
Prefrontal lobes are disproportionately affected by aging
changes
Subcortical monoaminergic cell populations are subject to
prominent decline in aging
Normal aging -- neuropsychiatry
Cognition Takes longer to learn new materials
IQ remains stable until age 80
Verbal ability maintained with age
Psychomotor speed declines
Encoding ability diminishes
Simple recall declines
Normal aging -- Sleep
Latency to sleep onset
Frequency of awakening
Total stage-3, & -4 sleep
Total stage-1, & -2 sleep
Redistribution of REM sleep
精神疾病盛行率 -- TOADS
憂鬱症 21.2% 含重鬱症與輕鬱症
器質性精神病 14.3% 含癡呆症
其他精神疾病 2.1% 精神分裂症、強迫症、慮病症、畏懼症、焦慮症
無精神科疾病 62.4%
Features of Mental Problems among the elderly
Highly comorbid with Medical illness Disabilities
Complication of psychopathology Cognitive dysfunction Distinct clinical courses
Barrier to assess mental health resources
Long-term care (LTC) facilities- USA data
4.13% elders in LTC facilities in 1995
8% of nation’s total health care costs
Mean age increased in LTC facilities
Very disabled Options and setting becoming
diverse
Jones A: Vital Health Stat 13 2002:1-116Gabrel C and Jones A: Vital Health Stat 13 2000:1-83
行政院主計處 國情統計通報第 207號
10/29/2004
所 比例 *
安養 65 0.38%
養護 781 0.96%
護理養護 25 0.04%
Total 871 1.38%
* 佔全體 213 萬老人的比例
長期照顧機構與人數
Barriers to geriatric mental health care
Poorly served by the mental health system Fewer visits for mental health care Rely more heavily on primary care physicians Low rate of depressive elders taking antidepressant
Possible reasons Stigma Low rate of case identification by primary physicians
Multiple medical illnesses divert physicians’ attention Depression and anxiety may be viewed as normal
Neglect by family
Life events
Death of significant others Medical ill of oneself or partner Disability Financial issues Relationship with family Retirement
失智症 又名癡呆症 隨著全世界的老年人口增加,預期失智症病
人也會愈來愈多 失智症成因很多
阿滋海默症為最多 血管性失智症與 Lewy body 式症其次
失智症造成個人、家庭很大的負荷與巨大的醫療支出
失智症患者常有精神症狀 高達 90% 的失智症患者至少有一種精神症狀症狀 %
妄想 20-73
錯認 23-50
幻覺 15-49
憂鬱 Up to 80
躁症 3-15
人格改變 Up to 90
行為問題 Up to 50
攻擊 / 敵意 Up to 20
照顧者負荷 照顧者因素
照顧提供者 > 照顧管理者 配偶 > 其他親人 女 >男 親近的互動 ( 例如住在一起 ) 來自家人與朋友的支持較少者 對失智症了解較少者 之前關係較不好者 負向情緒表露者 之前有憂鬱者 健康不佳者
照顧者對精神障礙的影響 惡化精神障礙的照顧者行為
瞬間更動例行活動與環境 超出病患能力的要求 堅持病患按照一定的方法完成事情 過度批評 忽略病患需要 過度僵化與控制 反覆詢問”讓”病患記住事情 對病患發脾氣或攻擊 被激怒
照顧者對精神障礙的影響 減輕精神障礙的照顧者行為
同理、耐心、溫暖 努力了解問題行為的原因 不急躁 有彈性不堅持 可以接受變化 對病患的能力有合理的期望 能容忍問題的行為例如反覆詢問 努力讓病患完成每日的活動
照顧者對精神障礙的影響 減輕精神障礙的照顧者行為
強化病患個人的獨特性 允許病患有些主控生活與環境的感覺 真誠關心病患的福祉與利益 尊重病患的情緒與感覺 對於親愛的病患不會有愧疚 不忌諱別人知道病患的疾病 保持幽默感 不會老是想著病患的限制 尋找與維持一個情緒支持的依靠
Causes of delirium
Drugs and alcohol Intracranial causes Metabolic and endocrine disorders Systemic infections Postoperative states
Late life depression
Late-onset vs. early onset Vascular depression Subsyndromal depression Depression-executive dysfunction syndrome
Increases with:
agebereavementisolationdeteriorating healthpain
Actual & attempted are closely linked
Suicide
Vascular depression hypotheiss
Subtype Vascular risk factors, neuroimaging findings More cognitively impaired, more disabled,
more psychomotor retardation, less insight Disruption by vascular lesions of striato-
pallodo-thalamo-cortical pathways
Medications associated with depression
Antihypertensions Reserpine Methyldopa βblockers
Oral contraceptives Steroids BZD H2 antagonists
Cimetidine Ranitidine
Chemotherapy ….. Interferon
Psychoactive substances Alcohol Opiates Amphetamine
withdrawal
Treatment Treating underlying medical conditions &
reducing disability Psychopharmacology: selection depends on
Side effect profiles Concurrent conditions and medications Target symptoms Previous treatment responses
ECT Psychotherapy
Sleep disorders
Lack of social or vocational activity Disturbed circadian rhythm
living in nursing home, without daily routines degenerative brain
Breath related sleep disorders Alcohol or drugs induced sleep disorders Sleep related accidents
Neuropsychiatric syndrome
Post Stroke syndrome Depression, anxiety, apathy, psychosis, mania,
emotional lability Parkinson’s disease and Parkinsonism
Depression, anxiety, mania, psychosis, drug induced psychosis
Principles of pharmacological treatment
Pretreatment medical evaluation Given in equally divided dose Reduced dose to 1/4~1/2 as the young need Simplified medicine Slow titration from low dose Know the interaction between medicine
認知功能評估 篩選評估
e.g. Mini-Mental State Examination (MMSE) 臨床評估
e.g. 簡易床邊檢查 e.g. 臨床失智評估 (Clinical Dementia Rating,
CDR) 完整的認知功能評估
e.g. 臨床心理師施測
記憶力 學習記憶 (Anterograde)
記住姓名與住址例如:屏東縣 萬丹鄉 新庄村 中正路 42 號 王 智中
立即記憶 ( 三次 ) /7, /7, /7
五分鐘後記憶 /7
回溯記憶 (Retrograde) 常識
例如:現任總統是誰?前任總統是誰?中秋節哪一天?
定向感 時間
今天是民國幾年 ___幾月 ___幾日 ___星期幾 ____
現在幾點 _____
地點 這裡是哪裡 ____幾樓 ____
人 陪你的人是誰 ____叫什麼名字 ____幾歲 ____
注意力 十二生肖倒著說 錯誤幾個 ___ 數字記憶廣度 (Digit Span)
正背 倒背 5-8-2 3-9 6-9-4 6-2 6-4-3-9 3-7-2 … … 4-1-7-9-3-8-6 1-4-9-3-7-4
失能 (disability)
Activities of daily living (ADL) 用餐、穿衣、整理儀容、走動、上下床、洗澡、上廁所
Instrumental activities of daily living (IADL)使用電話、使用交通工具、購物、準備三餐、處理家務、自行服藥、處理金錢
Top Related