Lecture - Older Adult Mental Illness Flashcards
How do you assess an older person with mental illness?
-
Use biopsychosocial approach for assessment and management
- History, examination, collateral and request GP records
- Look for organic cause and assess cognition (labile?); look for psychiatric cause .
- Use ACEIII, GDS, personality
- Assess for falls, ADLs, vulnerability, loneliness
- Ix: bloods FBC, U&Es, TFTs, HbA1c +/- B12, folate, Ca, syphilis, HIV, urine MC&S, CXR, head scan
How do you manage an older person with mental illness?
- Biopsychosocial approach
- Treat physical/reversible causes, correct hearing/eyesight CBT, supportive psychotherapy, HTT
- Safeguarding, POC, respite, key safe; carer stress
- Risk management – least restrictive?
Why is mirtazipine good for depression in elderly?
Helps with insomnia and appetite - NB it has a paradoxical effect so lower doses have more of a sedative effect
What is the most common mental illness in old age?
Depression
Depressive symptoms appear in up to a third
What are the suicide risk factors in old age?
- Male
- Widowed
- Older
- Social isolation
- Physical illness
- Pain
- Alcohol
- Depression
What is the management of depression in old age?
1st line = Sertraline or mirtazapine first line
2nd line = Older adults less likely to receive talking therapy, but IAPT now includes older adults and long-term conditions
- Antidepressants are beneficial, unless cognitively impaired but have increased risk adverse effects e.g. falls, hyponatraemia, bleeding*
- Give longer trials + may need higher doses*
What is the diagnosis and management?
68yo woman now fixated on the Quran, out of keeping with family’s beliefs, believes she is being poisoned, has stopped eating and drinking, saying she is unable to swallow.
This is severe depression with psychosis
Mitrazipine and Olanzapine
How do you treat psychotic depression in old adults?
- Antidepressant with antipsychotic
- ECT if severe
Usually have mood congruent delusions e.g. guilt, poverty, nihilistic
What is the diagnosis?
70yo man with behavioural change, forgetting things, poor sleep, bought chocolates worth £1,500 and designer clothes worth £2,000, bought air tickets toUSA but couldn’tfind passport then got angry at passport office and police were called, was later arrested for travelling without a passport.Concerns his flatmate may be abusing him financially.
BAD - bipolar affective disorder
What medications in the elderly can induce mania?
Steroids
Antidepressants (treat depression with Quetiapine instead)
What is the management of BAD in old patients?
Less common in old adults so look for organic cause if no previous history
1st line for Mania
- Antipsychotic like lithium or valproate
- Stop antidepressant
1st line for Bipolar depression
- Quetiapine or lamotrigine +/- antidepressant
Mood stabiliser for life
What are some possible diagnoses?
78yo man in hospice with mesothelioma, confusion over medications, accidental overdose of analgesia, episodes of paranoia, feels the nurses are attacking him, and that the carer shot him with a stun gun
- Delusional disorder (most likely in old adults with this presentation)
- Late onset schizophrenia
- Acute and transient psychotic disorder
What are some features of late onset schizophrenia?
- Persecutory delusions
- Multimodal hallucinations - visual, tactile, auditory
- Fewer negative symptoms - less social withdrawal, less effects on cognition and personality
- High rates of hospital admission
What are the risk factors for late onset schizophrenia?
- Female
- Sensory impairment (esp hearing)
- Social isolation
- Poor social functioning
What is the management of late-onset schizphrenia?
1st line - medication; all antipsychotics superior to placebo:
- Amisulpride, olanzapine or risperidone
- Maybe aripiprazole
- Clozapine if treatment-resistant but higher neutropaenia
Considerations:
- Don’t treat unless risks/distress
- Longer half-life, higher plasma levels
- START LOW,GO SLOW
- Risks of EPSEs, falls, cardiac effects, sedation, hyperprolactinaemia, osteoporosis
- Increased risk of death (worse with typicals)
