theories of ageing and psychological disorders in elderly

1. Dr. DOHA RASHEEDY ALY
Lecturer of Geriatric Medicine
Department of Geriatric and Gerontology
Ain Shams University

2. Ageing

Aging is a process of general, irreversible,
and progressive physical deterioration that
occurs over time.
This process usually occurs after sexual
maturation and continues up to the time of
maximum longevity (life span) for members
of a species.
Death is the final event.

3. 
 Biologically, ageing is defined as a deteriorative
process.
 Socially too, ageing appears as a time of loss of roles
and relationships.
 Thus it is not surprising that consideration of
adjustment should have such a prominent role in the
psychological study of ageing.

4. 

5. Definition
(Conceptual)

Normal Ageing
 without biological or mental pathology
Optimal Ageing’ Successful ageing’
 Ageing under development enhancing and age-friendly
environmental conditions
Pathological Ageing
 Ageing process determined by pathological processes.

6. Conceptions of Age

 Chronological age—number of years elapsed since
person’s birth
 Biological age—age in terms of biological health
 Psychological age—individual’s adaptive capacities
 Social age—social roles and expectations related to
person’s age

9. Theories of ageing

 Aging processes occur at the biological,
psychological and social levels. There are any
number of different theories of aging, which are
generally specific to each discipline. The truth is, no
one is really certain why we age, although we are
beginning to identify different processes which
regulate or govern the rate of aging.

10. Psychological Theories of
ageing

Life span
 Selective optimization:
 Socioemotional selectivity
 Cognition and aging
 Personality and aging

11. Life Span Development Theory

 Life-Course Theories
 ·Erikson's developmental stages, which here approaches
maturity as a process. Within each stage the person faces a
crisis or dilemma that the person must resolve to move forward
to the next stage, or not resolve which results in incomplete
development

12. 

13. Psychological Theories of
ageing

 Life span
Selective optimization:
 Socioemotional selectivity
 Cognition and aging
 Personality and aging

14. Selective Optimization With
Compensation Theory
 Optimization = Engagement
in behaviors that will enrich
ones life and help people
age successfully.

15. Psychological Theories of
ageing

 Life span
 Selective optimization:
Socioemotional selectivity
 Cognition and aging
 Personality and aging

16. Socioemotional Selectivity
Theory

 The theory that social exchanges and interactions
are reduced over time.
 As one ages a person may become more selective
with whom they choose to spend their time with.
Emotional closeness may become more
important with significant others. The idea to
which one can selectively choose with whom
they want to dedicate their time for becomes
more important as ones ages. * (quality verses
quantity)

17. Psychological Theories of
ageing

 Life span
 Selective optimization:
 Socioemotional selectivity
Cognition and aging
 Personality and aging

18. Cognitive and Aging Theories

 ―The theory of cognition is the age-related decline in
fluid cognitive performance (the efficiency or
effectiveness of performing tasks of learning,
memory, reasoning and spatial abilities.) However,
crystallized abilities are more stable across the life
span and may even increase with age. (Representing
social cultural influences on general world
knowledge)‖. (Bonder, 2009)

19. Cognitive and Aging
Theories

 Cognitive changes with aging are well documented
and affect a broad range of functions. There are at
least three fundamental cognitive-processing
affected: the speed at which information can be
processed, working memory, and sensory and
perceptual skill.

20. Processing Speed

 Perhaps the most predictable of all cognitive changes
is the reduced speed of information processing and
response. Slowed execution of component perceptual
and mental operations can affect attention, memory,
and decision making and can influence performance
even on tasks that have no obvious speed
requirements (Salthouse 1996).

21. Working Memory

 Working memory refers to short-term retention and manipulation
of information held in conscious memory, Examples include
consciously recalling a telephone number long enough to write
it down, mentally calculating the sale price of an item that is
reduced by 15%. Information fades from working memory
within about 2 seconds, so to keep details ―alive‖ for a longer
time requires active rehearsal or continuing refocusing of
attention.
 Aging is associated with a decline in working memory skills,
especially when active manipulation of information is required
(e.g., repeating numbers backward as opposed to forward).
Reductions in working memory, in turn, place limits on other
complex cognitive skills, including reasoning and other
executive processes, and learning and recall of new information

22. Sensory and Perceptual Changes

 Most older adults experience decrements in visual and
auditory acuity and other perceptual changes. Some, but
not all, of the age-related visual changes can be corrected
by glasses, and although hearing aids help with detection
of low-frequency tones, they often amplify background
noise. In effect, many older adults find it hard to hear or
see well, especially with competing background noise and
poor lighting conditions.
 Recent studies suggest a strong correlative link between
sensory and perceptual changes and cognitive
performance in old age

23. 
 These changes increase the likelihood of processing
overload in circumstances that may have once
presented little challenge.
 In advanced old age, even basic activities such as
walking or maintaining postural control become less
automatic, with the result that older persons must
devote more conscious cognitive resources to these
activities.

24. 

25. 

26. moderating variables

 Genetic factors About 50% of cognitive variability in old age can be traced to genetic factors.
 Health Optimally healthy elderly persons outperform those with medical illnesses on many
cognitive tests.
 Education Education accounts for up to 30% of cognitive variability in old age.
 Mental activity Mentally stimulating activities correlate with higher cognitive performance and
reduced longitudinal decline.
 Physical activity Aerobic fitness is associated with better cognitive performance in old age.
 Expertise Aging experts may develop compensatory strategies to maintain a high level of
performance despite some erosion in underlying cognitive skills.
 Personality and mood Depression correlates with self-perceived memory failure and with
performance impairments if symptoms are severe.
 Social and cultural milieu Everyday memory lapses may be judged more critically when
experienced by older people than by young adults.
 Cognitive training Cognitively unimpaired older persons benefit from practice and training in
specific cognitive skills.
 Sex differences Cognitive aging trends are similar for the two sexes, but women may show
decrements on spatial tasks at an earlier age than men, and men may show decrements on verbal
tasks at an earlier age than women.
 Racial and ethnic differences Performance differences favoring elderly white persons have been
reported on some cognitive tests, but when education is equated across groups, these differences
are reduced or eliminated.

27. Psychological Theories of
ageing

 Life span
 Selective optimization:
 Socioemotional selectivity
 Cognition and aging
Personality and aging

28. Personality & Aging Theories

 Theories focus on the nature and extent of personality
stability and how they change over a persons life span.
 Developmental Explanations and Personality Trait
Explanations based on the ―big five‖:
1) neuroticism
2) extroversion
3) openness to experience
4) agreeableness
5) conscientiousness
 Many believe that personality traits are more stable later
in life whereas ―goals, values, coping styles and control
beliefs‖ are more that likely to change. (Bonder, 2009)

29. Personality and
Emotional Changes

 Personality and emotions have not been studied as thoroughly
as cognition in old age. Moreover, it is unknown whether
observations about personality made within the confines of a
particular generation and culture can be generalized to other
places and times.
 Core features of personality remain stable throughout
adulthood, and any marked change in mood or social behavior
may indicate a disorder. However, more subtle reordering of
personal priorities and shifts in coping styles are common with
normal aging. It is particularly important not to measure older
people’s coping by youthful standards.
 Emotion-focused coping may be a sign of personality
development rather than regression, particularly if the problem
being faced (e.g., bereavement or serious illness) is difficult to
resolve through action.

30. 
 In one study comparing the emotions of younger to older
people, volunteers were asked to state how often in the
previous year they had experienced each of 46 different
emotions. The results showed that older people
experience stronger direct feelings of anxiety in the form
of fear or being scared, whereas younger people tend to
experience more guilt-related anxiety.
 Older people also report fewer experiences of depression,
hostility or shyness. So, the overall structure of emotion
between older and younger people seems similar, but the
strength the relationship and frequency of emotional
experience does differ.

31. 
 It appears that older people do experience less intense
emotions. It may also help to explain why they find the
emotional dysregulation of early stage Alzheimer's so
troubling. In some situations the elderly may show very
little or no emotion where some might be expected; in
other situations they may be moved to tears in a display
of emotion that may seem out of place.
 Variation in emotional pattern is something that needs to
be considered in any assessment of the elderly by
younger people. Caution against using phrases such as,
'flattened affect', or 'emotionally labile', should be
exercised in the realization that what is being observed is,
in fact, perfectly normal.

32. Hanighurst stated that for older people to progress they
must meet the following tasks

1. Adjust to declining health & physical strength.
2. Adjust to retirement & reduced income.
3. Adjust to the death of a spouse or family members.
4. Adjust to living arrangements different from what
they are accustomed.
5. Adjust to pleasures of aging i.e. increased leisure &
playing with grandchildren

33. Psycho-Social Theories of
Aging
Disengagement
Theory
Activity Theory
Continuity Theory

34. Disengagement
Theory

 developed by Cummings and Henry in late 1950’s.
 ―aging is an inevitable, mutual withdrawal or
disengagement, resulting in decreased interaction
between the aging person and others in the social
system he/she belongs to.‖

35. Activity Theory
 in the 1960’s.
 developed by Robert Havighurst
 supports the maintenance of regular activities, roles, and social
pursuits.
 persons who achieve optimal age are those who stay active.
 as roles change, the individual finds substitute activities for
these roles.

36. Continuity Theory

 proposed by Havighurst and co-workers in reaction
to the disengagement theory
 ―basic personality, attitudes, and behaviors remain
constant throughout the life span‖

39. Developing psychopathology
(Psychodynamic models)

 Busse & Pfeiffer 1969: Loss people, roles, physical
capacity, opportunity. (nb depression is no greater in
elderly)
 Gutmann 1992: losses in later life re-enact losses in
childhood
 Vaillant 1993:Immature defence mechanisms provide
insufficient defence against problems of old age
 Gutmann 1992: loss of physical, cognitive, emotional
strengths undermine functioning of ego.

40. 
• Stressors faced by older people
• Mediators shaping a person’s response to stress
• Moderators that act on the stressor to lessen its
intensity or buffer its effect

41. Stressors

 Demands that call forth a physiologic, behavioral, or emotional
response
 TYPES OF STRESSORS:
 Chronic
 May be health-related (eg, the pain and mobility limitation of arthritis)
 May be psychologic (eg, the prolonged worry over a chronically ill
spouse)
 Acute
 May be health-related (eg, a newly diagnosed medical condition)
 May be psychologic (eg, experiencing the unexpected death of a close
friend

42. Examples OF STRESSORS

 Caregiving
 Loss and Grief
 Role Loss ( spouse , friends, work) and Acquisition
(Grandparenthood and great-grandparenthood)
provide both new demands and opportunities.
 Social Status
 Changes in social identity: due to role loss in retirement
 Losses in physical capacity and reserve
 Functional losses may place older persons in help-
seeking rather than help-providing roles

43. Mediators

 The internal and external resources a person can
bring to bear to:
 Assess and interpret a stressor
 Assess his or her capacities for addressing it
 Formulate a coping response
 Often modifiable through interventions such as
psychoeducation and family counseling

44. Types of Mediators
 SELF-EFFICACY BELIEFS: Sense of one’s own ability to manage
situations.
Strong self-efficacy beliefs:
 Contribute to good choice-making, good performance, and persistence of effort (especially in
women)
 Contribute to increased productivity
 COPING STRATEGIESCommon coping strategy: selection, optimization,
compensation
 Elderly select activities based on what they already do well
 They do the selected activities more often and derive optimal credit
for doing them
 As performance diminishes, they employ compensatory strategies to
put remaining capacities in the best light possible
 SOCIAL INVOLVEMENT: there is an association between lack of
social involvement and affective disorders such as depression.

45. MODERATORS (Buffer)

 Behaviors or components of a person’s life that affect
the demands of stressors
 May be in place before the onset of a stressor or
may be developed in response to it
 Three major types:
 Social involvement
 Spiritual or religious activity
 Engaging in healthy lifestyle behaviors

47. Coping with Psychosocial
Changes & Developmental Crises

Support System
Community Resources
Counseling
Prayer/Religion

48. Spirituality and
Religiosity
 confused.
 These concepts are frequently
 Studies have found that nurses tend to avoid
addressing spiritual needs of patients.

49. Spirituality is the:
 which all other
―totality of man’s inner resources,
 the ultimate concerns around
values are focused,
the central philosophy of life that guides conduct,
and the meaning-giving center of human life
which influences all individual and social
behavior‖ (Moberg, 1979)
―trust & faith in a power greater than oneself‖
(levin & Taylor, 1997)

50. Religion is:

 only one aspect of spirituality;
 an organized practice of beliefs;
 may or may not fill an individual’s spiritual needs
eg. spiritual needs are much broader & more
personal than any particular religious persuasion

55. Ageing and mental
disorder

Mental illness is not a manifestation of ageing
Approximately 88% of people over the age of
65 do not suffer from mental disorder
Excluding cognitive impairment means that
people over the age of 65 have the lowest
prevalence of mental disorder by age group.

56. Mood disorders

Anxiety disorders
Psychotic disorders
Personality disorders

57. Depression


58. 
Is depression a normal
response to the aging
process?
NO

59. EPIDEMIOLOGY

Prevalence over 65
▫ 1.4%
▫ 0.4%
▫ 1% overall
▫ Higher in institutional setting: Up to
25-40% in a general hospital setting
and in long term care

60. 
Depression is under-reported: WHY?
 Communication issues (eg. hearing impairment)
 Presence of dementia
 Symptom overlap
 Stigma of aging
 Depression is ―normal‖
 Symptoms ―masked‖ by co-morbid illness
THEREFORE YOU MUST SCREEN IN THOSE AT
HIGHER RISK!
Geriatric Depression Rating Scale

61. 
What are risk factors for depression in the
elderly?
 Recently bereaved
 Female gender
 Single/widowed (recently)
 Stressful life events (eg. prolonged hospitalization,
recent move to nursing home)
 Social isolation
 Persistent complaints of memory difficulties, diagnosis
of dementia
 Chronic disabling illness or recent major physical illness
(eg. Parkinson’s disease, stroke)
 Chronic sleep problems or anxiety

62. 
Does depression look different in the elderly?
• ―Depressed mood‖ may be less prominent
• More anxiety
• More likely to express somatic complaints
▫ 65% have hypochondriacal symptoms
• Less likely to report guilt feelings
• Cognitive impairment more common
• Psychosis more common
▫ Typical delusions – more common
 Somatic, persecution, nihilism, poverty

63. DSM-IV DIAGNOSTIC
CRITERIA

• 5 or more symptoms lasting >2 wk,
change from previous functioning:
▫ Depressed mood and/or loss of interest
▫ Altered sleep, loss of energy, appetite
change or weight loss, feelings of
worthlessness/guilt,psychomotor
changes, loss of concentration and focus,
recurrent thoughts of death

64. Medical Conditions Mask
or Cause Depression

• Autoimmune • DRUGS
▫ Propranolol
• Cerebrovascular
▫ Cimetidine
• Chronic pain ▫ Clonidine
• Degenerative Disease ▫ Benzodiazepines
• Endocrine ▫ Steroids
• Metabolic ▫ Tamoxifen
▫ Many more...
• Neoplasms
• Infections

65. Depression &Parkinson’s Disease

 About 50% of patients develop depression
 Useful treatment includes TCA’s
 ECT helps depression and PD sx’s:
 tremors, rigidity, & bradykinesia improved with 3-4
sessions
 depression improved after 7-9 sessions

66. Depression in Early Alzheimer’s

 Presents with:
 insomnia
 fatigue
 agitation
 psychomotor retardation
 decreased interest & energy
 concentration problems
 50% of AD pt’s have depressive sx’s (15-20% with
major depression)

67. Vascular Depression

 Cerebrovascular disease can precipitate or
perpetuate depression
 Caused by ischemia (―silent strokes‖) in prefrontal
cortex and basal ganglia; motor & sensory deficits
usu. not found.
 Marked apathy
 Lack of insight into depression
 Less depressed ideation
 Executive dysfunction
 Treatment resistance

68. Pseudodementia

“dementia of depression”
 cognitive decline that clears if depression is treated
 however, dementia rate in these patients is still
20%/year even after full recovery of intellectual
function.

69. SUICIDE IS A REAL
RISK

 25% of all completed suicides are > 65
 Suicide rate for depressed men over 65 is 5 times
higher than for younger men
 20% of older people who committed suicide saw a
physician that day
 Increased risk: financial problems, physical illness,
recent loss, abuse, isolation

70. ASSESSMENT

1-History:
 Recent symptom profile
 Recent changes/ how long?
 Past psychiatric history
 Past medical history
 Current medications
 Any recent medication changes

71. ASSESSMENT

 Social history/ Personal history(include interests and
hobbies)
 Functional ability/level of care
 Any recent changes in ADL’s / IADL’s
 Any stressors (past/new)
2-Screening tool:
 Geriatric Depression Rating Scale
 Mini- Mental Status Exam
3-medical work-up (includes blood work, urines, CT Scan,
X-Rays etc..)

72. INTERVENTIONS

 Seek out medical illness
 Recognize medical side effects
 Rehab services to maximize remaining function and
retrain impaired iADL’s
 Involve family and caretakers
 Counselling: role transitions, grief, dependency
 Medications / ECT

73. MEDICAL THERAPY IN
GERIATRIC DEPRESSION

 Select based on symptoms, prior response,
concurrent illness, side effect profile
 Reassess after 4-6 weeks:
 Increase dose, augment with second agent, add
psychotherapy
 Consider psychiatric consult/referral

74. Guidelines for Starting Antidepressants:
“Start low, go slow”

 Start at half the dose of younger people
 Aim to reach an average dose at one month

75. Guidelines for Switching
Antidepressants

Change if:
 No improvement in symptoms after at least 4 weeks at
maximum tolerated or recommended dose
 Insufficient improvement after 8 weeks at maximum tolerated
or recommended dose
When recovery is incomplete after an adequate trial, consider:
 Further 4 weeks of treatment, with or without augmentation
(meds or psychotherapy)
 Switching to another antidepressant
 When switching, it is safe to reduce the first medication
while starting the alternate (cross-over titration)
 Consider specific interaction profiles

76. 
Long-term Treatment Guidelines:
 After 1st episode continue to treat for at least a year
 Monitor for recurrence up to 2 years
 Medication discontinuation should be slow (over months)
 Patients with partial resolution of symptoms, more than 2
episodes, severe or difficult to treat depression, or
treatment requiring ECT, should receive indefinite
treatment
 Treatment response in nursing home patients should be
evaluated monthly after initial improvement, and at
quarterly care conferences and annual assessment once
remission is achieved
 Consider tolerance of treatment versus risks of
discontinuation

77. ANTIDEPRESSANTS TO
AVIOD IN THE ELDERLY

 Too many side effects:
 Older TCA’s:
 amitriptyline, clomipramine, doxepin, imipramine,
protriptyline, trimipramine
 MAOI’s:
 phenelzine, tranylcypromine

78. 
PROGNOSIS?
Similar response rates to younger
patients

79. Other Treatments

Counseling
Electro-convulsive therapy (ECT)
Support Groups
Day Hospital Treatment programs
Social/ Community groups
Combination of medications and above items
Volunteer work
Hobbies
Pet therapy

80. Other Treatments

 Music therapy
 Humor therapy
 Reminiscence
 Depression education
 Bereavement therapy

81. Electroconvulsive Therapy

 Relatively safe (complication rate 1 in 1400
treatments, mortality rate 1 in 10,000)
 Effective - about 80% respond, although this drops to
50% if all other modalities have been tried
 Particularly useful for active suicidal ideation,
psychotic depression, Parkinson’s-related
depression, and for medication failures
 Very effective short term, but with high relapse rates
over next 6-12 months.
 Drug therapy can reduce relapse

82. PSYCHOTHERAPY

 Cognitive-behavioral therapy (CBT), problem-
solving therapy (PST), and interpersonal
psychotherapy (IPT) are effective treatments for
major depression either alone or in combination with
pharmacotherapy.

83. Personality disorders


84. Ageing & Personality

 There is no clear answer to the question of whether or not
personality changes with age.
 Several studies have demonstrated remarkable stability of
personality factors with aging. Others have shown age-related
changes in certain personality traits, including decreases in
extraversion and an increase in harm-avoidance.
 It is possible that the apparent stability of personality with age
relates to genetic factors and environmental stability. The
changes reported in some studies may reflect adaptations to
changing life-roles, medical co-morbidity and social
circumstances. The issue is complex, as changes in behavior do
not necessarily reflect shifts in personality.

85. 
 personality disorders as persistent, pervasive
patterns of inner experience and behaviour that
begin in childhood or adolescence, continue into
adulthood and are stable over time.
 These disorders manifest in cognitive, affective and
behavioural patterns that deviate markedly from
cultural norms and lead to distress or impairment.
 None of the instruments for assessment of
personality disorder have been validated for use in
elderly.

86. 

87. 

88. 

89. 
 Cross-sectional studies of personality disorder in old
age suggest that there is a lower prevalence of cluster
B disorders and a higher prevalence of cluster C
disorders.
 However, some suggest that features of borderline
personality disorder are relatively dormant in
middle life and re-emerge in old age.

90. Anxiety disorder


91. Anxiety disorder

 Determining the epidemiology and prevalence of
anxiety disorders in old age is complicated by the
fact that anxiety is a symptom of most psychiatric
and many medical conditions in old age.
 Classes of Anxiety Disorders
 Panic Disorder
 Phobic Disorders
 Obsessive-Compulsive Disorder
 Posttraumatic Stress Disorder
 Generalized Anxiety Disorder

92. ASSESSMENT
DIFFICULTIES

 Medical comorbidity
 Difficulty in differentiating anxiety from depression
 Falsely high scores on anxiety rating scales due to
cardiac and respiratory problems
 Tendency of older patients to resist psychiatric
evaluation

93. PANIC DISORDER
 Panic attack:

 Acute, discrete episode of intense anxiety
 Reaction to some perceived threat
 Lasts between a few minutes and a half hour
 Symptoms may include:
 Trembling, dizziness, sweating, nausea
 Accelerated heart rate, chest pain, shortness of breath
 Sense of detachment from surroundings
Slide

94. DIAGNOSIS OF PANIC DISORDER
 Recurrent and unpredictable panic attacks

 Have occurred for at least 1 month
 Patient spends time in worried anticipation of
possible recurrence
 Onset after age 55:
 Fewer panic symptoms
 Less avoidance
 Lower score on somatization measures
 Less likely to persist into old age
Slide

95. SPECIFIC PHOBIA
 Involves a distinct trigger, such as a specific person,

animal, place, object, event, or situation that results in
symptoms of anxiety
 Commonly, the patient’s anxiety level increases
instantly when the feared trigger is encountered
 Patient is able to identify this fear as unrealistic and
unsupported, even though the cognitive and
physiologic responses persist
Slide

96. SOCIAL PHOBIA
 Fear of reactions that are embarrassing in social
situations, such as: 
 Trembling, Blushing, Sweating profusely
 Feared situations include:
 Giving public speeches, Socializing with others at a
function or party
Slide

97. OBSESSIVE-COMPULSIVE DISORDER

 Obsessions: persistent thoughts or ideas that come to
mind in a particular situation
 Compulsions: behaviors performed in an effort to
decrease the anxiety experienced as a result of the
obsessions
 Chronic and often disabling
 New onset in late life is unlikelycommonly associated
with a depressive syndrome or early dementia
Slide

98. POSTTRAUMATIC STRESS DISORDER

 Common symptoms:
 Re-experiencing of the traumatic event
 Avoidance of associated stimuli (both cognitively and
behaviorally)
 Hyperarousal (eg, difficulty falling or staying asleep,
 Often comorbid with depression, panic disorder, and
substance abuse
 Diagnosis requires presence of symptoms for 1 month and
clinically significant distress or functional impairment
Slide

99. GENERALIZED ANXIETY DISORDER
 Distinctive symptoms: 
 Feeling easily tired
 Muscle tension
 Trouble sleeping through the night
 Difficulty concentrating on a task
 Feeling irritable or on edge
 Diagnosis requires:
 Presence of symptoms for at least 6 months
 Sense that one cannot control the anxiety
Slide

100. COMORBIDITY

 Mixed Anxiety and Depression
 Anxiety and Agitation in Dementia
 Anxiety and Medical Disorders
Slide

101. Management

Pharmacological
 Antidepressants are probably the treatment of choice. Studies in older adults are
limited but citalopram and venlafaxine have been shown to be effective and well
tolerated.
 Benzodiazepines are effective in treating the symptoms of anxiety but at the cost of
confusion, sedation, falls, tolerance and dependence. Use of benzodiazepines is
limited to low doses for short periods and is generally avoided.
 Buspirone has been shown to be effective in the treatment of GAD and does not
cause sedation or dependence. It may be less effective than antidepressants in the
treatment of anxiety. Response delayed for 2-4 wks.
 Beta-blockers are sometimes prescribed to treat the physiological symptoms of
anxiety.but in elderly patients the benefit is likely to be outweighed by the risk of
side effects.

102. Non-pharmacological

 CBT is effective in elderly patients. but less so than in
younger adults.
 Nondirective supportive therapy may be as effective
as CBT in the elderly.

103. Psychotic disorders


104. PSYCHOTIC SYMPTOMS

 Hallucinations are abnormal perceptions that can
affect any of the 5 sensory modalities (auditory,
visual, tactile, olfactory, gustatory)
 Delusions are false fixed believes that can be:
 Suspicious (paranoid)
 Grandiose
 Somatic
 Self-blaming
 Hopeless

105. Differential diagnosis PERSON WITH
PSYCHOTIC SYMPTOMS

 Delirium
 Dementia
 Delusional disorder
 Primary mood disorder and Schizoaffective disorder
 Schizophrenia
 Temporal lobe epilepsy
 Medications
 Isolated Suspiciousness
 Syndromes of Isolated Hallucinations
 Charles Bonnet Syndrome
 Organic Hallucinations

106. 
 Only after other causes are excluded should the
diagnosis of a schizophrenia-like state be made
 Delirium, most often superimposed on an underlying
dementia, is the most common cause of new-onset
psychosis in late life
• Next, consider a primary mood disorder

107. PSYCHOTIC SYMPTOMS IN
DELIRIUM

 Hallucinations, particularly visual hallucinations,
can be a symptom of delirium, even when it is mild
 Onset is usually acute, and there is often an
identifiable metabolic or infectious cause
 Mental status examination reveals:
 Multiple cognitive impairments
 Diminished or waxing and waning level of
consciousness

108. PSYCHOTIC SYMPTOMS IN
MOOD DISORDER

 Delusions are ―mood congruent‖
 In patients with depression:
 Delusional content usually reflects self-deprecation,
self-blame, hopelessness, or the conviction of ill health
 In patients with mania:
 Delusions are grandiose.

109. PSYCHOTIC SYMPTOMS IN
DEMENTIA

 Patients with dementia experience both
hallucinations and delusions
 Usually less complex than the delusions seen in
schizophrenia or mood disorder
 Common delusions in dementia:
 Belief that one’s belongings have been stolen
 Conviction that one is being persecuted
 Belief that one’s spouse is unfaithful

110. ISOLATED SUSPICIOUSNESS

 Suspiciousness is a personality trait (common to all
humans but varying in its prominence)
 May become more common in those 65
 Distinguished from psychotic disorders by:
 The understandable nature of the ideas (for example,
excessive worry about safety)
 The absence of other psychotic symptoms

111. CHARLES BONNET SYNDROME

 The criteria for this syndrome are:
 Visual impairment
 Visual hallucinations
 Partially or fully intact insight (the patient is aware that the
perceptions cannot be real but still reports that they appear
absolutely real and vivid)
 Lack of evidence of brain disease or other psychiatric disorder
 Affects 10%–13% of patients w/ bilateral acuity <20/60
Reassure the patient that the hallucinations are
a sign of eye disease, not mental illness

112. SCHIZOPHRENIA

 Chronic psychiatric disorder characterized by both positive and
negative symptoms
 Examples of positive symptoms:
 Hallucinations
 Delusions
 Thought disorder
 Examples of negative symptoms:
 Social dilapidation
 Apathy
 Exclude mood disorder and cognitive disorder

113. SCHIZOPHRENIA-LIKE
SYNDROMES OF LATE LIFE

 Onset after age 44
 Female:male ratio ranges from 5:1 to 10:1
 Prominent persecutory (paranoid) delusions and
multimodal hallucinations
 Differences from early-onset schizophrenia:
 Much lower incidence of thought disorder
 Personality often intact

114. 
 Unlike individuals with early-onset schizophrenia, many
persons with late-onset schizophrenia-like psychosis have
been able to:
 hold responsible jobs
 work efficiently
 But premorbid symptoms are common:
 Isolation
 ―Schizoid‖ (socially isolated personality) traits
 For that reason, can be confused with frontotemporal
dementia (formerly called Pick’s disease)

115. NONPHARMACOLOGIC TREATMENT
OF LATE-ONSET SCHIZOPHRENIA

 Establish trusting therapeutic relationship
 Empathize with distress caused by symptoms
 Encourage patient to maintain important
relationships
 Ask permission to discuss source of symptoms with
close family members or friends

116. PHARMACOLOGIC TREATMENT OF
LATE-ONSET SCHIZOPHRENIA

 Antipsychotic drugs are as effective in late-onset
schizophrenia as in early-onset cases
 Increase dose semiweekly or weekly, as needed
 Responders should continue for at least 6 months
 For patients who relapse on treatment or when the dose is
lowered, maintain treatment for at least 1 to 2 years
 Monitor for extrapyramidal side effects (EPS), such as
tremor, dystonic reactions, and bradykinesia
 Avoid polypharmacy by reducing or switching medication
rather than adding a medication for EPS

117. 