Organization of inpatient care for Geriatric Mental Health Care

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Organization of inpatient care for Geriatric
Mental Health Care

• SHIV GAUTAM
• MD(psych), DPM, FAMS
• Sr.Professor, HOD Supdt.
• Psychiatric Centre Jaipur
• Addl.Principal SMS Medical College Jaipur

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Aging Physiology

• Individuals become more dissimilar as they grow.
• Abrupt decline in any system is always due to
  disease and not to normal aging.
• Normal aging can be attenuated by modification of
  risk factors.
• In the absence of disease decline in homeostatic
  reserve causes no symptoms and imposes few
  restrictions in activities of daily living
  regardless of age.

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Aging Pathology

• Multiple Pathology
• Cataracts, deafness, degenerative joint diseases,
  like osteoarthritis or osteoporosis, varicose
  veins are all conditions which are likely to
  develop slowly and to progress.
• Cancer, pernicious anaemia, thyrotoxicosis,
  myxoedema common due to deterioration of immune
  mechanisms.
• Obesity, diabetes, depression and dementia
  frequently seen

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Under reporting of illness

• Callous Attitude Towards Health
• Attitude of the Relatives

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Barriers to Obtaining Proper History

• Mental Confusion
• Deafness
• Concentration
• Co-operation
• Idiosyncrasis

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Neuro-Psychiatric Disorders

• Cerebrovascular Diseases
• Depressive and other Psychiatric Disorders
• Cognitive Impairment and Dementia
• Neurodegenerative Disorders
• Infections of the Central Nervous System, Sleep
  Disorders and Coma.

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Laboratory Evaluation and Other Investigations

• Routine Haematological Tests -
• Complete Blood cell count Platelets count
• Prothrombin time Serum Electrolytes
• Blood glucose level Renal Panel
• Hepatic Panel
• Routine Diagnostic Tests -
• Lipid Profile, Blood sugar fasting,
  Electrocardiogram, Chest radiograph,
• Optional EEG, CT Scan, MRI

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Facilities for an inpatients Geriatric Mental
Health Care

• Entrance with ramp and wheel chair
• Adequate OPD space with waiting facilities
• Consultation chambers for mental health team
  (Psychiatrists, Clinical Psychologist,
  Psychiatric Social worker)
• Nursing Station and Drug dispensing

• Inpatient wards with attendant facility
• Semi ICU
• Lab investigations facilities
• Recreation room
• Rehabilitation activities
• Storage and Documentation space

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INTERDISCIPLINARY TEAMCONSULTATION-LIASION

• Medical internist Gynaecologist
• Ophthalmologist Orthopaedician
• Physiotherapist Dietician
• Yoga trainer

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Age related changes in the Central Nervous System

• Gross brain atrophy
• Ventricular enlargement
• Selective regional neuronal loss
• Remodeling of dendrite, axons synapses
• Appearance of intraneuronal lipofuschin
• Selective regional decrease in neurotransmitter
  neuropeptides.

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Contd...........

• Selective modification of neurotransmitter
  metabolism
• Possible dysregulation of gaseous
  neurotransmitter metabolism
• Glucocorticoid neurotoxicity
• Changes in receptors
• Changes in neurotrophins
• Changes in signal transduction

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contd.

• Impairment of calcium homeostasis
• Possible changes in cell cycle regulations (eg,
  cyclins)
• Possible changes in extra cellular matrix
  proteins (eg. Laminin, proteoglycans)
• Possible regional decline in cerebral blood flow
• Possible regional decline in metabolic rate
• Appearance of senile plaque neurofibrillary
  tangle

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PHARMACODYNAMICS AND AGING
Neurotransmitter Pharmacodynamic changes with
aging Dopaminergic system Dopamine D2
receptor in the striatum Cholinergic system
Choline acetyl transferase Cholinergic cell
numbers
Contd...........
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Contd...........
Adrenargic system cAMP production in response
to beta-agonists Beta adrenoceptor number
Beta receptor affinity Alpha 2
adrenoceptor responsiveness Gabaminergic system
Psychomotor performance in response to
benzodiazepines ? Post synaptic receptor
response to GABA.
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PHARMACOKINTIC CHANGES WITH AGING
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Points to remember before prescribing medication
in elderly
Magnitude of effect (clinical response)
Pharmacodynamics x Pharmacokinetics x biological
variance

• In elderly medical complication of
  pharmacotherapy alone constitute a highly
  significant treatable health problem.
• Adverse reaction to drugs of all types is seven
  times higher in those aged 70 to 79 years, than
  in those 20 to 29 years old.
• Non compliance with therapy is a major problem
  for psychiatric patients, and this dilemma is
  exacerbated with age.
• Age related health problems combines with
  physiological changes to increase the probability
  of adverse effect from medication which in turn
  increase the likelihood of non compliance.
• Complexities of medication regimens are further
  complicated by communication difficulties arising
  from impaired hearing, cognitive impairment,
  language cultural difficulties.

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Psychopharmacological Treatment of Geriatric
Disorders
The psychiatrist of an 87 year old patient
suffering from heart disease, arthritis and
depression must ask a number of questions to
himself. Q. What is the best treatment -
Pharmacotherapy? Psychotherapy? E.C.T.? Q. If
pharmacotherapy, what is the most appropriate
drug? Q. Balancing the adverse effect and
efficacy. What is the best dosage? Q. How soon
will the patients symptom decrease? Q. If the
drug is effective. How long will the treatment
last? Q. If the drug is ineffective how long
should the wait before changing the treatment?
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GERIATRIC MANIA
Risk of Mania decline in late life, nonetheless
mania and hypomania affect 5-10 of psychiatric
patients.

• Established mood stabilizers
• Lithium salts
• Valproate
• Carbamazepine
• Calcium channel blockers
• E.C.T.
• Putative Mood stabilizes"
• L. Thyroxine
• Phosphatidyl choline
• Progesterone

• Clozapine,
• Olanzapine
• Magnesium salt
• Newer Anticonvulsants
• Lamotrigine,
• Gabapentin
• Topiramate,
• Tigabine
• Omega 3 fatty acid

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Antidepressants in old age depression

• Cumulative incidence of depression in people aged
  upto 70 years is 26.95 for men 42.5 for
  women, still most of the drug trials exclude
  elderly subjects.
• In addition, most of the drug trials also exclude
  subjects with medical comorbidity, which is a
  rule rather than exception. Hence the results of
  drug trials done in young adults can't be
  generalized to elderly.

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Antidepressants in old age depression contd.

• Prior to 1995, there were occasional studies
  which evaluated the use of antidepressants in
  elderly. But fortunately in the last 10 years
  many studies have evaluated the use of
  antidepressants in the elderly.
• These studies can be broadly classified as
• Noncomparative studies
• comparative studies using either placebo or
  another antidepressant or both and
• meta-analyses of the above studies.

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Antidepressant Drugs and Dosages Preferred for
Use in the Elderly
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Anticonvulsants in Depression with medical
comorbidity
Cardiovascular ü üü üüü Renal
ü üü üüü Diabetes üü üü üü Hepatic üüü ü ?
ü Hematological üüü ü ü ü Thyroid
ü üü üüü Arthritis ü üü üüü Infectious
disorders üü üü üü Metabolic üü ü üüü
Disorders
Lithium
CBZ
VPA
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Psychotic agitation in the elderly with mania

• Initial treatment
• Haloperidol 0.25 to 0.5 mg IM or PO
• After one hour, administer lorazepam 0.5mg IM or
  PO
• Stabilization
• Repeat alternating doses every hour until calm
• Monitor carefully to avoid over sedation
• Alternative regimen if extra pyramidal symptoms
  develop
• Atypical antipsychitic riseperidone (0.5mg), or
  olanzapine (2.5 - 5 mg)
• Avoid chlorpromazine and thioridazine due to
  their anticholinergic and hypotensive side
  effects.
• Chronic medication
• Daily dose of medication is determined by adding
  the total dose of each medication required to
  calm the patient and dividing it equally
  throughout the day.

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Adjunctive antipsychotic medication

• Risperidone
• Daily divided doses of .5 to 3mg
• Monitor patient carefully for orthostatic
  hypotension and EPS as dose is increased
• Olanzapine
• Daily doses of 2.5 to 10 mg /day
• Transient elevation in liver enzyme have been
  reported
• Risepeidone plus olanzapine
• Observe for increased agitation or other manic
  symptom because of breakthrough mania with
  risperidone.
• Clozapine
• Reserved for patients who are intolerant of
  risperidone and olanzapine,
• Daily doses start at 12.5mg, increase to 50mg
• If history of seizure disorder should be
  maintained on an anticonvulsant
• Monitor for orthostatic hypotension and weekly
  complete blood count to assess for evidence of
  bone marrow toxicity

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ATYPICAL ANTIPSYCHOTICS IN THE ELDERLY
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COMMON ANTIPSYCHOTIC DRUG INTERACTION IN THE
ELDERLY
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Expert consensus guidelines

• SPECIAL ISSUE IN USING ANTIPSYCHOTICS IN THE
  ELDERLY
• Formulatory decision should be based on cost when
  drug of comparable efficacy are available.
• It is especially important to consider safety and
  tolerability along with efficacy and cost.
• Avoid low and mid-potency conventional
  antipsychotics as well as clozapine ziprasidone
  in elderly patients who have corrected QTc
  interval prolongation.

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Expert consensus guidelines

• DISEASE DRUG INTERACTION
• Avoid low mid potency conventional
  antipsychotics, clozapine and olanzapine in
  patients who have diabetes mellitus, dyslipedimia
  and or obesity.
• Avoid ziprasidone, low and mid potency
  conventional antipsychotics and clozapine in
  patients who have a prolonged QTc interval or
  congestive heart failure.
• Quetiapine is the first line recommendation for a
  patient with Parkinsons disease , also consider
  low dose olanazapine or clozapine for patients
  with Parkinsons
• Avoid high dose of risperidone in patients with
  Parkinsons disease

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Management of Cognitive symptoms-Dementia

• Cholinesterase inhibitors-mild to moderate
  dementia (Cummings et al., 2004).
• Prescription only for-
• probable Alzheimers disease
• duration of illness gt 6months
• MMSE gt 10
• 3 phase response evaluation-
• Early (2 wk)-assess tolerance side effects
• Late (3 mth)-assess cognition
• Continued (6 mth)- assess disease state

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Management of Cognitive symptoms contd.

• Stop treatment if-
• Early evaluation-poor tolerance or compliance
• Deterioration continues at pretreatment rate
  after 3-6 month of medication
• On maintenance doses, accelerated deterioration

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Drugs useful for reducing the signs of dementia
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Thank you