MENTAL DISORDERS. Mental Health VS Psychiatry. Mental Health VS Psychiatry. Community Mental Health in Elderly and Geriatric Psychiatry.
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1 Mental Health VS Psychiatry Community Mental Health in Elderly and Geriatric Psychiatry THITIPHAN THANEERAT, M.D., M.S. Director of Nakhonsawan Rajanagarindra Psychiatric Hospital Mental Health VS Psychiatry MENTAL DISORDERS 4'Ds Distressing Promotion/Prevention Treatment/Rehabilitation Disturbing Mental Health Community Mental Disorders Health Service System and Community Disable / Dysfunction Diagnosis
2 Hierarchy of Mental Disorders Outlines Organic Mental Disorders Psychotic Disorders Mood Disorders Anxiety Disorders Physical and Psychological Changes in Elderly Common Mental Problems and Psychiatric Disorders in Elderly Rules of Effective Community Mental Health System Miscellaneous Disorders Population Pyramids Stages of Elderly Young Old (60-69 y/o) Middle Old (70-79 y/o) Very Old (80+ y/o) Increasing continuously In 2050 : Very-old group proportion 25% of old population or about 5% of general population Forman, D.E., 1992
3 Physical Degeneration Physical Degeneration Ageing process / Senescence (to grow old) Gradual onset of degenerative processes Depends on 1. Genetic factors 2. Environmental factors Physical Degeneration Elderly: Ability to Perform Daily Life Functions Cellular level Protective factors A. Regular physical examinations B. No caffeine and alcohol C. Occupational satisfaction D. Self value awareness E. Healthy life style Life span expectancy: Female > Male well-old : healthy sick-old
4 Psychosocial Theory: Developmental Tasks; Erik Erikson Developmental Task for Elderly Stages Complete Task Unmet Task Infant Basic trust Mistrust Toddler Autonomy Shame & Doubt Pre-School Initiative Guilt School age Industry Inferiority Teenage Identity Identity confusion Adulthood Intimacy Isolation Middle Life Generativity Stagnation Elderly Ego integrity Despair Integrity VS Despair Keeping balance of body and physical appearance Reviewing one s past experiences Maintaining the activity and relationships Dealing with grief Adaptation for retirement Coping with physical degeneration Managing the attachment & stagnation Prepare for death with dignity Integrity Despair Mental Health Aspects for Elderly Life review : Succession and Mistakes For Peace & Wisdom Integrity : a sense of having lived one's life well Despair : feeling that life is too short Degeneration Retirement & Social Changes Death and Dying Good quality of life Good health Good social contexts Productive involvement Affective status Cognitive status
5 Mental Marks of Old Age Adaptable Caution Depressed mood Fear of crime Mental disorders Reduced mental and cognitive ability DEATH & DYING COMMON REACTIONS TO BAD NEWS DENIAL ANGER BARGAINING DEPRESSION ACCEPTANCE Set in one s way : preference for the routine Common Mental Problems and Psychiatric Disorders in Elderly Geriatric Depression (and Suicide) Dementia Geriatric Depression Thitiphan Thaneerat, M.D., M.S.
6 Geriatric Depression Geriatric Depression Prevalence: % of geriatric population (Female:Male = 2:1) Depression: Normal VS Disorder (4D s) Biological Factors 1. Distressing 2. Disturbing Etiology 3. Disability or Dysfunction 4. Diagnosis (DSM-5) Psychosocial Factors Biological Factors Psychological Factors Genetics Neurotransmitters and Hormones Brain structures Substance-inducing Risk Factors No quality relationship with parents Experiencing of significant loss before the age of 11 Being tortured or neglected Having chronic or serious physical illness Dependent personality or Perfectionism Poor self-value High morality Cognitive Triads Worthlessness : negative thought of self Helplessness: negative thought of world Hopelessness: negative thought of future
7 Social Factors Characteristics of Geriatric Depression Family and Social Context: Poor Distorted Distanced Disappointed Failed Prevalence: Higher proportion than other age group Risk factors: Low socio-economic status Loss of spouse Chronic physical illness Poor social relationship Elderly with depression are often neglected or misdiagnosed due to marked somatic complaints and agism-like symptoms Instruments: Suicidal Risk: Suicide risk in psychiatric patients: 3-12 times of general population Thai Geriatric Depression Scale (Thai-GDS) 0-12 Normal Mild Depression About 2/3 of depressive patients have suicidal ideation, while 10-15% of them committed suicide Committed suicide - Male : Female = 4:1 Suicide relates to inadequate treatment Moderate Depression Severe Depression
8 Geriatric Depression Treatment of Geriatric Depression Suicide risk assessment and suicide precaution Biological Treatment Biological Treatment Antidepressants : proper consideration for elderly Start Low, Go Slow Treatment Psychosocial Treatment Duration: At least 6-9 months for first episode Psychosocial Treatment Individual psychotherapy (CBT, IPT) Group psychotherapy Family Therapy Memory Problems in Elderly Normal Forgetfulness Dementia Thitiphan Thaneerat, M.D., M.S. Mild Cognitive Impairment: MCI Dementia
9 Dementia World Situation of Dementia Syndrome of Memory Impairment with/without 1. Aphasia Nowaday 24.3 million people worldwide are affected by dementia, and in 2040, the number is rising to 81.1 million 5% of people with the age of years and 40% of those with the age > 85 years 2. Apraxia 3. Agnosia 4. Disturbance in executive function 15% of demented patients has preventable cause Alzheimer's Disease 10 Warning Signs of Alzheimer s Disease Cortical Atrophy 1 Temporal lobe Parietal lobe Frontal lobe Neuropathologic Hallmarks 2 Amyloid Plaques Extracellular deposits of β-amyloid protein The Alzheimer s Association s 10 Warning Signs 1 1. Memory loss that disrupts dailylife 6. New problems with words in speaking and writing 2. Challenges in planning or solving problems 7. Misplacing things and losing the ability to retrace steps 3. Difficulty completing familiar tasks at home, 8. Decreased or poor judgement at work, or at leisure 4. Confusion with time or place 9. Withdrawal from work or social activities 5. Trouble understanding visual images and spatial relationship 10. Changes in mood and personality Neurofibrillary Tangles Abnormal intraneuronal fibrillar material tau protein 1. Alzheimer s Association Available at: Accessed May 19, Halliday GM, et al. Neurobiol Aging. 2003;24: Ng'walali PM, et al. Leg Med. 2002;4:
10 Symptoms of Dementia Instruments: Activities of Daily Living MMSE Score (Max=30) KEEP APPOINTMENTS TELEPHONE Years OBTAIN MEAL/SNACK TRAVEL ALONE USE HOME APPLIANCES FIND BELONGINGS SELECT E CLOTHES DRESS GROOM MAINTAIN HOBBY DISPOSE LITTER CLEAR TABLE WALK EAT Mild Moderate Severe Progressive decline in cognition is accompanied by increasing loss of functional abilities. 25% 75% Loss of Optimal (Independent) Performance (%) Thai Mental State Examination (TMSE) for Dementia Adapted from Galasko D. Eur J Neurol. 1998;5:S9-S17. Thai Mental State Examination (TMSE) for Dementia Instruments: Thai Mental State Examination (TMSE) for Dementia Montreal Cognitive Assessment (MoCA) for MCI
11 Dementia Screening Test: DST Non-health personnel rating instrument for dementia screening used in both community and health care setting Composed of 3 sub-tests to evaluate cognitive functions 3-object recall Serial calculations Clock-drawing test Presynaptic Postsynaptic Acetyl-choline imbalance in Dementia Choline + acetate E inhibitor E Acetyl CoA Choline Choline acetyltransferase = acetylcholine; E = acetylcholinesterase; CoA = coenzyme A. Wilkinson DG, et al. Drugs Aging. 2004;21: release Treatments of Dementia Biological Treatments Specific Treatments Biological Treatments Anti-Dementia Specific Treatments VS Symptomatic Treatments donepezil, galantamine, rivastigmine, memantine Cholinesterase inhibitor Slowing the progression of dementia symptoms High price, not in Thai-Essential Drug (ED) list Psychosocial Treatments Symptomatic Treatments : BPSD management
12 Psychosocial Treatments Memory Aids Support and compensate the impairments Environment manipulations: clock, calendars, light Avoid unfamiliar situations in severe dementia Fix-schedule of routine activities Psycho-education and skill-training of care-giver How to strengthen Mental Heath of Community for Elderly Healthy Elderly Risky Elderly Sick Elderly Prevention: Primary/Secondary/Tertiary Depression Dementia Other Mental Health Problems Community Based Approach Strong commitment of network Co-operation Community Participation Community Empowerment THANK YOU THITIPHAN THANEERAT, M.D., M.S. Director of Nakhonsawan Rajanagarindra Psychiatric Hospital
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