I. The concept of geriatric psychiatric disorder
Geriatric psychosis refers to serious mental disorders, the patient’s cognition, emotion, will, action behavior and other mental activities can appear lasting obvious abnormalities; can not learn, work, life normally, action behavior is difficult to be understood by the general public; under the domination of the pathological psychology, there is suicide or attack, injury to others action behavior.
Second, the common types of mental disorders in the elderly
Alzheimer’s disease, vascular dementia, cerebral organic mental disorder, geriatric depression, etc.
Three, the characteristics of mental health in old age
1. Intellectual changes: In the process of aging, mental decline is common, and memory loss is often the first to appear. The distant memory is better maintained while the near memory is poor.
2, emotional changes: various factors tend to make the elderly produce loneliness, desolate feeling, sense of loss, emptiness, uselessness, and some even anxiety, pessimism and disappointment, depression and other bad mood.
3, personality change: personality change is closely related to the degeneration of brain function in old age, and can gradually become impulsive, selfish, do not care about others, suspicious, etc. Interests become narrow, life is monotonous and stereotypical, gradually incongruent with the outside world, out of place, and more isolation, insecurity.
4. Behavior change: Due to the decline of cerebral cortex function, the perception, thinking, emotion, will and other mental activities of the elderly also change, resulting in abnormal behavior.
The difference between normal aging and Alzheimer’s disease.
Normal aging: people over 30 years old, as they grow older, the weight of the brain will be reduced, to about 70 years old can be reduced by about 5%. After entering old age, a series of corresponding changes can occur in the physical and mental functions of normal people, such as graying of the hair, wrinkling of the skin, old vision, near memory loss, and slowing of action. These senile changes are different from Alzheimer’s disease, which is a physiological aging rather than a pathological process.
Alzheimer’s disease: It is a group of syndromes caused by neurodegeneration, infection, trauma, tumor and other causes, with cognitive deficits as the main manifestation, usually seen in the elderly population. In addition to severe and persistent cognitive impairment, the disease is characterized by a variety of cognitive functions, including memory, comprehension, judgment, reasoning, calculation and abstract thinking, and most patients may also have hallucinations, delusions, behavioral disorders and personality changes, which seriously affect work, life and social skills, without abnormal consciousness. The pathological changes are mainly brain atrophy and neuronal degeneration; the cause is not known, so it is also called primary degenerative dementia.
V. Prevalence of psychogeriatric disorders
The prevalence of geriatric mental disorders is closely related to the increase of elderly population in the population. In the beginning of the 20th century, only 4-5% of the residents in the United Kingdom and the United States were over 65 years old, but by 1980, the proportion had risen to 10-15%. There is a significant increase in the number of people suffering from geriatric mental disorders. In the United Kingdom, 5.6% of people over 65 years of age have severe dementia, while the United States is nearly 6%. Among the elderly people with dementia, more than half are suffering from Alzheimer’s disease, nearly 1/4 are suffering from cerebrovascular dementia, the remaining 1/4 cases, half are mixed type of Alzheimer’s disease and cerebrovascular lesions, and the rest may be caused by multiple causes of brain lesions. In China, the prevalence of geriatric mental disorder was 3.75 per 1,000 in a 1982 survey of a sample of 12 regions nationwide, with 5.6% of the total population over 65 years of age. The prevalence of this disease increases with age.
VI. Common clinical syndromes
(A) Delirium
1, the concept of delirium: is manifested as an acute, transient, widespread cognitive impairment, especially the main feature of the impairment of consciousness. It is also called acute encephalopathy syndrome because of the acute onset, short duration and rapid development of lesions.
Clinical manifestations: The main manifestations are decreased clarity of consciousness, disturbed sleep rhythm, inattention, disorientation, impaired self-knowledge, patients are particularly sensitive to sound and light, and often show panic, fear or excitement and agitation due to illusion and hallucination, most of them have an acute onset, and the condition fluctuates lightly in the morning and heavily at night, lasting from a few hours to a few days, and a few can last for more than a month.
3.Treatment: The treatment of delirium mainly includes etiological treatment, supportive treatment and symptomatic treatment.
(B) Dementia
1, common types: according to the etiology and pathology can be summarized into three main categories: Alzheimer’s disease dementia (AD), is the most common type of dementia; vascular dementia (VD), is also more common; other causes of dementia, such as drug or alcohol poisoning, intracranial tumors, cranial trauma, intracranial infection (neurosyphilis), nutritional disorders (folic acid, VitB12 deficiency) and metabolic disorders (such as Hypothyroidism), etc.
2. Clinical manifestations of dementia syndrome.
Cognitive decompensation.
a. Memory impairment: It is often a prominent symptom in the early stage of dementia. Initially, it mainly involves recent memory, difficulty in memory preservation and difficulty in learning new knowledge. The symptoms are forgetfulness, forgetting things that have just been used, and losing things. What has just been said or done will be forgotten in a flash. As the disease progresses, distant memory is also impaired, and the patient cannot recall his or her work and life experiences. In severe cases, the patient could not even recall the number of family members, his name, age and occupation accurately. To compensate for the memory deficit, some patients fill the memory gaps with fictitious or wrong purchases.
b. Visuospatial impairment: This is manifested as getting lost in a familiar environment, not being able to find the door of one’s home, or even walking to the wrong door of a room or finding a toilet in one’s own home. During simple drawing tests, patients cannot accurately copy cube diagrams and often cannot copy simple shapes.
c. Abstract thinking impairment: Dementia patients have impaired cognitive functions such as comprehension, reasoning, judgment, generalization and calculation. First of all, the patient has difficulty in calculation and cannot perform complex operations, even addition and subtraction within two digits. Patients gradually develop slow thinking, reduced abstract thinking ability, and the inability to distinguish the similarities and differences between things. The patient is unable to analyze and summarize. The patient is unable to read novels, movies, etc., or understand other people’s conversations. The patient is unable to complete and perform familiar tasks and techniques, and finally loses the ability to live completely.
d. Language impairment: Language change is a more sensitive indicator of cortical dysfunction, and the particular pattern of language impairment helps in the diagnosis of this disease. In patients with dementia, the earliest language abnormalities are spontaneous speech hollowness, difficulty in finding words, inappropriate use of words, redundancy, inability to make sense, and inability to list the names of similar items. Dyslexia may also occur, followed by an inability to name. This is followed by sensory aphasia, inability to carry on a conversation, repetitive speech, imitative speech, and stereotyped speech. Finally, the patient can only make unintelligible sounds or be silent.
e. Aphasia: The inability to recognize faces is the most common. Patients cannot recognize people based on their faces, do not recognize their relatives and friends, and even lose the ability to recognize themselves.
f. Disuse disorder: The patient is unable to make continuous complex movements correctly, such as brushing teeth. When dressing, he or she puts on clothes in the wrong order, such as inside and outside, front and back, left and right. When eating, they do not use chopsticks and spoons, but often grab food with their hands or lick food with their mouths.
g. Personality change: The initial personality change is characterized by lack of initiative, reduced activity, loneliness, difficulty in adapting to new environments, selfishness, reduced interest in the surrounding environment, and lack of enthusiasm for people. Later, the interest becomes narrower and narrower, cold to people, even indifferent to relatives, irresponsible, emotionally unstable, easily provoked, angry over trivial matters, reprimanding or scolding, vulgar language. Beating up family members, etc. Lack of shame and sense of ethics, disregard for social norms, unkempt, unhygienic, picking up rags, taking other people’s things for oneself, fighting for food and drink. They may also exhibit hyperactive instincts, public nudity, and even abnormal sexual behavior.
Decreased ability to live: Dementia is caused by the decline of memory, judgment, thinking and other abilities, resulting in a significant decline in the ability to perform daily activities, and gradually requires the care of others, and the dependence on others is increasing. Initially, patients may show an inability to manage finances and shop independently; gradually, they may be unable to complete previously familiar activities, such as laundry, cooking, dressing, etc.; in severe cases, they may not be able to take care of their personal life at all.
Psycho-behavioral symptoms include hallucinations, delusions, misidentification, depression, mania-like symptoms, agitation, aimless wandering, wandering, physical and verbal aggression, shouting, open defecation and sleep disturbance. Many symptoms are based on cognitive symptoms, e.g., stolen delusions are mostly seen when memory impairment is present. Similarly, failure to recognize family members or spouses because of character orientation disorder and the belief that they are liars and impostors. Some symptoms are secondary to personality changes, such as withdrawal, eccentricity, pestering others, hiding, and disruptive behavior. Sleep disorders are quite common. Patients show sleep inversions, staying awake at night, walking around, or making aimless movements, and being depressed and sleepy during the day.
(C) Amnesia syndrome
1. Concept: Amnesia syndrome, also known as Korsakoff syndrome, is a selective or focal cognitive dysfunction caused by organic pathological changes in the brain, mainly characterized by impairment of near-matter memory, no impairment of consciousness, and relatively intact intelligence.
2. Clinical manifestations: The main manifestation is severe memory impairment, especially near memory impairment, with normal attention and immediate memory. Patients have difficulty in learning new things and cannot remember newly happened events. During intelligent examination, the patient has little problem when asked to recall an address or three items immediately, but has difficulty recalling them after 10 minutes. There is also fiction, and patients often fabricate vivid and detailed episodes to compensate for near-memory deficits. Other cognitive functions and skills remain relatively intact. Thus patients can carry on normal conversations and appear more rational.
VII. Clinical types of common geriatric mental disorders
(I) Alzheimer’s disease (AD).
1, concept: is a group of primary degenerative brain degenerative diseases of unknown etiology, a large number of primary dementia occurring in old age and pre-geriatric (40-65 years old), latent onset, slow and irreversible course, clinical manifestations of intelligent damage is the main, the onset before 65 years old old old old called pre-geriatric dementia, or progeria, more family history of the same disease, faster development of lesions, temporal lobe and parietal lobe lesions are more significant. There is often aphasia and loss of use. In the old age, it is called Alzheimer’s disease old age type.
2, the pathological changes of Alzheimer’s disease are mainly: brain atrophy, the most significant in the parietal and temporal lobes, especially the hippocampus damage is the most serious; there is a widening of the cerebral sulcus and enlargement of the ventricles. Microscopically, the brain cortical neuronal cells are reduced, stellate cells are proliferated, and silverophilic staining reveals age spots and neuronal fiber tangles, which are characteristic changes of the disease.
Clinical manifestations: The disease generally starts slowly, with a persistent and progressive course without remission, and lasts for an average of about 8-10 years from onset to death, but in some patients the disease can last for 15 years or more. The clinical course of AD is broadly divided into 3 stages.
Stage 1 (1-3 years): a mild dementia stage. Initially, amnesia is manifested, especially near-event amnesia; the symptoms are mild and often do not attract the attention of others. However, it can be combined with other physical illnesses and suddenly intensify, and acute disorders of consciousness (called senile delirium) appear. The early personality changes of this disease are quite prominent, the patient becomes stubborn, selfish, paranoid, speech rumbling words ark liao (9) overrate over the bed live Jun? The patient is careful about the polycarbonates. The delusions of jealousy can be one of the early manifestations of the disease; there can also be delusions of suspicion, poverty, exaggeration or persecution. Patients do not sleep well and often get up at night to move around.
The second stage (2-10 years): the stage of moderate dementia. It shows severe impairment of distant and near memory, and its memory impairment and intellectual impairment progressively increase, and there may be memory misconstruction or fiction. Patients have poor simple structured visual-spatial ability, time and place orientation disorder; they are unable to perform outdoor activities independently, and need help in dressing, personal hygiene and maintaining personal appearance; they have significantly reduced intellectual activities such as comprehension, judgment and calculation, vague pronunciation, garbled speech, childish emotions, absurd behavior, inordinate eating, often collect scraps as treasures, and become disoriented when they go out, followed by speech dysfunction, naming The next stage is the emergence of speech dysfunction, naming, loss of recognition, and loss of use.
The third stage (8-12 years): the stage of severe dementia. It is a comprehensive dementia state and motor system disorder. In the late stage, the patient is bedridden, mumbling, and eventually aphasic, groping with hands aimlessly, unable to take care of personal life, incontinence, tonic and flexed body position, primitive reflexes such as strong grip, sucking reflex, etc., and eventually dies of infection or failure. The course of the disease is progressive, with death occurring on average 4 to 5 years after the onset of the disease; there are also cases that develop faster or up to 10 years. The prognosis is worse in cases with parietal symptoms.
4.Treatment.
Improve cognitive dysfunction: commonly used cholinesterase inhibitors such as anlisin and staphylococcus aureus can improve the patient’s memory.
Non-pharmacological treatment and pharmacological treatment of psychiatric-behavioral symptoms: The principle of treatment is to improve the patient’s quality of life and reduce the burden that the patient brings to the family. Antipsychotic drugs can be used to counteract psychotic symptoms, agitated behavior or aggressive behavior. Antidepressants can be used in patients with dementia accompanied by depression, which can significantly improve the dementia syndrome.
(II) Vascular dementia (VD).
1. Concept: It refers to dementia caused by cerebrovascular lesions.
2. Vascular dementia typology: It includes multiple infarct dementia and dementia secondary to acute cerebrovascular accident. The process, clinical features and course of dementia are different from those of Alzheimer’s disease, mainly caused by multiple cerebral infarcts and other cerebrovascular lesions due to atherosclerosis or hypertensive cerebrovascular disease, which can coexist with Alzheimer’s disease.
3.Clinical manifestations.
a. Early symptoms: the latent period is long and generally not easy to detect. The symptoms are mainly emotional instability and various somatic symptoms, i.e., cerebral debilitation syndrome.
b. Restricted neurological symptoms and signs: the prominent ones are: pseudobulbar palsy, dysarthria, dysphagia, central facial palsy, different degrees of hemiparesis, aphasia, loss of use or recognition, grand mal seizures and urinary incontinence, etc.
c. Dementia: VD mainly manifests as limited dementia with memory decline as the main feature. The main feature is that although memory impairment occurs, but for a considerable period of time self-awareness exists, know that their memory decline, easy to forget things, some patients will produce anxiety, depression, some performance pathological superfluous (performance speech ron (10) arguing to put on a lot of flowers Wei (10) eddy Ying K薮患患且淞ο陆担粘I Touyue ballast security Α郊野郊野郊野 Α (1) unloading force and the ability to treat people can be maintained for a longer period of time, personality also maintain a good state. The personality also remains better. In the process of dementia, some patients have various delusions based on memory impairment, such as delusions of victimization, delusions of theft, and delusions of poverty. As the dementia progresses, some patients may change their behavior and personality, such as becoming stingy, selfish, and waste collectors. Clinical manifestations similar to those of full-blown dementia may appear in the late stage.
d. Neurological signs: The primary disease of VD is cerebrovascular disease, so different neurological localization signs of cerebrovascular lesions can appear.
4.Treatment and prevention: Prevention and treatment of risk factors of VD can reduce the incidence of VD. Treatment can prevent VD patients from continuing to deteriorate and sometimes improve their condition.
(C) Cerebral organic mental disorder
1. Concept: It is a mental disorder caused by brain infection, degeneration, vascular disease, trauma, tumor and other lesions, also called brain organic psychosis. With the increase of human life expectancy and the gradual increase of the aging population, the incidence of organic brain psychosis has also increased significantly.
2. Clinical manifestations.
(1) Acute organic brain syndrome has an acute onset, rapid development, short duration, limited damage, and good prognosis, and the lesions are often reversible.
(2) Chronic organic brain syndrome has a slow onset. The development of the disease is slow, with a tendency of gradual aggravation, and the course of the disease is long-lasting, and the prognosis is poor. The lesions are often irreversible. Many cerebral organic mental disorders have both organic clinical features and some manifestations of obvious organic disorders, and the two are intertwined and overlapping.
(D) Geriatric depression.
1, overview: for the more common mental disorders, the prevalence of geriatric depression is 1%-5%. Women are significantly higher than men, and 50%-80% of elderly people who commit suicide suffer from major depression.
2. Etiology: It is “multifactorial”, but current brain imaging studies suggest the presence of frontotemporal lobe atrophy and frontal white matter lesions in elderly depressed patients. Damage to the “striatum-pallidum-thalamus-cortex” pathway leads to dysfunction of neurotransmitters related to mood control, such as norepinephrine and 5-hydroxytryptamine, resulting in depression.
3, the characteristics of the clinical phase of geriatric depression: neurological lesions and physical diseases account for a large proportion, cognitive impairment, complaints of physical discomfort, strong suspicion; weight change, early awakening, loss of libido, lack of energy and other factors become less prominent due to age; some elderly depressed patients will be irritable, aggression, hostility as the main performance; insomnia, loss of appetite is obvious; emotional vulnerability, mood volatility, sadness The emotions are often not well expressed; suicidal ideation is often not clearly expressed. Secondary depression accounts for a significant proportion.
4, the regression of geriatric depression: Post has proposed the 1/3 principle: 1/3 will improve, 1/3 remain the same, 1/3 getting worse;
Geriatric depression regression: 97% recover; 32% relapse after recovery; 14% are in persistent disease; 31% die or develop dementia in the follow-up.
5. Treatment of geriatric depression.
Acute phase treatment: In treating elderly patients with depression, the following factors should be taken into account: pharmacogenetic characteristics of the elderly; drug interactions; physiological characteristics of the elderly make them more sensitive to cognitive impairment of drugs; psychosocial factors of the elderly are complex.
Maintenance therapy: the older the age of onset, the greater the number of relapses, and the higher the risk of relapse again. Most researchers advocate that depressed patients over 60 years of age with a first episode of depression should be maintained on treatment for at least 12 months after achieving clinical recovery. In case of relapse, medication should be taken for more than 2 years, and the medication should be taken for life for another relapse.
VIII. Treatment of geriatric mental disorders
The following comprehensive measures are appropriate.
①Good family care ;
②Comfortable recuperation environment;
③Supportive psychotherapy;
④ Encourage participation in recreational and therapeutic activities;
⑤Ensure adequate nutrition;
⑥Prevention of physical comorbidities such as infections and accidents such as wandering;
(7) Reasonable medication.
IX. Prevention of dementia.
1.Raise people’s awareness of dementia through various means, reduce risk factors, protect susceptible people, and prevent the occurrence of dementia;
2.Guiding and helping elderly patients who have or may have dementia to actively seek medical treatment and receive timely medical help;
3.Establish a practical social support system. Help and guide patients’ life caregivers to take care of dementia patients scientifically and prevent complications from occurring. Prolong life and improve the quality of survival of patients.
X. Care for the mental health of the elderly.
For geriatric mental disorders, experts point out that in addition to reasonable medication and life conditioning, the treatment of geriatric psychosis is more important is the communication and care of children’s relatives, and needs the psychological patience of the relatives around. Therefore, as children, no matter how busy we are, we need and should take the appropriate time to care for our elderly parents or elders, so that they can spend their twilight years in a warm and caring atmosphere and enjoy the joy of family life!