I. What is geriatric psychosis?
Psychosis refers to a serious mental disorder in which the patient’s cognitive, emotional, volitional, motor behavior and other psychological activities can have persistent and obvious abnormalities; unable to learn, work, live, and act normally; difficult to be understood by the general public; under the domination of the pathological psychology, there are suicides or attacks, or actions and behaviors that hurt others.
Second, the common types of mental disorders in the elderly: Alzheimer’s disease, vascular dementia, geriatric depression, etc.
Three, the characteristics of mental health in old age
1, intellectual change: 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: Emotional changes vary considerably among the elderly population and are sensitive to stress factors. Retirement, reduction in economic income, increase in chronic diseases, and challenges to dominance and authority in family and society are all changes that can have a negative impact on the mental and physical health of the elderly. With the development of society, the number of “empty nesters” has increased, which may lead to loneliness and desolation, as well as the loss of friends and relatives, which may lead to depression and even physical discomfort, called “empty nest syndrome”. In addition, retirement will also have a huge impact on the elderly who are used to work for a long time, easily produce a sense of loss, emptiness, uselessness, and some even anxiety, pessimism and disappointment, depression and other bad moods.
3, personality change: personality change with the elderly brain function degeneration is closely related to the frontal lobe of the brain than other cortical areas first degeneration, and the frontal lobe with the character of the relationship is particularly close, so the elderly are prone to personality change, such as gradually become impulsive, selfish, do not care about others, suspicious, etc., interests become narrow, monotonous life stereotypes, and make the elderly gradually and the outside world inconsistent, out of place, and more isolation The elderly will feel more isolated and insecure.
4. Behavior change: As the cortical function of the elderly declines, their perception, thinking, emotion, will and other mental activities also change, resulting in abnormal behavior.
The difference between normal aging and Alzheimer’s disease.
Normal aging: Under normal circumstances, the weight of the brain of people over 30 years old will be reduced as they grow older, and it can be reduced by about 5% at the age of 70. 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, skin wrinkling and pigmentation, old vision, near memory loss, slowing of action, and certain personality changes. These senile changes are different from Alzheimer’s disease and are physiological aging rather than pathological process.
Alzheimer’s disease: It is a syndrome caused by brain lesions, and is a relatively serious and persistent cognitive impairment, characterized by a decline in memory, comprehension, judgment, reasoning, calculation and abstract thinking, and may be accompanied by hallucinations, delusions, behavioral disorders and personality changes, seriously affecting work, life and social skills, without abnormal consciousness. It is a chronic progressive mental retardation that starts in old age (usually over 60 years old). The pathological changes are mainly brain atrophy and neuronal degeneration; the cause of the disease is unknown, so it is also called primary degenerative dementia.
V. Prevalence of psychogeriatric disorders
The onset of geriatric mental disorders is closely related to the increase in the elderly population in the population. In the United Kingdom and the United States at the beginning of the 20th century, only 4-5% of the residents were over 65 years of age, but in the 1980s, this proportion had increased to 10-15%. There has been 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 of them have Alzheimer’s disease, nearly 1/4 of them have cerebrovascular dementia, the remaining 1/4 cases, half of them are mixed type of Alzheimer’s disease and cerebrovascular lesions, and the rest of them may be dementia caused by multiple causes of brain lesions. In China, the prevalence of senile mental disorder was 3.75 per 1,000 in 1982, when a sample of 12 regions was surveyed, and 5.6% of the total population was over 65 years old. There are more women than men with this disease, more rural than urban, and its prevalence increases with age.
Six, the clinical types of common geriatric mental disorders.
(a) common types of dementia: according to the etiology and pathology can be summarized into three main categories: (1) Alzheimer’s disease dementia (AD), is the most common type of dementia in the elderly; (2) vascular dementia (VD), is also more common dementia; (3) 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 (e.g. hypothyroidism), etc.
(B) Introduction to common clinical dementias.
1, 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), latent onset, slow and irreversible course, clinical manifestations are mainly intelligent damage, the onset of the disease before the age of 65 years 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 more significant. There is often aphasia and loss of use. The disease is often characterized by aphasia and dysfunction, while those in old age are specifically referred to as Alzheimer’s disease in the elderly.
(2) The cause of Alzheimer’s disease: The cause is not known, but may be related to the following factors.
(1) Genetic factors, especially related to chromosome 21 abnormalities;
②Choline acetyltransferase activity, which synthesizes acetylcholine in the cerebral cortex and hippocampus, is significantly reduced;
(iii) Aluminum, which has neurotoxic effects, is present in higher levels in the brain of patients with this disease;
(iv) autoimmune effects;
⑤ Lentiviral infection of the central nervous system. However, all these claims need to be confirmed by further studies.
(3) The pathological changes of Alzheimer’s disease are mainly: brain atrophy, most notably in the parietal and temporal lobes, especially hippocampal damage is the most severe; there is widening of the cerebral sulcus and enlargement of the ventricles. Microscopically, there is a decrease of neuronal cells in the cerebral cortex and a proliferation of stellate cells. Silverophilic staining reveals senile plaques and neuronal fiber tangles, which are characteristic changes of the disease. The number of senile plaques in the brain tissue often shows a parallel relationship with the severity of the patient’s cognitive impairment. It is generally believed that brain cell degeneration can lead to decreased glucose utilization and reduced local cerebral blood flow; in particular, degeneration of the acetylcholine-producing septum and the nucleus accumbens in the inferior optic thalamus can cause severe damage to cholinergic neurotransmission and lead to hypofunction.
(4) Clinical manifestations: The disease generally starts slowly and has a persistent, progressive course without remission, with 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 initial manifestation of amnesia, especially near event amnesia; symptoms are mild and often go unnoticed by others. However, it can be combined with other physical illnesses and suddenly intensify, and acute delirium of consciousness (called senile delirium) appears.
(5) Treatment.
(①Improve cognitive dysfunction: commonly used cholinesterase inhibitors such as Anlisin and Staphylococcus aureus can improve the patient’s memory.
② Non-pharmacological treatment and pharmacological treatment of psycho-behavioral symptoms: a. The principle of treatment is to improve the patient’s quality of life and reduce the burden the patient brings to the family. b. Anti-psychotic drugs can be used to combat psychotic symptoms, agitated behavior or aggressive behavior. c. Antidepressants can be used in patients with dementia accompanied by depression and can significantly improve dementia syndrome.
2. Vascular dementia.
(1) Concept: It refers to dementia caused by cerebrovascular lesions.
(2) Vascular dementia subtype: including multiple infarct dementia and dementia secondary to acute cerebrovascular accident. Its onset, clinical features and course are different from those of Alzheimer’s disease. It is mainly caused by multiple cerebral infarcts and other cerebrovascular lesions due to atherosclerosis or hypertensive cerebrovascular disease. These lesions can coexist with Alzheimer’s disease.
(3) Clinical manifestations.
Early symptoms: the latency period is long and generally not easy to detect. Symptoms are dominated by emotional instability and various somatic symptoms, i.e., cerebral debilitation syndrome.
Restricted neurological symptoms and signs: the more prominent ones are: pseudobulbar palsy, dysarthria, dysphagia, central facial muscle paralysis, varying degrees of hemiparesis, aphasia, loss of use or recognition, grand mal seizures and urinary incontinence, etc. Dementia: VD mainly manifests as a limited dementia with memory decline as the main feature. The main feature is that although memory impairment occurs, self-awareness exists for a long time, and patients are aware of their memory decline and tend to forget things, some of them may have anxiety and depression, and some of them show pathological redundancy, such as delusions of victimization, delusions of theft, delusions of poverty, etc. As dementia worsens, 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 appear in the late stage.
Neurological signs: The primary disease of VD is cerebrovascular disease, so different neurological localization signs of cerebrovascular lesions may appear.
(4) Treatment and prevention: Prevention and treatment of risk factors for VD can reduce the incidence of VD. Treatment can prevent VD patients from continuing to deteriorate and sometimes improve their condition.
(iii) Geriatric depression.
1. Overview: It is a more common mental disorder, and the prevalence of geriatric depression is 1%-5%. The prevalence of geriatric depression is 1-5%. It is significantly higher in women than in 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: (1) positive family history is rare, neurological lesions and physical diseases account for a large proportion, cognitive impairment, complaints of physical discomfort, strong suspicion; (2) weight change, early awakening, loss of libido, lack of energy and other factors become less prominent due to age; (3) some elderly depressed patients will be irritable, aggression, hostility as the main manifestation; (4) insomnia, loss of appetite obvious; (5) Emotional vulnerability, mood volatility, and sadness are often not well expressed; (6) Suicidal ideation is often not clearly expressed. (7) Secondary depression accounts for a considerable proportion.
4, the regression of geriatric depression: Post (1978) has proposed the 1/3 principle: 1/3 will improve, 1/3 unchanged, 1/3 getting worse, Cole (1997) and other comprehensive analysis of the regression of geriatric depression is summarized as: 97% recovery; 32% recovery after relapse; 14% in a persistent state; 31% in the follow-up of death or dementia.
5. Treatment of geriatric depression.
Acute phase treatment: In treating elderly patients with depression, the following factors should be taken into consideration: ① pharmacogenetic characteristics of the elderly; ② drug interactions; ③ physiological characteristics of the elderly make them more sensitive to cognitive impairment of drugs; ④ psychosocial factors of the elderly are complex.
Maintenance therapy: the older the age of onset, the more relapses there are and the higher the risk of relapse again. Most researchers advocate that depressed patients over 60 years of age with their first onset 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 again relapse should be taken for life.
VII. Differential diagnosis of Alzheimer’s disease.
Differentiation of senile depressive pseudodementia: Some manifestations of senile depression are very similar to organic dementia. On the basis of depressed mood, it presents psychomotor retardation, reduced interest in the environment, inattention, and significant near memory loss. Due to aging, the patient loses weight, behaves lazily, cannot take care of himself, walks with trepidation, has difficulty in striding, and gives a strong impression of dementia. Patients often complain of physical discomfort and ignore their emotional experience, which can easily lead to misdiagnosis. In general, endogenous depression has an acute onset and a short duration, and a careful history often reveals obvious depressive symptoms, with painful internal experiences without significant memory or intellectual decline. A family history of affective disorders and effective antidepressant treatment can be helpful in the diagnosis of depression.
In addition,organic dementia such as normal pressure hydrocephalus, frontal lobe tumor, paralytic dementia, B vitamin deficiency, and cerebral infarction with insidious symptoms should also be excluded by careful history taking and appropriate laboratory tests. If there is no intracranial occupying lesion or increased cranial pressure, cerebrospinal fluid should be included in the routine examination; brain ultrasound and electroencephalogram are both beneficial to detect focal lesions. In the absence of CT examination, radionuclide brain scan, pneumoencephalography and cerebral angiography can still provide important help for diagnosis and differential diagnosis.
VIII. Management of geriatric mental disorders
The following comprehensive measures should be taken.
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.
Nine, care for the mental health of the elderly.
For geriatric mental disorders, psychiatrists point out that the main point of treatment for geriatric psychosis is not to take drugs and life conditioning, but more importantly, communication and care from children and relatives, and the need for psychological patience and care from the relatives around. Therefore, as children, no matter how busy we are, we need and should take 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!