Discussing the interdisciplinary character of psychogeriatry and its place among other medical specialties the author points to the need for observing the holistic paradigm in treating the elderly patient in health and illness.
Multiplicity of pathogenic factors in elderly patients is pointed out in the paper, as well as the need for a multifaceted approach to the treatment in gerontology, with an emphasis on the importance of factors affecting the patient's mental status and social situation. (Ed.)
The author refers to Seligman's conception of learned helplessness. Seligman assumed a similarity between learned helplessness and psychogenic depression (as regards causes and symptoms). Depression may result from the individual's belief about his/her lack of control over life events, or from his/her stable habits of pessimistic explanation of events (causal attribution of failures). However, depressive people perceive their influence on the reality more accurately than do non-depressives. Losses more and more frequent with years increase the probability of experiencing depression among older people. The social environment affects not only the course of depression, but also efficacy of its treatment.
Causes of difficulty in recognizing depression and differentiating between depressive syndromes and the most common somatic diseases of the old age are discussed. It should be noted that treatment applied in somatic diseases may also cause or aggravate depressive symptoms. Thus, importance of knowledge of interactions between antidepressants and drugs used in internal medicine is highlighted.
The paper presents a review of the current literature on determinants of depression and selected somatic diseases concomitance and etiopathogenetic relationship.
A review is presented of some current issues related to the diagnostics and treatment of masked depression among elderly patients. A special emphasis was laid on difficulties in the differential diagnosis of depression masks.
A review of the literature on depression after cerebral stroke is presented, including the issues of prevalence, etiopathogenesis, clinical picture, and problems related to the treatment of post-stroke depression.
Specificity of pathology and especially of symptomatology associated with senile involution is the factor underpinning mental disorders due to, and sometimes being the only symptom of somatic disease processes in the elderly. Primary and direct causes of such mental disorders are discussed.
Assuming as a starting point the immunological system tasks in the human organism it was shown that an increasing impairment of this system functioning with age is due to a cumulative effect of many factors, and particularly of physiological involution of the thymus, progressing with age and resulting in a decreased cellular and humoral immunity; changes in biochemical and genetic factors underlying immunological phenomena, and accumulated detrimental effects of human habitat. The net result of these disadvantageous changes in older people most often consists in: (l) a low ability to extinguish infections; (2) inability to efficiently resist neoplasms; (3) a tendency to autoimmunization. Regular patterns of change in the immunological system of the aging man suggest a number of elementary immunopreventive and immunotherapeutic measures to be applied by physicians of the first contact with elderly and aged patients.
Prevalence and nature of neurological and mental disorders typical of old age in the course of lupus erythematosus, rheumatoid arthritis, rheumatoid polymyalgia, and temporal artery inflammation are discussed in the paper. (Ed.)
The need for attaining an antipsychotic effect in elderly patients should not prevail over caution and striving to avoid undesirable symptoms. Thus, the decision to administer neuroleptics should be preceded by a careful analysis of not only possible beneficial results, but also the risk of side effects. Due to their tolerance profile, classical neuroleptics are less useful in the treatment of older patients. Atypicality implies here the following effects: absence (or much less pronounced level) of extrapyramidal symptoms and tardive dyskinesia, efficacy in the treatment of both positive and negative symptoms, improvement of cognitive functions, and none, or only negligible increase in prolactin level. Possibilities of treating elderly patients were discussed on the example of some older and more recent neuroleptics.
Elderly patients suffering from a neoplastic disease are in a particular plight. Their psychological situation due to the diagnosed malicious disease is extremely difficult. Diagnostic examinations and treatment are very invasive, and therefore these patients need not only a special approach, hut also in their case some changes should be introduced and the most appropriate treatment based on clinical research should be worked out.
The study deals with elderly female in patients treated at a general psychiatry ward. Patients in this age range constituted almost 20% of total admissions. Mean duration of the elderly inpatients' stay was not much longer than that of the remaining patients. The most frequent diagnosis in this age group was depression. In 15% of cases hospitalization was due to qualitative impairment of consciousness resulting from an underlying somatic disease.
The paper presents results of an analysis of medical records of elderly psychiatric inpatients, taking into account: causes of hospitalization, relationship between age and the onset of mental disorders, and the presence of concomitant somatic diseases.
Subjects in the study were 28 inpatients aged over 60 years treated in the Gastroenterology Department of Internal Diseases Institute, Medical Academy in Poznań, and 104 residents of a nursing home. A detailed subjective examination was carried out to establish clinical symptoms of postprandial hypotonia, concomitant ailments, and received medication, while an objective examination – to determine the patients' BMI. A preliminary diagnosis of postprandial hypotonia was confirmed by additional measurements. Arterial blood pressure was measured typically on the brachial artery 15 minutes prior to a meal and at 15-minute intervals after meal during the following 90 minutes. A decrease of arterial blood pressure by the required 20 mmHg was found usually in the interval of 45 to 90 minutes after meal in 14 patients, i.e. in 50% of the group selected due to a high risk for postprandial hypotonia.
The paper presents results of a study on dementing and depressive symptoms in elderly (aged over 65 years) medically ill inpatients of the Gastroenterology and Human Nutrition Department of Medical Academy in Poznań. A screening was carried out using an abbreviated version of the Geriatric Depression Scale and the Folsteins' Mini-Mental State to assess cognitive junctions. A 100% concordance was found between results of the screening and findings of a specialist psychiatric examination. The Geriatric Depression Scale and Mini-Mental State Examination may be considered as a brief and reliable method of diagnosing depressive and dementing disorders in elderly patients of internal diseases departments.
Delirium in the old age is the most common syndrome of qualitative impairment of consciousness. Its prevalence rate amounts to 22-38% cases of elderly inpatients. In cardiac diseases delirium is most often noted in myocardial insufficiency and myocardial infarction.
A retrospective analysis was performed on case records of 34 elderly patients (aged over 65 years) with mental disorders, selected out of the total of 1749 inpatients treated in the years 1995-1996 in the Gastroenterology Department, Institute of Internal Diseases, Medical Academy in Poznań. The diagnosed digestive system diseases as well as the presence of impairment of consciousness and/or mental disorder s were taken into account. Impairment of consciousness was usually caused by severe cirrhosis of the liver or by cancer of this organ, and somewhat less often – by acute bleeding from the digestive system, with a subsequent anemia. Among causes of mood, drive, sleep, memory and personality disorders the predominating ones were chronic pain and neoplastic diseases. Mental disorders were more frequent in females than in males (12: l). The presence of mental disorder s in medically ill older people is an unfavorable prognostic sign. Out of the 34 cases under study 12 patients died during their hospitalization at the Gastroenterology Department.
The authors outline activities of a new form of open health care services in Poland, on the example of two psychogeriatric outpatient facilities functioning in two cities (district capitals). Usefulness of establishing such units, and further implications of their functioning in the network of health care services for elderly patients are considered. An important role of outpatient treatment accessibility for more efficient helping older patients is emphasized.
The paper presents an initial situation of psychiatric care for the elderly, its current status, and a planned project of integrated psychogeriatric care delivery in the catchment area of the District Psychiatric Treatment Center in Toruń (a town with 350 thousand inhabitants).
Three cases of depression in patients with cardiac pacemaker are presented, and good effects of treatment with fluvoxamine are emphasized.