CMESAC290311 Geriatric psychiatry

Geriatric Psychiatry complementing through Ayurveda : 

Geriatric Psychiatry complementing through Ayurveda Dr. Sanjeev Rastogi MD, DHHM, GHC(US) Dept of Kaya Chikitsa State Ayurvedic College, Lucknow

What is geriatric psychiatry? : 

What is geriatric psychiatry? A specialized domain in psychiatry dealing with special psychiatric health care needs pertaining to elderly. The word first came into existence in 1991 as Geropsychiatry when American Board of psychiatry and Neurology ,recognized it as a subspecialty in psychiatry.

Why geriatric psychiatry? : 

Why geriatric psychiatry? Increasing elderly population globally Increased prevalence of mental disorders in elderly Special psychiatric health care need in elderly

Global increase in elderly population : 

Global increase in elderly population Historically unprecedented phenomenon 60+ and 80 + age group share in total population is now higher than any time in history This share is still increasing

Global growth of elderly population : 

Global growth of elderly population

Unequal elderly population growth : 

Unequal elderly population growth In developed counties 20% of total population in now 60+ This is expected to be 30 % in next 4 decades In developing countries less than 10 % of total population is now 60+ This is expected to be over 20% till 2050

Exponential rise of elderly population in 3rd world : 

Exponential rise of elderly population in 3rd world What makes this to happen? Increased fertility +decreased mortality=Absolute elderly population growth( Increase in number) Decreased fertility + decreased mortality = relative elderly population growth( increase in proportion)

Elderly population burden in 3rd world : 

Elderly population burden in 3rd world Is supposedly greater for intense increase in elderly population rapid socioeconomic changes making elderly cohorts exposed to inexperienced situations

Elderly population growth in India : 

Elderly population growth in India

Elderly population growth in India : 

Elderly population growth in India Growing exponentially Grown three fold in last 40 years. Is supposed to grow four folds in coming 40 years.

Prevalence of Psychiatric illness in elderly : 

Prevalence of Psychiatric illness in elderly About 25% of elderly people in general are supposed to have significant psychiatric symptoms In India this is 15-20%( S Gupta, Prev. Soc. Med , 2006 ) In total population the prevalence of psychiatric illness is 7-8% ( Math SB, IJMR,2007) Psychiatric illnesses are known to increase with age so with increasing cohorts of old old( 70+) and oldest old( 80+) this ratio is bound to increase further.

Special psychiatric health care needs in elderly : 

Special psychiatric health care needs in elderly Elderly are more prone to psychiatric illness for plenty of stressors Physical Mental Emotional and Socioeconomic stressors

Old age: a tail of disengagements : 

Old age: a tail of disengagements Contrary to the young age which is predominated by possessions, old age is characterized by loosing the things often involuntarily. This loosing is divergent and affect every aspect of human life, physical , mental , economical and social.

Gradual loss of psycho-physical determinant during aging : Ayurvedic view : 

Gradual loss of psycho-physical determinant during aging : Ayurvedic view Balyam vriddhischa chavirmedha Twaga drishti: shukra vikramau/ Buddhi: karmendriya cheto jeevitam dashato hriset// Sha.sam.Pu.6/61

Decadal losses during aging : 

Decadal losses during aging

Common stressors to elderly : 

Common stressors to elderly Loss of partner 2001 census in India says that about 33% elderly are without their life partners Loss of spouse ( and other beloved) is a major disaster in old age Such individual require a suitable and adequate social safety net work irrespective of their gender

Common stressors to elderly : 

Common stressors to elderly Economic instability NFHS-2 says that more than half of the elderly population continues to work irrespective of their ages. This is largely the economic instability which forces them to work.

Common stressors to elderly : 

Common stressors to elderly Poverty NFHS -2 says that about 7.8% elderly population in India is deprived of food, clothing and medical care. This is most pathetic in Assam where it contributes to 14.6% of elderly followed by Andhra (11.6) and Bihar( 8.6) In Himalayan states this seems to be much better with a lowest of 1% At Jammu and 1.3% at Himanchal Pradesh.

Common stressors in elderly : 

Common stressors in elderly Associated physical illness Old age often goes hand in hand with various physical illnesses Common physical illness of elderly are primarily prone to cardio-vascular, uro-genital and neuro-locomotory system They arrive through degenerative, neoplastic and metabolic pathways

Physical illness among elderly : 

Physical illness among elderly Majority of physical illness occurring in elderly are Difficult to treat Require cost intensive management Need a continuous palliation May have a neurodegenerative component

↑Disease prevalence and ↓resources , the deadly combo among elderly : 

↑Disease prevalence and ↓resources , the deadly combo among elderly When an increased prevalence of physical illness among elderly requiring cost intensive management is clubbed with economic instability and poverty of old age, the stress may increase many fold Can easily lead to psychiatric symptoms

Slide 22: 

Contrary to the psychiatric illness of young age (which can be managed through medication alone) ,these contributing reasons of psychiatric illness in elderly are required to be duly addressed while making any management plan

Reviewing the resources : 

Reviewing the resources Psychiatric health care infrastructure in India is absolutely inadequate 2-3% of population suffer from incapacitating mental illness requiring hospitalization There are more psychiatric patients from rural area who do no have an access to psychiatry unit 10-50% adult patients in general OPD are diagnosed mentally ill but are not worked out further for want of facilities

Reviewing the resources : 

Reviewing the resources There are only 3500 psychiatrists in India (Hindustan 26.2.09) Only 100 in UP We require minimum 32,000 psychiatrist to meet the current demand This demand is expect to rise many fold in coming future Ayurvedic physicians due to their inherent understanding of Body & mind composite, with due training in psychiatry can act as a bridge between patient and psychiatrist

NMHP 1982 : 

NMHP 1982 National mental health program launched in 1982 in India does not address the issue of geriatric psychiatry and hence needs a revision in concurrent perspective

Mental disorders of old age : 

Mental disorders of old age What is important to know? Many mental disorder of old age can be prevented , ameliorated or reversed if diagnosed and treated early. Can progress to irreversible stage requiring hospitalization if not treated early.

Synthesis of mental disorders in old age : 

Synthesis of mental disorders in old age A complex interplay of Biologic Sociologic & Psychological factors

Biological factors : 

Biological factors Paranoid ideation may directly be related to the sensory decline specially of hearing loss Hypochondriasis is frequently a mechanism to compensate decreased functions (preoccupation with bowel symptoms)

Sociological factors : 

Sociological factors Play in response to the stress generation through a general disengagement Retirement Loss of spouse and friends Migration of children Lack of active responsibility and engagements leads to depression

Psychological factors : 

Psychological factors Psychological withdrawal of elderly is often related to loss of self esteem Economic insecurity loss of financial and social independence Recognition of decreasing physical and mental ability Fear of approaching death. A real or imagined loss of physical attractiveness may have a traumatic impact upon the person ( more in the culture putting more stress upon physical attractiveness).

Prevalence of Psychiatric disorder in Indian elderlyChaudhari etal 2008, internet journal of health : 

Prevalence of Psychiatric disorder in Indian elderlyChaudhari etal 2008, internet journal of health

Common psychiatric illness in Indian elderly : 

Common psychiatric illness in Indian elderly Depression Dementia Anxiety Together constitute near half of the total prevalence There are clear gender difference in their prevalence

Depression : 

Depression Commonest psychiatric illness presented in elderly(23.6%) More common in female(27.7%) Prevalence increase as the age advances Commonly present as somatic complaint ( predominantly bowel symptoms)

Causes of depression in elderly : 

Causes of depression in elderly Associated physical illness leading to disability ( Stroke, RA, Parkinsonism) Co-prescribed drugs( anti-hypertensive, anti epileptics) Loneliness Financial dependence Lack of active engagements An awareness to reduced physical and mental ability

Risk association of Depression : 

Risk association of Depression Alcohol abuse Suicide is more common in elderly depressed than their young counterparts. (nearly 2/3 patients of depression contemplate to suicide and 15 % of total succeed)

Management of depression in elderly: inherent issues : 

Management of depression in elderly: inherent issues Early identification Drug safety profile Simultaneous management of co morbidities Correction of risk factors use of collaborative care model involving family, social workers, family physician , psychiatrist and peers in the management

Ayurvedic drugs for depression in elderly : 

Ayurvedic drugs for depression in elderly Aswagandha( Withania somnifera) Kapikacchu( Mucuna prurience) Mandukparni( Centella asiatica) Guduchi (Tinospora cardifolia) Vacha ( acorus calamus)

Evidence base Ayurveda for depression in elderly : 

Evidence base Ayurveda for depression in elderly Antidepressant effect of Ashwagandha is comparable to TCA ( Bhattacharya ,Phytomedicine ,2000) Yoga intervention is found better than Ayurveda to cope depression in elderly(Krishnamurti ,Journal of Gerontological nursing, 2007) Bright light is conductive to manage depression in elderly ( reduction of Tama) Sumaya ,Journal of Gerontology 2001

Dementia : 

Dementia 2nd largest psychiatric presentation among elderly in India A higher prevalence in male Characterized by progressive loss of short term memory Often coexist with depression and other cognitive disturbances Aphasia ( inability to speak ) Apraxia ( loss of fine movements) Agnosia( loss of recognition)

Causes of dementia in elderly : 

Causes of dementia in elderly Alzheimer’s disease accounts for approx 2/3rd causes Vascular dementia ( multiple infarcts) accounts for rest 1/3rd causes

Reversible/preventable causes of cognitive impairment in elderly : 

Reversible/preventable causes of cognitive impairment in elderly Stroke ( avoidance of the risk factors) Drug induced (anti epileptic, anti hypertensive, antipsychotic) Depression ( pseudo dementia) Thyroid disease Vit.B12 deficiency Hypercalcemia Subdural haemetoma Normal pressure hydrocephalus

Alzheimer’s disease : 

Alzheimer’s disease 8th leading cause of death (6th to the elderly) Prevalence doubles every 5 year reaching 30-50% at 85 year age Women are less prone to suffer Begins with problem of memory followed by personality and behavioral changes (agitation , inappropriate sexual behaviour,wandering) Terminates as near mutism, difficulty with eating and swallowing , bowel and bladder incontinence and recurrent respiratory /urinary infection

Sub cortical dementia (Parkinsonism, vascular dementia) : 

Sub cortical dementia (Parkinsonism, vascular dementia) Characterized by Psychomotor slowing, Reduced attention Early loss of executive function Personality change

Dementia with Lewy bodies : 

Dementia with Lewy bodies Abnormal aggregates of protein that develop inside nerve cells Fluctuating cognitive impairment Complex visual hallucination ( people or animal is typical to lewy bodies, D/D with Alzheimer’s ) Rigidity and bradykinesia are primary sign No tremor No response to dopaminergic agonist therapy

Dementia management in elderly : 

Dementia management in elderly Require a comprehensive approach Should be Composed of Medical Social Behavioral components Psychological therapies are not helpful in dementia

Dementia management in elderly : 

Dementia management in elderly Medical management Acetylecholineesterase inhibiters (Donepezil,Galantamine Rivastigmine) Mementine( N methyle D aspartate NMDA antagonist) Ginko biloba Medhya Rasayana (Guduchi, Mandukparni, Yashti madhu,Shankhapushpi)Ashwagandha, Brahmi,Bala, Smriti sagar rasa Social Management A setting of familiar people and objects Behavioural Management Teaching specific skills to demented people to help their routine activity

Geriatric psychiatric disorder management : 

Geriatric psychiatric disorder management The golden rule is Identify preventable and correctable causes occurring at physical , mental or social level and act accordingly

Take home message : 

Take home message Early diagnosis and earliest management is the key for best out comes A planning for old age should start early in the age may it be related to the financial security or a health security(Purve vayasi madhye va)

Role of Ayurveda in Geriatric psychiatry : 

Role of Ayurveda in Geriatric psychiatry Ayurveda can complement to existing geriatric psychiatry care model through its Formulations ( Medhya Rasayana,Individual herbs) Satvavajaya ( cognitive behavioral therapy) Moral teachings ( Achara Rasayana) Ayurvedic physician can play the role of family physician for rapid screening of the elderly patients for any possible psychiatric illness

Role of Ayurveda in Geriatric psychiatry : 

Role of Ayurveda in Geriatric psychiatry Practicing Ayurvedic physician ( specially in rural area) ,for their exquisite knowledge about patients family, with due training to psychiatric tools, can act nodaly in comprehensive management of psychiatric illness in their area and can also act as a bridge between higher psychiatric centers and patients

The final word of caution : 

The final word of caution While advising for the Ayurvedic drugs to the elderly a care should be taken for Dose of the drug Scheduling of the drug Cost of the drug Co-morbidity Care for the co prescribed medication for any Drug –herb interaction