Physical symptoms occur. These may include difficulty concentrating, difficulty falling asleep, feeling tired all the time, losing weight. Violent behavior or substance abuse occurs more often in depressed men than in women, though depression is more common in women.
When depression is unipolar, the episode will ease with medication. Since the 1950s, tricyclic antidepressant (TCA) drugs have been used for depression, but since 1990 they are being replaced by selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs). Moderate exercise for 3 hours weekly has been shown to reduce the symptoms of depression by 47%. It is believed to alter the serotonin chemistry in the brain. In electroconvulsive therapy (ECT) seizures are electrically induced in anesthetized patients to treat severe depression that has not responded to other treatment.
(used to be called manic-depressive disorder)
Some medications for bipolar disorder treat only the manic phase, some treat only the depressive phase, some treat both. Cognitive therapy, family education, and group education may be used in conjunction with medication therapy. Electroconvulsive therapy is used only as a last resort.
In the manic phase, the person is hyperactive and distractible and may not sleep for days, yet shows no fatigue. Thinking and speech are rapid and disjointed and cannot be interrupted. The person may give away possessions or go on a spending spree. Untreated pure manic episodes usually last 6 weeks. Untreated mixed (manic and depressive) episodes usually last 17 weeks.
There are five major categories of anxiety disorder:
(1) Generalized anxiety disorder (2) Posttraumatic stress disorder (3) panic disorder (4) phobias (5) OCD
Most patients recognize the senselessness of their behaviors; but if they resist doing them, the fear and anxiety become intolerable. Treatment is with CBT and one of the selective serotonin reuptake inhibitors (SSRIs) listed
Symptoms include excessive worry, uncontrollable anxiety, palpitations, insomnia, irritability, and difficulty concentrating. May be treated with medication and psychotherapy.
Treatment is multimodal, involving psychopharmacotherapy, psychotherapy, social interventions, and patient and family education. Forms of psychotherapy are cognitive behavioral therapy (CBT), in which the traumatic experiences are relived and worked through, and cognitive processing therapy (CPT), in which the thoughts and beliefs generated by the trauma are explored and reframed. Eye movement desensitization and reprocessing (EMDR) is also used. Social interventions to restore a sense of safety and security are a crucial element in therapy.
Physical symptoms include SOB, palpitations or tachycardia, sweating, and disorientation.
Treatment may include biofeedback, medication (Table 18.2) and (psychotherapy) cognitive behavioral therapy.
Numerous treatment options for phobias are available, including psychotherapy and the SSRIs, benzodiazepines, and monoamine oxidase inhibitors (MAOIs).
to drive out anxiety or obsessions
Used for PTSD
People with schizophrenia have their sensory perceptions jumbled and distorted, have difficulty concentrating, and perceive things without a stimulation—hallucinations. Hallucinations can occur in any of the senses but are most often auditory. These people also suffer from delusions, mistaken beliefs that are contrary to facts. The delusions can be paranoid, with pervasive distrust and suspicion of others. People with schizophrenia can withdraw from society, become homeless, and refuse to communicate.
Their speech is disorganized and can be incoherent. Their behaviors are often totally inappropriate. Their blunted emotions and withdrawal can progress to catatonia, motor immobility that can last for hours. Mutism is the inability or refusal to speak.
Magnetic resonance imaging (MRI) and positron emission tomography (PET) scans show brain abnormalities and changes in function.
Symptoms of schizophrenia typically come on in the late teens and twenties. Although there is no cure, it can be effectively treated with medications and programs of psychological rehabilitation. The goals of therapy are to reduce schizophrenic symptoms, prevent their return, and enable the patient to function in society. Antipsychotic medications such as olanzapine, quetiapine, and risperidone are used, either singly or in combinations if necessary, and mood stabilizers such as lithium are also used.
Treatment for personality disorders is not successful.
The basic origin of all these disorders is the need to escape, usually from extreme trauma, and most often from sexual, emotional, or physical abuse in childhood.
The most severe of this group of disorders is DID. Two or more distinct personalities, each with their own memories and behaviors, inhabit the same person at the same time. Treatment is with psychotherapy.
Intermittent explosive disorder, which is characterized by recurrent episodes of unrestrained aggression toward people, furniture, or property, with violent resistance to attempts to restrain. The etiology is thought to be epileptic-like activity in the brain. Medications that generate some improvement include propranolol, lithium, valproate, and phenytoin.
Kleptomania, which is characterized by stealing—not for gain, but to satisfy an irresistible urge to steal. Behavioral therapy can help, and SSRIs appear to be of value.
Trichotillomania (TTM), which is characterized by the repeated urge to pull out scalp, beard, pubic, and other body hair.
Substance abuse and chemical dependence, which involve a person’s continued use of drugs or alcohol despite having had significant problems or distress related to their use. This addiction affects the brain and behavior and develops an increased need for the substance and an inability to stop using it.
Pyromania, which is repeated fire setting with no motive other than a fascination with fire and fire engines. Some pyromaniacs end up as volunteer firefighters. Treatment with behavioral therapy is sometimes successful.
According to the statistics published by the Administration on Aging of the United States Department of Health and Human Services in 2011:
The older population (65+) numbered 40.4 million in 2010; this is 13.1% (more than 1 in 8) of the total population of the United States.
Older women (23.0 million) outnumber older men (17.4 million). Forty percent of older women are widows.
Women reaching age 65 in 2010 had an average life expectancy of an additional 20.0 years; males 17.3 years.
The older population is expected to increase to 55 million in 2020.
The 85+ population is projected to increase from 5.5 million in 2010 to 6.6 million in 2020.
Most older people have at least one chronic medical condition, and many have multiple conditions. The most frequently occurring chronic conditions among the elderly are diagnosed arthritis (50%), hypertension (38%), all types of heart disease (32%), any cancer (22%), and diabetes (18%). Alzheimer disease occurs in 13% of older people and accounts for 70% of all dementias.
Life expectancy is the average length of life for any given population.
Longevity is living beyond the normal life expectancy.
Aging is the gradual, spontaneous change resulting in maturation through childhood, adolescence, and young adulthood. Changes then cause decline in function rather than maturation, through late adulthood and old age.
Senescence is the loss over time of the ability of cells to divide, grow, and function, a process that terminates in death. It is sometimes used interchangeably with the term aging.
Exercise and good nutrition help prevent osteopenia.
Exercise and good nutrition help prevent muscle degeneration.
Exercising your brain enhances your quality of life in old age.
Exercise and good nutrition extend longevity and enhance the quality of life.
Bronchitis and emphysema, the chronic obstructive pulmonary diseases (COPDs), are the cumulative effects of cigarette smoking and are a leading cause of death in old age.
The kidneys of an 80-year-old receive only half as much blood as those of a 30-year-old because of atherosclerosis.
Because they have lowered immunity, the elderly are advised to receive vaccinations against influenza and other infections.
Free radicals can damage cells and can be neutralized by antioxidants.
It is highly likely that senescence has more than one etiology.
Both PVS and MCS differ from coma, in which the individual is unresponsive and keeps his eyes closed.
Many diseases in elderly persons may present with very vague and nonspecific symptoms. For example, pneumonia can present with low-grade fever, confusion, or falls rather than with the high fever and cough seen in younger adults. Delirium in the elderly can be caused by something as simple as constipation. Some elderly people may have difficulty describing their symptoms, particularly if they have cognitive impairment. Therefore, time and care have to be taken to discover the root cause.
Many elderly patients take multiple medications, sometimes prescribed by different specialists without reference to other medications prescribed by other specialists. This polypharmacy can result in adverse drug interactions. In addition, most drugs are excreted by the liver or kidneys, either of which can be impaired in the elderly. As a result, the dosage of medications may need to be adjusted to avoid excessive levels in the blood and undesirable side effects.
A study of 27,600 Medicare patients documented more than 1,500 adverse drug effects (ADEs) in a single year.
When a physician or nurse practitioner or a pharmacist oversees an elderly patient’s medication regimen, drug-related problems are less likely to occur.
The elderly patient should bring all of his/her medications to every hospital or office visit, including prescription, over-the-counter (OTC) drugs, and all supplements.
Alzheimer disease accounts for 70% of all dementias; it is progressive and there is no cure. Other types of dementia are vascular dementia, frontotemporal dementia, and dementia with Lewy bodies.
Delirium is a set of symptoms including an inability to focus attention; mental confusion; impairments in awareness, time, and space; and perhaps hallucinations. It often has a fluctuating course, and it can follow head trauma, stroke, drug withdrawal, hypoxia, hypoglycemia, physical illness of almost every type, and the use of opiates and benzodiazepines. Delirium is probably the single most common disorder affecting adults in hospitals and occurs in 30-40% of elderly hospitalized patients and in up to 80% of intensive care unit (ICU) patients. Treatment is to the underlying disease causing the delirium.
Urge incontinence, the loss of urine before one can get to the toilet, is the most common form in the elderly. It can be caused by strokes, multiple sclerosis, dementia, and pelvic floor atrophy in women or prostate enlargement in men.
Stress incontinence is caused by weak bladder muscles. It occurs when the abdominal pressure when you cough, sneeze, laugh, or climb stairs overcomes the closing pressure of the bladder.
Overflow incontinence is rare. It occurs when the bladder never completely empties and leaks small amounts of urine.
Functional incontinence is an inability to reach the toilet in time, for example, due to arthritis, stroke, or dementia.
Mixed incontinence is usually a combination of stress and urge incontinence.
Fecal incontinence occurs in about one-third of the elderly in institutional care, and is the second most common reason for committing the elderly to a nursing home. It can be produced by local causes such as chronic laxative abuse or muscle damage to the sphincter muscles in surgery or childbirth. It is also seen in dementia, multiple sclerosis, and diabetes.