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12 - Mental health problems in older people

from Part II - Clinical issues

Published online by Cambridge University Press:  02 January 2018

Carolyn Chew-Graham
Affiliation:
Professor of Primary Care in the School of Community Based Medicine, University of Manchester
Robert Baldwin
Affiliation:
Consultant in Old Age Psychiatry at Manchester Royal Infirmary and Honorary Professor of Old Age Psychiatry at the University of Manchester
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Summary

This chapter is divided into four main sections, presenting, in turn, the primary care management of the commonest mental health problems in older people: delirium, depression, dementia and delusions (the first three of these are compared in Table 12.1). The presentation and management of a typical case are illustrated for each. Although the discussion largely refers to the UK context and the general practitioner (GP), the majority of it will apply internationally and to primary care physicians (and indeed other professionals) more generally.

Delirium

Clinical presentation

Delirium is a syndrome comprising disturbance of consciousness (often manifest as impaired attention or concentration), cognitive deficits (such as memory, orientation or language problems), disturbed sleep–wake cycle, associated features such as delusions or hallucinations (especially visual) and behavioural disturbances (such as agitation or apathy) and alterations in affect, notably fear (Table 12.1).

The onset is often sudden (hours or days) and fluctuation is a hallmark. A useful mnemonic is the four ‘I's (Crausman, 2004):

  • intermittent impairment of cognition

  • inattention

  • incoherent thought

  • impaired consciousness.

  • Delirium is synonymous with ‘acute confusional state’ (see Chapter 16).

    Case 1. Delirium: Marjorie

    The GP is called to see an 83-year-old lady, Marjorie, who lives in a residential home and who has quickly become confused, withdrawn and irritable. She has wandered out of her room, awake, for the past three nights.

    She has a history of diabetes, ischaemic heart disease, peptic ulcer and recurrent urinary tract infections.

    Her medication comprises gliclazide, digoxin, aspirin, ramipril, atorvastatin, thyroxine, omeprazole and paracetamol.

    The nurse in charge has asked the GP to see her because Marjorie is being disruptive.

    What does the GP need to consider in relation to assessment, diagnosis and management?

    Two main presentations are recognised:

  • hyperactive delirium (hallucinations, delusions, agitation and disorientation)

  • hypoactive delirium (cognitive impairment with apathy or withdrawal, less often accompanied by hallucinations and delusions).

  • The latter form can easily be overlooked in older patients.

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    Information
    Publisher: Royal College of Psychiatrists
    Print publication year: 2009

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