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Geriatrics
Depressions of the old subject
Courses of Geriatrics
 


 

Data epidemiology:

Field which takes extension.

One tends to underestimate the number of the depressions at the old subject.

It is nevertheless the most frequent diagnosis.

Often, existence of a disease, an accident or death of a child in the years which precede.

3% of depressions of the old subject in their complete and severe form.

Vary according to authors'.

Clinical and etiopathogenic forms:

A - FORM NEVROTIQUE AND REACTIONAL:

Very frequent at the old subject.

Generally bound to an event.

Three essential signs:

1) PATHOLOGICAL SADNESS:

The subject cannot separate some.

Tears without apparent reasons.

Sadness centered on painful topics.

The subject is absorbed by death and can have ideas of suicide.

The person feels useless and tests a feeling of trouble, of unexplainable vacuum.

Often somatic complaints of pace hypochondriaques.

Tendency to all to dramatize.

Can make think of a hysteria.

The subject does not test any pleasure.

All its existence is directed towards the suffering.

2) INHIBITION OR PSYCHOMOTOR DECELERATION:

Loss of interest and taste for any activity.

Disinterest for the things and the people.

Invades the intellectual sphere.

Frequent lapses of memory of the recent facts.

Possible confusion with an irrational state.

Disorders of the intellectual concentration appearing by a lability of the attention preventing the old person getting information, and especially from communicating.

On the emotional level, one finds this indifference.

One speaks about emotional anaesthesia.

Inhibition can also appear on the behavioral level by:

• A psychomotor deceleration

• A prostrate attitude

• A voice monocorde

• A very poor speech: monoideism

3) DISTURBANCES KNOWN AS “INSTINCTUAL”:

a) Anorexia:

Frequent.

Often unperceived master key because one regards it as normal during ageing.

Can be accompanied by digestive disorders.

Slimming.

b) Insomnia:

• Of drowsiness

• Night Alarm clocks

Can involve a diurnal somnolence with clinophilie.

To an inversion of the cycle takes care/sleep can lead.

c) urinary Disorders:

Arterial hypotension which can result from this.

Mixed repeated low volume: polakiurie.

Or oliguria.

4) ANXIETY:

Fear of a vital and imminent danger.

The physical demonstrations of the anguish mask the psychomotor deceleration.

The person can completely carry out a passage to the suicidal act.

Personality disorders which express the anxiety.

The people become irritable with respect to the entourage.

5) PSYCHOPATHOLOGICAL ASPECTS:

These depressions are called reactional because they are regarded as normals in reaction to certain events.

Certain factors are important to know:

a) Social insulation:

Cut of with the close relations.

Distress abandonment.

b) Social rejection:

Involved in particular by the retirement.

Abandonment of the social status.

Losses, mournings, which weaken the individual unceasingly.

Revelation of a fragile personality.

B - THE MELANCHOLIES PSYCHOTICS:

One can qualify them the endogenous ones, even if one can sometimes find a starting event.

1) The ACCESSES FRANK MELANCHOLIC PERSON:

One finds the same symptoms as in the depression but thorough with their paroxysm.

Delirious culpability: to have made impression reprehensible acts.

Self-accusation taking the form of one is delirious.

Ideas of unworthiness and incurability.

The contact is different with these patients.

Looking after often smell themselves pushed back.

The people are very slowed down.

One speaks about sideration of the psychic life.

Insomnia is often morning: alarm clock with 4 or 5 hours of the morning.

2) TABLE OF MELANCHOLY KNOWN AS Of INVOLUTION:

Characterized by the dramatized expression of the depressive disorders.

Can simulate a hysterical state.

Demonstrations suitable for old age.

They appear as from 50 years.

Very agitated people, expressing many complaints.

But the person does not seek the contact with the looking after team.

On the contrary: tendency to push back any help.

The person feels incurable.

It is what makes the difference with a décompensée hysteria.

Frequent dumbness.

Opposition to the care.

Delirious ideas: be delirious of negation of bodies.

Ideas of damnation, punishment, or contrary to immortality.

Auditive hallucinations can be found.

The unit constitutes the syndrome of Cotard.

Often same symptomatology as the access frank melancholic person.

But with demonstrations of the hysterical type.

Differentiated by the fact that the patient does not seek the contact.

3) PLACE NOSOGRAPHIQUE OF THE MELANCHOLIES:

Either one is in front of a first episode which one can attach to a PMD.

Either it is about a new episode of an old PMD.

C - ATYPICAL FORMS:

1) DEPRESSIONS MASQUEES:

Endogenous or psychogenic depressive State (reactional).

In fact the somatic symptoms prevail:

• Insomnia

• Asthenia

• Dyspnea

• Digestive Disorders

• Pains

The psychic symptoms are in the second plan.

It is the therapeutic test which will confirm the diagnosis: if the antidepressant treatment makes disappear the somatic complaints.

2) MASKING DEPRESSIONS:

The physical signs are noisy.

One often finds a thyroid problem or a neurologic affection.

A proportioning of the TSH systematically is made.

3) SOMATOGENIC DEPRESSIONS:

Follow upon the resolution of a serious physical problem.

The person keeps the same disorders although the physical problem is solved.

4) DEPRESSIVE EQUIVALENTS:

Episodes without depressive symptoms express, but where one locates other symptoms which make suspect a real depression.

Cyclic character.

Disappearance of the symptoms under antidepressant treatment.

5) ASSOCIATED DEPRESSIONS:

Occur among patients nevrotic who will know a depressive episode.

D - BORDERS OF THE DEPRESSION:

THE SYNDROME OF SLIP:

Situations where a fall of mood is found: syndrome of slip.

Fast Décompensation of the state general in the continuations of a somatic or psychic affection acute.

Occurs once the first affection was cured.

Can lead to dead in a few days.

People expressing a great opposition.

Adynamy.

Refusal of the care.

Refusal of the contact.

Syndrome of investment withdrawal:

• Vestimentary Negligence

• Refusal to feed

• Refusal of any stimulation

The cure is possible by antidepressant treatment.

E - EVOLUTION:

The forecast depends on the moment when one will take in load the depression and of the intensity of the clinical picture.

Death is to be feared; that it occurs by:

• Suicide

• Denutrition, dehydration

• An intercurrent disease

The cure is nevertheless the most frequent possibility.

The repetitions are not rare.

Need for a follow-up and establishment of a relation of confidence.

The evolution can be done towards chronicity or an irrational state.

Depressions and insanities:

A - CATEGORIELLE APPROACH:

The patient either lunatic or is depressed.

The differential diagnosis is sometimes difficult because these two affections have very close and badly known clinical signs.

The diagnosis of depression is carried by excess.

This error which appears of no importance practical must be corrected because there are treatments for certain diseases.

In addition, certain antidepressants have a worsening effect on the cognitive disorders of the disease of Alzheimer.

The question often arises in front of behavioral problems.

1) CLINICAL ELEMENTS OF DISTINCTION:

The depressed patient often only presents himself.

Frequently the family at a patient reached of an organic affection.

a) The mnemic complaint:

Very severe at the depressed subject.

Accompanied by somatic complaints.

The disorders contrast with the precision of the anamnèse.

The patients suffering from a disease of Alzeimer will minimize their disorders.

They present disorders of the memory of the recent facts.

b) Behavioral modifications:

They are common to both syndromes:

• Reduction of the activity

• Tiredness

• Disinterest

• Anhédonie: loss of the research of the pleasure

At the depressed subject, the loss of interest and the anhédonie are total.

The demented person preserves interest for certain activities which get pleasure to him.

At depressed, the disorder of mood is constant.

In the demented person, it is irregular.

Irrational table: deceleration of the simple gestures must make seek an associated affection or a subcortical lesion.

Insanity: no disorders of the appetite and sleep.

No the guilt feeling, self-accusation and idea suicidal.

c) Antecedents:

One is interested in the antecedents: many psychiatric antecedents, one are directed towards the depression.

.d) Evolutionary data:

The beginning of the disorders is difficult to specify in the degenerative affections.

In the depression, it is easier to specify.

Sometimes a starting event.

e) Neurological examination:

Normal at the beginning.

f) Clinical examination of the memory:

The earliest sign among Alzheimer patients is the incapacity to retain three words over the duration of the examination.

At the depressed subject, the association of the words improves the performances; not in the demented person.

2) THREE EXAMINATIONS PARACLINIQUES:

a) The neuropsychological examination:

Tests.

Does not allow to distinguish at the beginning the insanity from the depression.

b) Cerebral scanner or IRM:

Diffuse or localised atrophy at the patient lunatic.

Is convincing only at the young subjects.

c) standard Electroencephalogram:

Is disturbed only at the subjects demented person.

B - INSANITY AND DEPRESSION CAN COEXIST:

That is to say coincidentally.

Maybe because the depression would be the bed of the insanity (assumption).

Most probable is that the insanity can involve a depressive symptomatology.

The depression would be generally secondary with the insanity.

The therapeutic biological ones:

A - GENERAL BASES:

The antidepressants are more active than the placebos.

60% of depressed improve.

But some keep residual symptoms.

The majority of the antidepressants are also effective whatever the age.

The medicamentous compliance of the old people is a difficulty.

70% of the old patients neglect to take 25 to 50% of their treatment.

Important comorbidity.

Many old people present other pathologies which will worsen the depression.

The effects appear more tardily: 6 to 12 weeks.

Factor of noncompliance.

The treatment must be followed to the long course.

B - PHARMACOLOGICAL TREATMENTS:

1) ANTIDEPRESSANTS:

a) IMAO:

• MOCLAMINE: tolerance higher than the other IMAO

Cardiac counter-indications which make them difficult to use at the old subjects.

b) Imipraminiques and related:

Also called tricyclic.

• ANAFRANYL

• LAROXIL

• QUITAXON

c) Sérotoninergiques selective:

Inhibitors of recaptures serotonin.

• ZOLOFT

• DEROXAT

• SEROPRAM

Inhibitors of recaptures serotonin and noradrenalin

• IXEL

• EFFEXOR

2) REGULATORS OF MOOD:

Lithium.

To check if counter-indications do not appear.

Posology differs according to the age.

Regular Lithiémies.

After 75 years, the startup must be reserved for certain cases.

• DEPAMIDE

• TÉGRÉTOL

3) AUXILIARY TREATMENTS OF THE ANTIDEPRESSANTS:

a) Hypnotic:

b) Anxiolytiques:

c) Benzodiazepines:

C - NONPHARMACOLOGICAL BIOLOGICAL TREATMENTS:

1) SHOCK THERAPY:

Electric shocks.

Patients of more than 60 years, at which one cannot use antidepressants any more. Indications:

• Delirious Forms

• Severity of the depressive state: suicidal risk

• Forms resistant to the antidepressants

2) PHOTOTHERAPY:

Preliminary ophthalmologic assessment.

Go mainly on the seasonal depressions.

3) TEST DIAGNOSIS BY ANTIDEPRESSANT TREATMENT:

Can be a tool to differentiate the insanity from the depression.

Place psychotherapies:

Several types:

a) Psychotherapy of support:

Primarily consist in establishing a climate of confidence around the patient.

It is a realistic psychotherapy.

b) Psychodynamic therapies:

Psychoanalyse and therapies of psychoanalytical inspiration Vise to restore the regard of oneself compromised by the senescence

c) behavioral Therapies:

Rest on the idea that the depression results from a loss of the positive reinforcements.

Aim at supporting the positive interactions compared to the environment.

d) Cognitive therapies:

The modification of the irrational beliefs remarks of oneself, world and future aim at which maintain the depressive state.

e) Interpersonal therapy:

To improve the interpersonal relations of the patients.

f) Therapy of couple:

g) Family therapy:

h) Group therapy:

It is necessary that the old subject accepts psychotherapy.

That passes inter alia through the looking after team.

To make in kind centre a network of care which will constitute the pivot of a psychotherapy of support.

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