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Geriatrics
Geriatric psychology
Courses of Geriatrics
 


 

Introduction:

A - DEFINITION:

The psychogériatrie is the psychiatry of the old people.

It includes/understands:

a) General psychiatric diseases:

• Psychoses

• Neuroses

b) Confusional episodes:

Disorders of the conscience.

They are reversible things.

c) irrational states:

They are organized and reversible.

B - WHAT A SUCCESSFUL AGEING?

People who can suffer from their health physical or psychic, but which preserves a taste for the life, with emotional ties, family, friendly and social and activities.

The anguish of death exists but remains bearable and does not have the capacity to disorganize the psychic life.

C - EPIDEMIOLOGY:

The number of old people increases. More than 60 years:

• 15% today

• 20% in 2010

• 35% in 2035 In the most 85 years:

• 20% autonomous

• 30% of irrational disorders

• 50% presents disorders requiring of the specific care

75% of people are maintained in their residence.

That supposes an often heavy catch of load.

Confusional episodes:

A - DEFINITION:

Confusion is a disorder of the conscience.

One speaks about episodes because they are pathological states of which the duration is theoretically short.

No matter who can present a confusional episode, at the time of a fever for example.

But the vulnerability increases with the age.

The evolutionary risks are severe.

Mortality is high if one ignores an etiology or in the event of diagnostic error.

Between 10 and 30% of the diagnoses to the urgencies.

60% of the people concerned have more than 60 years.

B - CLINICAL PRESENTATION:

1) FORMS AGITEES CONFUSO-ONIRIQUES:

Existence of hallucinations.

In the USA, one speaks about delirium.

In France one speaks about it only for the confusion caused by alcoholic weaning.

The patient speaks in a confused way, without interruption.

He repeats his gestures constantly.

Very fast fluctuations of mood:

Sometimes anxious, perplexed and sad  

• Sometimes aggressive and violent one

2) SLOWED DOWN FORMS STUPOREUSES:

The disorders of the conscience are in the foreground.

It is necessary to shake the person to increase her vigilance.

Stupor:

• Hypersomnolence

• Obnubilation

C - DIAGNOSIS:

It rests on a whole of symptoms.

Difficult because there is a great fluctuation in time.

1) DISORDERS OF STANDARD CONSCIENCE A Of OBNUBILATION:

Difficulty of fixing, of maintaining or of moving its attention.

There is the feeling of a disorder of the contact.

The subject does not include/understand the situation.

It does not have the clear ideas.

One does not succeed in obtaining and maintaining his co-operation to answer simple questions.

2) DISORDERS OF VIGILANCE:

That is to say an hyper-awakening with insomnia.

That is to say on the contrary a fall of vigilance with hypersomnolence.

That can fluctuate at the same person.

One can have an alternation with a diurnal somnolence and a night agitation.

Loss of the nychthemeral rate/rhythm (alternation takes care/sleep).

3) BEHAVIORAL PROBLEMS DRIVING:

That is to say an agitation forces.

That is to say a deceleration.

With sometimes an alternation of both.

4) DISORDERS Of ONE OR SEVERAL COGNITIVE FUNCTIONS:

a) Disorders of the memory:

Confusion temporo-spaciale.

b) Speech difficulties:

Touch:

• Comprehension

• Denomination

• Reading

• The writing

c) motor Disorders:

Does not manage to carry out simple operations.

5) DISORDERS Of ONE OR SEVERAL SENSORY PERCEPTIONS:

For example of the hallucinations and interpretations:

• Generally visual

• Sometimes auditive

6) DISORDERS Of ONE OR SEVERAL EMOTIONS:

That is to say indifference or euphoria.

That is to say sadness/anger/fear.

Anxious perplexity.

At the end of this episode, the patient will have a partial amnesia or complete.

D - RESEARCH OF THE ETIOLOGY:

It is done in three times:

1) HISTORY OF THE DISORDER:

Interrogation:

• Near the patient

• Of the family

• Of looking after

• Of the helps: firemen, SAMU

Somatic and psychic antecedents.

Pathologies in progress and their treatment.

All recent changes:

• Modifications of environment

• Changes of treatment

2) CLINICAL EXAMINATION:

Comprise a complete examination in the search of an etiology.

One insists on the neurological examination.

3) COMPLEMENTARY EXAMINATIONS:

Blood alcohol content.

EEG in the search of epilepsies partial.

ECG: arrhythmia, bradycardia, tachycardia, infarction.

Biology:

• Anaemia

• Polyglobulie

• Dehydration

• Hyponatrémie

Metabolic causes:

• NFS

• Ionogramme

• Hémocultures Glycemia.

Gas of blood.

Search of poisons or drugs in blood and the urines.

E - MANY AN ETIOLOGY POSSIBLE (TI - TV - TD):

1) POISONS:

a) External poisons:

- > Food/drink

Alcohol:

• Acute Intoxication

• Weaning

• Encephalopathies related to alcohol: Gayet-Wernicke, Korsakoff

• Hématome following a fall

- > Drug-addiction

It happens that old people take narcotics.

- > Toxic domestic

Intoxication with CO.

- > Medicamentous

• Anticholinergic

• Anxiolytiques

• Hypnotic

b) Other causes:

- > Metabolic

• Hyponatrémie

• Hypernatrémie

• Hypercalcémie

• Hypoglycemia

• Vitamin deficiency

- > Endocriniennes

• Hyperthyroïdie

• Hypothyroïdie

• Hyperparathyroïdie

• Hypoparathyroïdie

- > Insufficiency of an internal organ

• Renal Insufficiency

• Hepatic Insufficiency

• Respiratory Insufficiency: hypoxia

2) INFECTIOUS AND INFLAMMATORY:

a) Infectious:

- > Parasitic

• Paludism è Virus

• Herpetic Meningoencephalitis

• AIDS è Bactéries

• Acute Meningitides with méningocoques

• Chronic Meningitis: tuberculosis

• Typhoid

• Bruxellose

• Disease of Lyme: punctures of ticks

- > Let us request

• Encephalopathy of Creutzfeldt-Jakob

b) Inflammatory:

Disease of Horton.

knotty Side-arteritis. Lupus.

3) TRAUMATIC:

Hématome under-dural:

Following a fall.

Fluctuating lethargy evolving/moving over several months.

4) VASCULAR:

a) Weaken:

• Acute

• Chronic

b) Hypoxia:

c) arterial AVC:

More often hemorrhagic than ischaemic.

d) Venous AVC:

Thrombophlébite of the intracranial sines.

e) Low cerebral flow:

Can have several origins:

• Infarction

• Arythmie supplements with auricular fibrillation (ACFA)

5) TUMORAL:

Primitive tumour or metastases.

Confusion will be caused:

• By an intracranial hypertension

• By epileptic fits generated by the tumour

6) DEGENERATIVE:

The insanity involves an increased brittleness.

It increases the risk of confusion.

7) VARIOUS CAUSES:

a) Epilepsy:

• State of evil of a complex partial crisis

• Post-critical Obnubilation

b) Sensory deprivation:

The loss of the vision can be a supporting factor of a confusional episode.

c) postoperative Period:

d) After an intense emotional stress:

Also a supporting factor.

E - DIFFERENTIAL DIAGNOSES:

1) ACUTE DELIRIOUS PUFF:

Touch the young subject < 30="" ans="">

Auditive hallucinations rather than visual.

Absence of somatic signs.

2) THE INSANITY:

It can be a supporting factor of confusion.

But it is another diagnosis.

Slow evolution.

Intellectual deficit without disorder of the conscience.

A demented person can be confused.

3) MELANCHOLY STUPOREUSE AND/OR AGITEE:

Intellectual deceleration.

But not of disorders of the conscience.

4) SYNDROME OF KORSAKOFF:

Amnesias of fixing.

Confusion.

Mistaken recognitions.

Compensation fabulations.

Dependent on vitamin deficiencies.

F - EVOLUTION:

Unforeseeable.

Depends primarily on the cause of the confusional syndrome.

Favorable evolution when the causes are found and treated.

Without treatment, the risks could be:

• Fall

• Fracture

• Running away

• Défenestration

Complications related to subjacent pathology.

Even treated, iatrogenic complications and nosocomiales related on the application and the sedative treatment.

Approximately 5% of death of the old people hospitalized for confusion.

It is an urgency.

G - TREATMENT:

1) TREATMENT ETIOLOGIQUE:

It is an urgency requiring a hospitalization.

Treatment of the cause:

• Fécalome

• Dehydration

2) SYMPTOMATIC TREATMENT:

a) To make drink:

Rehydration per bone or IV.

b) Contributions:

• Electrolytic

• Energy: G5

• Vitamin: B1 in particular, B6, B12

c) psychotropic Treatment:

• Carbamate: EQUANYL

• Nerve sedative

• Benzodiazepines

Sedative aimings on agitation and the anguish.

Smaller possible effective amount.

d) Physical application:

To avoid: it increases agitation and distresses.

In any event for a time runs.

Increased monitoring.

3) CARE MALE NURSES:

has) Environment:

To try to create an environment calm and reassuring.

Insulation and accompaniment.

b) Care of nursing:

• Care of mouth

• Hydration

• Food

• Care of prevention of escarres

• Care of prevention of the phlebites

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