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 Post subject: Need for Psychogeriatric Services for Sri Lanka
 Post Posted: Sun Nov 27, 2005 8:30 pm 
Need for Psychogeriatric Services for Sri Lanka

By K. A. L. A. Kuruppuarachchi, MBBS, MD, MRCPsych., Senior Lecturer, Department of Psychiatry, Faculty of Medicine, University of Kelaniya.

@ Sri Lanka Journal of Medicine: 2000 Vol. 9 No. 1

Globally the old age population has been increasing and Sri Lanka is no exception. According to the Ministry of Health, Highways and Social Services statistical manual, in 1995 the population above 65 years was 6.2% and the predicted figure for the year 2010 is 8.6% and the year 2020 is 12.1%. The mid-year population for 1998 was about 18.8 million. One has to consider the rising population above 75 years and 85 years also, as health care and life expectancy are improving. Another interesting observation is that our extended family system is gradually disappearing, particularly in the urban sector and one has to seriously consider this issue when planning psychiatric services. Not only physical illnesses but psychiatric ailments too tend to increase parallely as the ageing process begins.

Pattern of morbidity

Even though research with regard to old age psychiatry in Sri Lanka is scanty, the available data suggest a great need for this discipline. A survey done in the North Colombo General Hospital regarding admissions to the psychiatry unit showed that 7% were above 65 years old and the commonest morbidity was dementia (26%). The other important illnesses identified were depressive illness (25%) and schizophrenia (24%). Other patients had delusional disorders (10%), mania (7%), brief psychotic episodes (3.5%) and delirium (3.5%). However, this was a hospital-based study and the figures may not represent the community.

In developed countries, for instance in the United Kingdom, numerous studies have been done since the original surveys of psychogeriatrics. Some of the classical surveys of old age psychiatry were done at Newcastle Upon Tyne. A more recent study regarding prevalence rates showed that among the population 65 years or more 4.6% had cognitive impairment, 13.5% were depressed, 10% had phobic disorders and 3.7% had generalized anxiety disorder.

Depressive illness in the elderly

Social factors as well as physical factors can precipitate psychiatric disorders of old age. For example, life events, lack of social support, lack of social stimulation, economic factors, and a variety of physical illnesses can contribute to psychogeriatric problems. According to Murphy6 there is an association between the onset of depressive illness in old age and severe life events, major social difficulties and poor physical health.

Depressive illness is a major problem in the elderly and symptoms can manifest in various ways. Somatic symptoms of depression are a common presentation particularly in developing countries. In addition to that, clinicians often see anxiety, neurotic symptoms, agitation, restlessness, poor concentration and attention span leading to “memory problems” (depressive pseudodementia) and paranoid symptoms in the depressed elderly. Some of these patients resort to alcohol to obtain relief. Alcohol misuse can be co-morbid with other psychiatric disorders such as depressive illness, phobic and anxiety disorders.

Even though depressive illness is a common clinical problem in the elderly, it is often undetected and inadequately dealt with particularly in non-psychiatric settings. A study done with regard to use of antidepressants by non-psychiatrists for the management of medically ill, depressed, hospitalized, elderly patients showed either inadequate treatment, improper treatment, or non-treatment.

Depression is associated with many physical ailments. It is common in neurological disorders, even though the exact causative factors and prevalence rates are still debatable 8. Also, inter-relationships between depression and diabetes mellitus/cardiac disease is better understood. Many of these physical illnesses tend to rise with increasing age and it is important to identify them early to reduce morbidity. A study done with regard to mortality of elderly patients with psychiatric disorders showed that late life psychiatric disorders to have an excess mortality10. Another study done with regard to age related factors on depression showed that physical illnesses and associated disability are risk factors; whereas normally functioning healthy elders are not at greater risk than young people, in developing depressive illness.

Other major concerns

Anxiety disorders and other stress disorders are common in the old age population. Bereavement reactions are also encountered as they experience many losses during this age: retirement, marriage of children who then leave home, losing the spouse etc. Delusional disorders or “paranoid states of late onset” are seen in the elderly and the suffering may be immense due to these delusional systems. Dementias, mainly Alzheimers or multi-infarct, mixed or other uncommon forms also contribute to significant morbidity and mortality.

Caring for the elderly

At present in our country relatives of elderly patients play a major role in the caring process. However in time to come, services for the elderly mentally ill may have to be more organized and strengthened. Services should include health care as well as social services. It is important to train the medical profession (starting from undergraduates) to identify these problems early and to provide remedies whenever possible. In western countries this issue has been addressed to a considerable extent. Another important area that needs to be highlighted is allowing the elderly people to have social stimulation and recreational facilities. . Caring for carers is another important issue, as carers need emotional support and counselling constantly, particularly when dealing with illnesses like dementia. A study done with regard to reducing the burden of care in carers of Alzheimer’s disease sufferers demonstrated that the family intervention helped to reduce distress and depression significantly in the carers, simultaneously there was a significant reduction of behavioural disturbances among the patients12. A variety of facilities including residential homes, elderly mentally infirm (E. M. I.) homes, private homes, day centres and nursing homes (in addition to acute beds and long stay beds in the hospitals) are available in developed countries. Old age psychiatry has been identified as a sub speciality in psychiatry and many trainees take up Psychogeriatrics as their career.

Multidisciplinary teams including psychologists, community psychiatric nurses, occupational therapists, physiotherapists and social workers attend to a variety of problems encountered in these populations. In Sri Lanka too, time has come to give due consideration to provide comprehensive care for the elderly using a multimodal approach.

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