노인정신의학

조맹제

서울대 의대 신경정신과

노인부양지수(한국)

2025년

2010년

1990년

Psychiatry의 분야

• Clinical subdivision: Child psychiatry Adolescent psychiatry Adult psychiatry Geriatric psychiatry

• Research areas: Biological psychiatry Psychological psychiatry Social psychiatry

Common Mental Disorders in the Elderly

• Depression• Dementia

– Primary degenerative D– Vascular and other D

• Delirium• Delusional disorder• Anxiety disorder• Late onset psychotic disorder

Mental disorders among older adults

Distribution of Psychiatric diagnoses(%) Category of illness Community

residents Medical-surgical

Inpatients Cognitive impairment Mood disorders Anxiety disorders Alcohol abuse/dependence Schizophrenic disorders Somatization Personality disorder Other psychiatric disorder

5.9 6.5 5.5 0.9 0.1 0.1 0 0

30.2 18.5 5.2 2.6 0 0

8.3 7.9

노년기:정신건강 상실의 취약기

• 신체적 기능저하• 만성 퇴행성질환• 직업과 사회적 지위의 상실• 배우자나 가까운 사람의 죽음• 경제적 어려움• 뇌의 퇴행성변화

노년기 우울증

Prevalence of Elderly Depression

- Community Studies -Author Country N Prevelence(%)

Blazer et al (1980)Ben Arie et al(1987)Copeland et al(1987)Kua(1990)Livingston et al(1990)Madianos et al(1991)Lobo et al(1991)Helmchen et al(1996)Suh & Cho (1998)Hong & Cho(1999)

USASouth Africa

UKSingapore

UKGreeceSpain

GermanyKoreaKorea

992439

1070612705215

1000516

1019768

3.713.711.25.315.99.76.617.810.16.7

Depressive disorders in Primary Care Settings

Author Country Prevalence(%)Madonald(1991)Illife et al(1991)Oxman et al (1990)Evans & Katona(1993)Borson et al(1986)

UKUK

USAUK

USA

30.621.22136

24.4

ICD-10 Depression criteriaCardinal symptoms

(1) Depressed mood to a degree that is definitely abnormal for the individual, present for most of the day.

(2) Loss of interest in pleasure in activities that are normally pleasurable

(3) Decreased energy or increased fatigability

Additional symptoms(1) Loss of confidence or self-esteem(2) Unreasonable feelings or self-reproach or excessive and

inappropriate guilt(3) Recurrent thoughts of death or suicide, or any suicidal

behavior(4) Complaints or evidence of diminished ability to think or

concentrate, such as indecisiveness or vacillation(5) Changes n psychomotor activity with agitation or

retardation(6) Sleep disturbance of any type(7) Changes in appetite with corresponding weight change

Symptoms specific to the Older Patient

• - less of subjective lowering of mood - less guilt feeling

- hypochondriacal preoccupation - more somatic symptoms and concerns

• Recent onset of anxiety of obsessive symptoms

• Prominent cognitive dysfunction (“pseudo-dementia)

• Recent “out of character” behaviors

Dementia or depressionDementia

* Insidious onset * No psychiatric history * Conceals disability * Near-miss answers * Mood fluctuation day to day * Stable cognitive loss * Tries hard to perform but is

unconcerned by losses * Short-term memory loss * Memory loss occurs first * Associated with a decline in

social function

Depression

* Abrupt onset * History of depression * Highlights disabilities *‘Don't know’ answers * Diurnal variation in mood * Fluctuating cognitive loss * Tries less hard to perform

and gets distressed by losses * Short- and long-term memory loss * Depressed mood coincides with

memory loss * Associated with anxiety

OR

Key Questions to Ask the Elderly Patient

• 기분은 어떤가?• 만사에 흥미를 잃었는가?• 예전과는 달리 즐거운 게 없는가?• 이런 증상들이 얼마나 지속되었는가?• 과거에도 우울증이란 진단을 받아본적이 있는가?• 지난해에 건강상태에 중요한 변화가 있었는가?• 지난 몇 개월동안에 인생의 중요한 변화가 있었는가?• 예를들어 ‘체중감소’와 같은 어떤 신체질환을 시사하

는 증상이 있는가?

• 차라리 죽는 게 낫다는 생각을 해본적이 있는가?

노인우울증의 치료

• 약물치료• 정신치료• 인지-행동치료• 물리치료(ECT)• 가족치료

신체질환을 동반한 노인우울증의 약물치료

• General Issues -alert to contraindications and side effects -potential for drug-drug interaction -side-effects more prevalent in frail elderly -risk of overdose -psychological therapy as adjunct -start low, go slow

치매환자에서 우울증 동반시 처치

• Dementia and depression do co-exist in the same patients

• Patients with dementia should have the same rights and opportunity to be happy and not depressed

• In placebo controlled studies, TCA showed no difference to placebo, but moclobemide, citalopram, maprotyline showed higher efficacy than placebo

Medical Illnesses Related to Organic Mood Disorders

• Medical Conditions- Endocrine/metabolic - Occult cardness

· hypo/hyperthyroidism · pancreas· Cushing’s disease · lung· hypercalcemia - Chronic infections· sub-nutrition · neurosyphilis· pernicious anemia · brucellosis

- Organic brain disease · neurocysticercosis· cerebrovasular disease/stroke · myalgic

encephala myelitis· CNS tumor - Parasitosis· Parkinson’s disease· Alzheimer’s disease· multiple sclerosis· SLE

Central-Acting Medications Related to Organic Mood Disorders

• Antihypertensive drugs • Anti-Parkinson- beta blockers - L-dopa

- methyldopa - amantadine

- reserpine • Psychiatric drugs- clonidine - neuroleptics

- nifedipine - benzodiazepines

- digoxin • Miscellaneous• Steroid - sulfonamide• Analgesic drugs - oral contraceptives

- opioids

- indomethacin

기존 TCA계통 약물을 노인에게 투여시 유의할 부작용들

Antihistaminic

• Sedation

Antiadrenergic

• postural hypotension

• dizziness• falls

Anticholinergic

• confusion• urinary retention• precipitation /

worsening of glaucoma

• blurring of vision• seizure

Advantages and disadvantages of major categories of

antidepressants

Category Advantages Disadvantages

First-line agents SSRIs

Benign side effects Once-daily dosing

Sexual side effects Interact with many medicationsprescribed for elderly patients Expensive

Bupropion

Benign side effects Relatively unlikely to cause rapid cycling

T.i.d dosing required Contraindicated in patients with seizures,

Eating disorder Very expensive

Venlafaxine

Benign side effects

Sexual side effects Expensive

Nefazodone

Benign side effects

May have therapeutic window between 300 and 500 mg/day Expensive

Continued

Category Advantages Disadvantages Second-line agents

Tricyclics

May be more effective than non-

Tricyclics in severe depression Inexpensive Once-daily dosing

Dangerous side effects (orthostatic hypotension, delayed cardiac conduction)

Trazodone

Inexpensive

Dangerous side effects (orthostatic hypotension)

Rarely causes priapism

Third-line agents MAOIs

Inexpensive Effective in atypical Depression

Dietary and medication restrictions Required Potentially fatal interaction with

Meperidine, sympathomimetics, SSRIS

Lithium Inexpensive Only two-thirds as effective as above agents Psychostimulants (methylphenidate, amphetamines)

Immediately effective Benign side effects

No controlled studies Development of tolerance common

MAOIs = monoamine oxidase inhibitors ; SSRIs = selective serotonin reuptake inhibitors ; Tid = three times per day.

Information about antidepressants for elderly patients

• Start low, go slow• Typical side effects• Delay in onset of therapeutic action• Lack of dependency potential• Need for continued treatment

following initial response

Other management of Depression in the Elderly

• Psychosocial Interventions• Psychodynamic therapy • Behavior cognitive therapy• Electro-convulsive therapy

–safe, effective: 80%이상 good outcomes-poorer outcome with concomitant physical illness,

medication resistance, and being old-old-depression related cognitive impairment improves -ECT may be safer for older, severely depressed

cardiac patients

Final stage of personality development

• Integrity : 화해용서나의 존재-숙명론평안죽음을 맞을 용기

• Despair: 원망분노타인의존 재-투사우울, 불안죽음에 대한 공포

Conclusion

• Common major mental disorder in elderly

• Disabling• Negative impacts on QOL• Increase mortality• Treatable• Requires longterm treatment

치 매

용어정의

정신지체 (Mental retardation)

치매 (Dementia)

조기(早期)치매 (Dementia praecox)

노년기(老年期) (Dementia senilica)

치매의 정의

인지기능의 저하

의식이 청명

서서히 발병

비가역적

Causes of dementia

Reversible dementias Irreversible dementias

• Common causes: – Depression– Delirium– Drug toxicity

• Common causes: – Alzheimer's disease– Vascular dementia

• Other causes– Lewy body disease– Pick's disease

(dementia of the frontal lobe type)

– Parkinson's disease with dementia

IDC-10 Criteria of AD

• Presence of dementia• Memory deterioration, Thinking &

reasoning deterioration 이 반드시 존재해야함-memory; registration, storage, retrieval의 장애

• insidious onset, slow deterioration, absence of clinical or lab. evidence of a syst. illness or brain disease

• absence of a history of sudden onset of neurological sign

DSM-IV definition of DAT

• Multiple cognitive deficits – memory impairment – aphasia

apraxia agnosia disturbance in executive function

• These lead to functional decline

임상증상

A. 다중 인지기능장애

기억력장애(새로운 지식학습, 학습된 지식 회상 장애)

다음의 인지기능장애 중의 하나 이상

a. 실어증

b. 실행증

c. 실인증

d. 집행기능(executive function)의 장애

B. 사회적, 직업적 기능의 장해와 이전기능의 상당한

정도의 하향

유 병 율(얼마나 많은가?)

• 65세 이상 노인인구 중 치매는 약 6-

10% 이중 3-5%가 알츠하이머치매(약

50%)

• 65세 이후 5세 증가시마다 발병율이 2

배 높아짐

• 85세 이상이면 40-50%가 이환

Epidemiology of AD

• Epidemiology– Folstein et al(1991, USA) : 4.9%– Graves(1996, USA) : 8.5%– O’Connor(1999, UK) : 7.9%– Park et al(1994, Korea) : 6.5% – Okura et al(1996, Japan) : 6.7%

Liu (1999, China) : 2.3%

– Suh and Cho (1998, Korea) : 4.2%– Cho and Bae (2001, Korea): 4.8%

AD의 위험인자는?

– Genetic(family history) : Chromo19, 14,1, 21, ApoE4

– Degenerative malignant : Age– Environmental : Low educational level– Vascular : Cerebrovascular amyloidosis– Toxic : Aluminum– Traumatic : Head trauma– Infectious : Slow-virus like

Protective factors

• Genetic (ApoE2)• High educational level• Longterm anti-inflammatory drug use• Longterm use of estrogens• Smoking(?)

진 단

• 확진 : 환자의 뇌조직을 생검하여 현미경 확인

• 병력청취 : 임상증상, 경과, 발병양상

• 간이정신상태 검사, 신경심리검사

• 진단적 검사 : CT, MRI, SPECT, PET

MRI of Mild AD Patient

Alzheimer’s D Normal

MRI of Severe AD Patient

Alzheimer’s D Normal

Four domains of Alzheimer’s disease

Cognition

ADL Mood & Behavior

Caregiver burden

Cognition(인지기능) 장애

• Memory: First & foremost impairments : early, progressive, largely global, recent and short memory impairment

• Language• Executive function• Visuospatial• Orientation

Typical Clinical features(1)Mood & Behavior

• Frequent abnormal behavior– Agitation ; 75%– Wandering ; 60%– Depression ; 50%– Psychosis ; 30%– Screaming ; 25%– Violence ; 20%– Sexuality ; 10%

경과 및 예후

• 50-60대에 발병, 5-15년에 걸쳐 서서히 진행

• 발병연령, 진행속도

• 유병기간 : 2-20년

• 대개 폐렴 등 2차적 원인으로 사망

Typical course of AD

|---------------

Death |------------------------------------------

Nursing home placement

25 ---------------------| Symptoms

20 |----------------------| Diagnosis

15 |-----------------------| Loss of functional independence

10 |--------------------------------| Behavioral problems

5 ----------------------------|

0

MM

SE sc

ore

1 2 3 4 5 6 7 8 9Years

Vascular dementia (VaD)

Definition:

VaD is an etiologic category of dementia that

include clinical forms of dementia resulting from

hypoxic-ischemic or hemorrhagic cerebrovascular

disease(CVD) or cardiac and circulatory

disorders

Vascular dementia

• Abrupt onset• Stepwise deterioration• Onset earlier than AD• male>=female• Preventive by risk factors control

Interactions between VaD and AD

VaDVaD ADADAD + CVD

infarcts, white matter lesions (WMLs)

vascular risk factorspost-stroke dementia

Source: Erkinjuntti

Dementia with Lewy Bodies (DLB)

• Dementia syndrome• Plus 2 of 3:

– Visual hallucinations– Fluctuating consciousness– Parkinsonism

Fronto-Temporal dementia• Onset between 45 and 65 years• Equal incidence in men and women• Mean duration of illness: 8 years(range: 2-20yrs)• Family history of dementia in ½ of cases• Insidious onset and gradual progression• Early decline in social interpersonal conduct• Early impairment in regulation of personal conduct• Early emotional blunting• Early loss of insight

Pharmacotherapy of Cognitive Dysfunction

1. Cholinergic enhancement

1) Cholinergic precursors

2) Cholinesterase inhibitors

3) Cholinergic agonist

4) Cholinergic releasing agents

2. Cerebral vasodilatators

3. Metabolic enhancers

4. Vitamins and Hormones

5. Nootropic drugs

6. Anti-inflammatory agents

7. Neuroprotective agents

8. MAO-Inhibitors

9. Narcotic Antagonists: Naltrexne, naloxone

Cholinesterase Inhibitors

- Physostigmine

- Cognex® (Tacrine Hcl)

- Aricept® (Donepezil Hcl)

- Exelon® (Rivastigmine)

- Metrifonate

- MF – 210- Reminyl (Galantamine)

기타 노년기 정신질환

거의 매일 불면: 11.9%

간헐적 불면: 14.8%

울산홍진표, 조맹제

(2000)수면장애

망상장애 : 0.39%

망상증상: 3.17%

경기

연천군

서국희, 조맹제

(1996)망상장애

평생 유병율 :13.43%

1년 유병율 : 4.37%

인천배제남, 조맹제

(2001)

평생 유병율 : 21.2%

1년 유병율 : 13.6%

강화도남궁기

(1989)알코올

사용장애

Delusional disorder

• One or two persistent systematized delusion

• Sometimes hallucination• No cognitive impairment• No shortening of life span expectancy• Women 3 times more frequent than men• 10% of admission to psychiatric ward• Good response to antipsychotics

Other problems

• 10% of alcoholics have late onset• Sexual assault• Violence is less common• Higher rate of suicide

노인정신의학노인부양지수(한국)Psychiatry의 분야Common Mental Disorders in the ElderlyMental disorders among older adults노년기:정신건강 상실의 취약기노년기 우울증Prevalence of Elderly Depression- Community Studies -Depressive disorders in Primary Care SettingsICD-10 Depression criteriaSymptoms specific to the Older PatientDementia or depressionKey Questions to Ask the Elderly Patient노인우울증의 치료신체질환을 동반한 노인우울증의 약물치료치매환자에서 우울증 동반시 처치Medical Illnesses Related to Organic Mood DisordersCentral-Acting Medications Related to Organic Mood Disorders기존 TCA계통 약물을 노인에게 투여시 유의할 부작용들Advantages and disadvantages of major categories of antidepressantsContinuedInformation about antidepressants for elderly patientsOther management of Depression in the ElderlyFinal stage of personality developmentConclusion치 매용어정의치매의 정의Causes of dementiaIDC-10 Criteria of ADDSM-IV definition of DAT임상증상유 병 율(얼마나 많은가?)Epidemiology of ADAD의 위험인자는?Protective factors진 단MRI of Mild AD PatientMRI of Severe AD PatientCognition(인지기능) 장애Typical Clinical features(1)Mood & Behavior경과 및 예후Typical course of ADVascular dementia (VaD)Vascular dementiaInteractions between VaD and ADDementia with Lewy Bodies (DLB)Fronto-Temporal dementiaPharmacotherapy of Cognitive Dysfunction기타 노년기 정신질환Delusional disorderOther problems