Geriatric MedicineTier 1Approach to a presentation

Psychiatric presentations, such as anxiety, depression, mania, and psychosis

Red flags

Acute onset/fluctuation -> delirium until excluded
Suicidal ideation/plan - late-life depression carries high completed suicide risk, esp. older men
Psychotic symptoms with self-neglect or risk to others
Catatonia - immobility, mutism, refusal of food/fluids
New mania in a patient with no prior psychiatric history -> organic cause (steroid, dopaminergic drug, hyperthyroid, frontal lesion)

Differential by mechanism

Organic/secondary (screen first - common in this age group)

Delirium (infection, drugs, metabolic)
Drug-induced - corticosteroids (mania/psychosis), levodopa/dopamine agonists (psychosis, ICD), anticholinergics, beta blockers/interferon (depression)
Endocrine - hypo/hyperthyroidism, Cushing's, hypercalcaemia
Neurological - stroke (esp. frontal/right hemisphere depression), Parkinson's disease depression, frontotemporal dementia (personality/behaviour change mimicking psychiatric illness), post-ictal states
Substance - alcohol, benzodiazepine intoxication/withdrawal

Primary psychiatric

Late-life depression (may present with somatic complaints, cognitive impairment - "pseudodementia")
Generalised anxiety, health anxiety
Late-onset psychosis / paraphrenia
Bipolar disorder (new mania rare - suspect organic first)
Grief/adjustment - bereavement, relocation, loss of independence

Focused history

Onset/tempo, collateral history essential
Screen mood (GDS - Geriatric Depression Scale), anxiety, psychotic symptoms, suicidal ideation directly
Full medication review including recent changes, OTC/complementary
Alcohol use - often under-reported
Cognitive complaints - concurrent or preceding (depression-dementia overlap)
Psychosocial - bereavement, isolation, financial stress, elder abuse
Physical symptoms - pain, sleep, appetite (somatic depression presentation common in elderly)

Focused examination

Cognitive screen (MMSE/MoCA) - distinguish pseudodementia from true dementia
Physical exam for organic clues - thyroid, Parkinsonism, focal neurology, Cushingoid features
Mental state exam - affect, thought form/content, insight, risk assessment
Functional assessment - self-care, nutrition, safety at home

Investigation strategy

Delirium/organic screen - FBE, UEC, calcium, TSH, B12/folate, glucose, LFT
Medication review for causative agents
CT brain if new focal signs, first-episode psychosis/mania, rapid cognitive decline
Urine drug screen/alcohol history if indicated
Avoid over-investigating chronic stable depression/anxiety - clinical assessment primary

Management

Sequence

1. Treat/remove organic and drug causes first

2. Non-pharmacological - psychotherapy (CBT adapted for older adults), social supports, exercise, treat sleep

3. Pharmacotherapy if moderate-severe, guided by comorbidity

Depression

SSRIs first-line (sertraline, escitalopram) - lower interaction burden
Avoid TCAs - anticholinergic, cardiotoxic, falls risk
Mirtazapine useful if poor appetite/sleep
Start low, go slow; allow 4-6 weeks for response; monitor for hyponatraemia (SSRI, esp. with diuretics)
ECT - effective, consider in severe/psychotic depression, refusal to eat/drink, or treatment resistance - not contraindicated by age

Anxiety

SSRI/SNRI first-line; avoid benzodiazepines - falls, cognitive impairment, dependence

Psychosis/mania

Low-dose atypical antipsychotic (e.g. risperidone, quetiapine) - caution: increased stroke/mortality risk in dementia-related psychosis; avoid in Lewy body disease
Treat underlying organic cause first if identified

Traps

Labelling somatic depression presentation as purely physical illness (or vice versa)
Missing pseudodementia - depression mimicking cognitive impairment, reversible with treatment
New mania/psychosis assumed primary psychiatric without organic workup
Benzodiazepine use for anxiety - falls, dependence, paradoxical agitation
Underestimating suicide risk in older men - highest completed-suicide demographic

Talk track

Acute or fluctuating change = delirium first. Otherwise screen for organic/drug causes before diagnosing primary psychiatric illness, especially new mania or psychosis in a patient with no prior history. SSRIs first-line for depression/anxiety over TCAs/benzodiazepines; always assess suicide risk directly - older men are the highest-risk group. Consider pseudodementia when cognitive complaints accompany depression.

7 more sections, plus exam facts

Premium unlocks every note across every specialty, and the full exam fact library behind it.

Get premium access