Geriatric Psychiatry: Comprehensive Mental Health Care of Older Adults
Geriatric psychiatry is the assessment, treatment, rehabilitation and prevention of mental, cognitive and behavioural disorders in older adults. Care requires integration of mental health with physical illness, medicines, sensory function, mobility, social support, capacity and safeguarding. Symptoms must never be dismissed as “normal ageing.”
First rule: sudden confusion, reduced attention or fluctuating behaviour is delirium until proved otherwise. Search urgently for infection, hypoxia, hypoglycaemia, stroke, urinary retention, constipation, pain, dehydration, medicine toxicity and withdrawal.
Effects of normal ageing
Normal ageing may slow information processing and recall, but established knowledge, vocabulary and independence are generally preserved. Dementia produces acquired decline that interferes with function. Depression can impair concentration and memory, while delirium causes an acute fluctuating disturbance of attention and awareness.
Common conditions
| Condition | Presentation in older adults | Important distinction |
|---|---|---|
| Delirium | Acute fluctuation, inattention, altered arousal, sleep reversal, illusions/hallucinations | Emergency secondary to physiological or toxic cause. |
| Dementia | Progressive memory, language, executive, visuospatial or behavioural decline affecting independence | Establish baseline and functional loss; subtype affects management. |
| Depression | Low mood may be less reported; loss of interest, anxiety, pain, sleep/appetite change, slowing, cognitive complaints and suicide risk | Not inevitable with ageing; grief does not exclude major depression. |
| Late-life psychosis | Delusions, hallucinations or disorganization | Exclude delirium, dementia, sensory loss, medicines and neurological disease before primary psychosis. |
| Anxiety/substance disorders | Worry, panic, insomnia; hidden alcohol, sedative or analgesic misuse | Withdrawal and drug interactions may mimic medical illness. |
Risk factors and protective factors
- Biological: cerebrovascular disease, diabetes, neurological disease, chronic pain, sensory impairment, frailty and polypharmacy.
- Psychological: previous illness, bereavement, fear of dependency, trauma and reduced coping resources.
- Social: loneliness, retirement, poverty, displacement, caregiving burden, ageism, abuse and loss of role.
- Protective: meaningful activity, family/community connection, physical activity, treated sensory loss, accessible healthcare and financial/housing stability.
Comprehensive assessment
- ABCDE and acuity: vitals, SpO₂, glucose, pain, consciousness, hydration, infection, injury and medication exposure.
- Collateral timeline: establish baseline cognition/function and exact change from family/caregiver records, while seeking the older adult’s own account.
- Mental-state examination: mood, psychosis, attention, orientation, memory, language, insight, suicide/self-neglect and vulnerability.
- Function: activities of daily living, cooking, medicines, finances, transport, continence, mobility, falls and nutrition.
- Physical/neurological: vision/hearing, gait, focal signs, parkinsonism, pain, oral health, retention, constipation and pressure injury.
- Social/safeguarding: living conditions, caregiver strain, neglect, physical/financial/sexual abuse and access to food/medicines.
- Capacity: assess for the specific decision; support communication with hearing aids, interpreter, simple information and adequate time.
Investigations
Use presentation to guide glucose, FBC, electrolytes/calcium, renal/liver/thyroid function, urinalysis/culture when symptomatic, HIV/syphilis or nutritional tests when clinically indicated, ECG and medicine levels. Brain imaging is important for focal deficit, head injury, rapid/atypical decline or suspected structural disease. Cognitive screening is affected by education, language, delirium, depression and sensory loss and never stands alone.
Management principles
Delirium
- Treat causes: oxygenation, infection, glucose, fluids/electrolytes, pain, retention, constipation and medicine toxicity.
- Provide clock/calendar, daylight, familiar people, hearing/visual aids, sleep preservation, mobility and hydration.
- Avoid unnecessary catheters, restraints and sedatives. If severe danger requires medication, use protocol-directed lowest dose with ECG, respiratory and movement monitoring.
Dementia and behavioural symptoms
- Explain diagnosis sensitively, treat reversible contributors, manage vascular risk and establish person-centred routine.
- For agitation, first look for pain, infection, hunger, constipation, fear, noise, loneliness, sleep disruption or caregiver approach.
- Cognitive stimulation, exercise, occupational adaptation and caregiver education support function. Cognitive medicines are diagnosis-specific and require specialist review and adverse-effect monitoring.
- Antipsychotics increase stroke, mortality, sedation, falls and EPS risks in dementia; use only for severe distress/danger after non-drug approaches, at lowest dose and with frequent review.
Depression, anxiety and psychosis
- Offer structured psychological intervention, social reconnection, activity scheduling, sleep and physical-condition treatment.
- When medicine is indicated, start low and titrate carefully—but treat adequately. Monitor sodium, falls, bleeding, QT, anticholinergic burden and early suicide risk according to drug/patient.
- ECT may be lifesaving for severe psychotic depression, catatonia, refusal of intake or urgent suicidality under specialist, anaesthetic and consent/legal safeguards.
Pharmacology and polypharmacy
| Problem | Mechanism/harm | Nursing action |
|---|---|---|
| Anticholinergic burden | Confusion, blurred vision, dry mouth, constipation and retention | Review antihistamines, bladder drugs, tricyclics and antipsychotics; report cumulative burden. |
| Benzodiazepines/sedatives | Falls, delirium, respiratory depression, dependence | Avoid routine insomnia use; never combine casually with opioids/alcohol; taper only under plan. |
| SSRIs | Hyponatraemia, bleeding, falls and interactions | Monitor sodium/risk symptoms, bleeding and response; review NSAID/anticoagulant use. |
| Antipsychotics | EPS, orthostasis, QT, metabolic effects, stroke/mortality in dementia | Document indication/target symptom, baseline risk, observation, response and review/stop plan. |
Detailed nursing care plan
| No. | Intervention | Rationale and measurable evaluation |
|---|---|---|
| 1 | Trend attention, consciousness, behaviour, vitals, glucose, intake/output and pain. | Distinguishes delirium and detects deterioration. Outcome: cause treated and attention stabilizes. |
| 2 | Use short sentences, eye contact, adequate response time, hearing/visual aids and one-step cues. | Improves comprehension without infantilizing. Outcome: patient participates in care decisions/tasks. |
| 3 | Falls plan: footwear, lighting, clear route, mobility aid, toileting schedule and supervised mobilisation. | Reduces injury while preserving mobility. Outcome: no preventable fall and maintained strength. |
| 4 | Assess weight, swallowing, dentition, food access and mealtime environment; record intake. | Identifies reversible malnutrition/aspiration causes. Outcome: safe intake and stable/improving nutrition. |
| 5 | Perform medicine reconciliation at admission, transfer and discharge; simplify schedule where possible. | Prevents duplication, interaction and adherence errors. |
| 6 | Assess skin, continence, pressure risk and caregiver ability; institute individualized prevention. | Frailty and immobility increase pressure injury and infection. |
| 7 | Screen abuse privately; document objectively and activate safeguarding pathway. | Older adults may depend on perpetrators and be unable to disclose safely. |
| 8 | Teach caregiver communication, triggers, respite, crisis signs and follow-up. | Reduces burnout and avoidable institutionalization. |
Suicide and safeguarding
Ask directly about death wishes, intent, plan, medicines/pesticides/weapons, previous attempts and recent losses. Older adults may use highly lethal methods and disclose less. Immediate intent, psychotic depression, severe self-neglect or inability to maintain safety requires urgent intervention. Respect autonomy while reporting/protecting according to Ugandan law and facility policy.
Healthy ageing, discharge and prevention
- Control hypertension, diabetes and cardiovascular risks; promote physical activity, nutrition, sleep, hearing/vision care and social participation.
- Discharge plan includes diagnoses, medicine purpose, adherence support, falls/nutrition plan, capacity decisions, caregiver contacts, warning signs and named follow-up provider.
- Return urgently for sudden confusion, focal weakness, fever, reduced intake, falls/head injury, medicine toxicity, suicidal statements or escalating aggression.
Revision questions
- Differentiate normal ageing, delirium, dementia and depression.
- Explain anticholinergic burden and four preventable harms of polypharmacy.
- Develop an eight-problem nursing plan for an older adult with cognitive decline.
- Outline capacity and elder-abuse assessment.
References
- WHO. Mental Health of Older Adults, 2025.
- WHO. mhGAP Guideline, 2023.
- WHO. Integrated Care for Older People (ICOPE).
- WHO. Risk Reduction of Cognitive Decline and Dementia, second edition.