Download Dementia- Diagnosis and Treatment

Mental Health and Older Adults
Vineeth John, MD and Kathleen Pace Murphy, PhD, GNP
The University of Texas Health Science Center at Houston (UTHealth)
Case of a New Onset Bipolar Disorder
A 60-year-old, right-handed, previously successful and
psychiatrically healthy businessman was brought by his family to a
university hospital neuropsychiatry service for consultation
regarding behavioral and personality changes.
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When he was age 55 years, his customarily excellent financial
and social judgment began to decline. Over the next four years,
his attention to personal hygiene deteriorated, his business
decisions became financially and ethically unsound, his range of
social interests narrowed dramatically, and he developed an
insatiable "sweet tooth."
Case of a New Onset Bipolar Disorder
A 60-year-old, right-handed, previously successful and
psychiatrically healthy businessman was brought by his family to a
university hospital neuropsychiatry service for consultation
regarding behavioral and personality changes.
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In the year preceding the consultation, his ability to maintain
sleep diminished, he began spending money recklessly and
impulsively and became unable to appreciate the feelings and
concerns of others, and his speech and behavior took on a
perseverative quality. Concurrently, he developed unprovoked,
brief, frequent, and excessively intense episodes of tearfulness
and laughing. These episodes lasted minutes at most, after
which he would return to his usual euthymic emotional state.
Case of a New Onset Bipolar Disorder
A 60-year-old, right-handed, previously successful and
psychiatrically healthy businessman was brought by his family to a
university hospital neuropsychiatry service for consultation
regarding behavioral and personality changes.
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One month before the neuropsychiatric consultation, he had
received a diagnosis of late-onset bipolar disorder and had
begun treatment with lithium carbonate. When his serum
lithium level reached the therapeutic range, his cognitive,
behavioral and motor function declined precipitously, prompting
the consultation for a second diagnostic opinion.
Is this patient’s presentation consistent with late onset bipolar
disorder?
What assessments are needed to clarify his diagnosis?
Late Onset Psychosis
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Psychosis of Alzheimer's disease
Late onset Schizophrenia
Late life delusional disorder
Psychotic disorders secondary to General Medical Conditions
Psychosis in AD
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Increased risk of agitation
Increase in aggression
Poor self care
Disruptive behavior
Wandering
High rate of institutionalization
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Between 30 to 50 % of AD
patients have psychotic
symptoms
Psychotic symptoms are
more prevalent as the
disease progresses but are
more common in the
middle stages.
Visual hallucinations are
more common than
auditory hallucinations.
Common Themes of Delusions in AD
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Stealing
Stranger in the house
Spying
Impersonating the spouse
or loved one
Photo by MorgueFile user ‘JKD_DE”. Morguefile.com
Psychosis in
Other Dementias
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Dementia of Lewy bodies –
VH and Delusions
Parkinson's Disease Delusions and Hallucinations
Vascular Dementia
Treatment of Psychotic
Symptoms in Dementia
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Low dose antipsychotics
are the norm.
Careful balancing of the
risks and benefits need to
be performed.
Delusions in Dementia
Hallucinations in Dementia
Agitation in Dementia
Depressed Mood in Dementia
Agitation in Dementia
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Treat reversible causes of agitation-UTI, medications, alterations in
renal functions, pain and discomfort
Behavioral Interventions
Antipsychotic medications
Anticonvulsants
Acetyl Cholinesterase Inhibitors/Memantine
SSRIs and antidepressant therapy
Proposed Algorithm
A proposed algorithm for decision making regarding the Use of antipsychotics in older
adults with dementia-related psychosis and/or agitation
Assess potential imminent danger
Behavioral/psychosocial intervention
de-escalates the imminent danger
No imminent
danger
Behavior/psychosocial intervention fails
to de-escalate imminent danger
Look for reversible treatment etiology of the symptoms
Potential
reversible/treatment
etiology found
Medical
illness or
delirium
Discomfort
(e.g., pain,
constipation)
No clear reversible
treatment etiology found
Predictable
antecedent
environmental
stimuli or other
psychiatric
illness (e.g.,
depression,
insomnia)
Explore past
treatments,
benefits, and
adverse effects
Offer oral antipsychotic
(consider liquid or sol-tabs)
but if necessary for safety,
administer medications
intramuscularly
Establish severity and
frequency of
symptoms, effect on
patient/caregiver
quality of life
Discuss what is known (and probably more important,
what is unknown) about the possible risks and benefits of
treatments (pharmacological and non-pharmacological)
for psychosis and agitation/aggression in dementia,
including atypical antipsychotics
Suggested Starting/Target Doses for Atypical
Antipsychotics in Patients with Dementia
Drug
Starting dose
Target dose
Aripiprazole
2-5 mg/d
7.5-12.5 mg/d
Olanzapine
2.5-5 mg/d
5-10 mg/d
Quetiapine
12.5-25 mg/d
50-200 mg/d
Risperidone
0.25-0.5 mg/d
0.25-1.5 mg/d
Late Onset Schizophrenia
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Schizophrenia is characterized by it's onset in youth and
subsequent deterioration of functionality.
Schizophrenia after 45 years of age was considered late onset by
APA DSM III R, 1987. International consensus panel chose 40 years
as the cut off point.
No such distinction is elaborated in DSM IV TR version.
Distinct Features
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Lack of negative symptoms
Lack of thought disorder
More paranoid schizophrenia subtype
Presence of the features of neurodegeneration –CVAs.
More in women than in men
Patients who develop late onset schizophrenia were also noted to
have sensory deficits - visual and hearing
Differential Diagnosis of Late Onset Schizophrenia
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Psychotic disorders secondary to general medical conditions
Psychotic symptoms which might be part of delirium
Early onset schizophrenia undetected
Mood disorders with psychotic features
Delusional disorders
PDGMC vs. Schizophrenia
INDICATORS
PDGMC
SCHIZOPHRENIA
ONSET
SUDDEN
GRADUAL
DRUG/ALCOHOL HISTORY
TEMPORALLY RELATED
COMORBIDITY
MEDICAL HISTORY
COMMON
INFREQUENT
CONCOMITANT MEDS
FREQUENT
INFREQUENT
FAMILY HISTORY
NOT FOR PSYCHOSIS
+/-
HALLUCINATIONS
MULTIMODAL
AUDITORY USUALLY
Treatment of Late Onset Schizophrenia
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Atypical antipsychotics
Psychosocial treatments-social skills, CBT
Family interventions for relapse prevention
Aging and Early Onset Schizophrenia
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Around 30% could show evidence for improvement and remission.
Cognitive deterioration is reasonably steady and do deteriorate
significantly
John Nash, Jr. — in his own words
“But after my return to the dream-like delusional hypotheses
in the later 60's I became a person of delusionally influenced
thinking but of relatively moderate behavior and thus tended to
avoid hospitalization and the direct attention of psychiatrists.
Thus further time passed. Then gradually I began to intellectually
reject some of the delusional influenced lines of thinking which
had been characteristic of my orientation. This began, most
recognizably, with the rejection of politically-oriented thinking as
essentially a hopeless waste of intellectual effort.”
Psychotic Disorders due to General
Medical Conditions in the Elderly
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Stroke
Parkinson's disease
Epilepsy
Herpes Encephalitis
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Thyroid and adrenal disorders
Folate, B12 deficiencies
Systemic lupus erythematosus
Alcoholic hallucinosis
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Medications Causing
Psychotic Symptoms
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Levadopa
Bromicriptine
Amantadine
Isoniazid
Corticosteroids
Amphetamines
Methylphenidate
Lidocaine
Cimetidine
Mood Disorders
Secondary to General
Medical Conditions
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Rate of depression in the
medical population is 12 to
20%.
Many physical illnesses and
medications can cause
symptoms mimicking
depression.
Common Medical Conditions Causing Depression
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Strokes
Parkinson's Disease
Hypothyroidism
Addison's Disease
Occult Carcinoma of the Pancreas
Collagen vascular disease
Multiple Sclerosis
Most Common Medications Causing Depression
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Antihypertensives - reserpine and methyl dopa
Steroids
Secondary Mania
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Stroke
Right hemisphere cerebral neoplasms
Multiple sclerosis
Encephalitis
Syphilis
Head injury
Uremia
Corticosteroids
Thyroxin
Levodopa
Bromocriptine
Amphetamines
Cimetidine
Dimensions of Grief and Bereavement
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Emotional and cognitive experiences
Coping strategies
Continuing relationship with the deceased
Health, occupational and social functioning
Relationships
Social identity and Self esteem
Complications of Grief and Bereavement
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Morbidity
Increased somatic complaints
Worsening of pre existing illnesses
Increased use of medical services
Mortality
Widowers: highest risk in the first six months
Widows: period of risk delayed by 1 or 2 years.
Psychiatric Complications of Grief
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Substance use
Anxiety symptoms
PTSD
Depression
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Risk Factors Leading to Depression in the Grieving Process
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Unnatural sudden unexpected death
Preexisting mood disorder
Early, intense depressive reaction after the loss
Poor physical health
Increased alcohol consumption
Family history of major depression
Poor social support system
Geriatric Depression
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Prevalence of geriatric depression is much higher in medical settings
than in the community — 30%.
50% of nursing home residents are at risk to develop depression.
Cognitive impairment is an expected complication in elderly patients
who develop depression
Under Diagnosis of Depression in the Elderly
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Under reporting of symptoms
More focus on physical symptoms
More anhedonia than sadness
Subsyndromal depression not meeting criteria
Medical illness detection overshadow the diagnosis of depression
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Reasons for Missed Diagnosis of Depression
in Elderly Patients
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Elderly patients under-report symptoms of depression (Lyness, 1995)
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Elderly patients may not acknowledge being sad, down or depressed (Gallo, 1997)
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Atypical presentations of depression frequently occur in old age (eg, somatic disorders, pseudodementia ,
behavioural disturbances) (Brodaty, 1993)
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Elderly patients and clinicians misattribute symptoms to comorbid physical illnesses (Booth, 1998;
Knauper, 1994)
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The acceptance of depression as a “normal” psychological reaction to physical illness, life in a nursing
home, widowhood or the aging process (Fawcett, 1972)
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General practitioners may lack confidence in diagnosing depression in elderly patients, especially when
the patient may not talk about feeling depressed, sad or irritable (Shah, 1997; Bowers, 1990)
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Current diagnostic categories of depression do not adequately describe many depressed older people,
particularly those with minor depressions that are most common in primary care (Beekman, 1999;
Callahan 1996)
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Education of general practitioners may focus too much on the types of depression seen in specialist
practice (major depression), and not enough on minor depression
Clinical Differentiation of Depression and Dementia
Depression with cognitive
impairment (pseudo dementia)
Dementia without depression
Onset and course
Over weeks to months with a relatively fast
decline (then plateau)
Alzheimer type: months to years, gradual
decline.
Vascular type: may be sudden onset with
stepwise decline
Presenting symptoms
Memory impairment, behavior and personality
change, impaired social functioning, depressed
mood, mood congruent delusions
Memory impairment, behavior and personality
change (including apathy), impaired social
functioning
Patient’s reaction and
behavior
Unmotivated, negativistic, distressed,
emphasizes shortcomings, inconsistent
performance, slow responses
Motivated, conceals errors, values
accomplishments, social skills consistent with
cognitive status
Affect
Pervasive depression
Variable, fatuous, sometimes shallow and
labile depression reactive to environment
Diurnal variation
Often worse in the morning
Often worse in the evening
Suicidal ideation
Common
Rare
Memory disturbance
Yes, but may be inconsistent
Yes
Poor recall
Yes
Yes
Poor recognition
No
Yes
Remote sensory impairment
No
Yes
Aphasia, agnosia, apraxia
No
Yes
Psychomotor retardation
Yes
No
Family history of affective
disorder
Common
Rare
Co-morbidity and Complications of Late Life Depression
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Depression worsens outcomes and prognosis of medical illnesses
Depression lengthens hospital stay
Depression increases perception of ill health
Depression increases economic burden on the health care system
Depression worsens disability
Depression also results in increased suicide risk
—White men over the age of 65, has the highest suicide rate
Risk Factors for Suicide in the Elderly
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Loneliness and poor social support
Presence of psychiatric disorder
Presence of fire arm
Impaired ability with IADLs
Medical co-morbidity
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Treatment Options for Depression in the Elderly
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SSRIs
TCAs
MAOIs
Bupropion
Mirtazapine
Augmenting agents
ECT
Psychotherapy
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References
• Devan and DP, Jacobs DM, Tang MX, et al. The course of
psychopathologic features in mild to moderate Alzheimer
disease. Archives of General Psychiatry. 1997;54:257–263
• Meeks, TW and Jeste, DV, Current Psychiatry, 2008
• Meeks, TW and Jeste, DV, Current Psychiatry, 2009
Photographs use for the cover are allowed by the MorgueFile free
photo agreement and the Royalty Free usage agreement at
Stock.xchng. They appear on the cover in this order:
Wallyir at morguefile.com/archive/display/221205
Mokra at www.sxc.hu/photo/572286
Clarita at morguefile.com/archive/display/33743
The Training Excellence in Aging Studies (TEXAS) program promotes
geriatric training from medical school through the practicing
physician level. This project is funded by the Donald W. Reynolds
Foundation to the division of Geriatrics and Palliative Medicine within
the department of Internal Medicine at The University of Texas Health
Science Center at Houston (UTHealth)
TEXAS would also like to recognize the following for contributions:
Houston Geriatric Education Center
Harris County Hospital District
Memorial Hermann Foundation
The TEXAS Advisory Board
Othello "Bud" and Newlyn Hare
UTHealth Medical School Office of the Dean
UTHealth Medical School Office of Educational Programs
UTHealth School of Nursing
UTHealth Consortium on Aging