Download Psychosis in the Older Patient

Psychosis in the Older
Patient
Module 3
Thomas Magnuson, M.D.
Assistant Professor
Division of Geriatric Psychiatry
Department of Psychiatry
UNMC
Updated 1/25/06
PROCESS
A series of modules and questions
Step #1: Power point module with voice
overlay
Step #2: Case-based question and answer
Step # 3: Proceed to additional modules or
take a break
Overall Objectives
Upon completion the learner will be able to:
Describe common treatment modalities for
psychosis in geriatric patients
Tom; here could we review case you gave in
the beginning and “weave” it into
treatment?
Treatment
If there is a medical cause, treat the cause as
well as the symptoms
Delirium
General medical condition
Substance-induced
• Intoxication
• Withdrawal
• Adverse event
Treatment
Primary method of treating psychosis is with
antipsychotics
Treat other psychiatric symptoms appropriately, i.e.
depression with an antidepressant
Non-pharmacologic interventions
In dementia
• Psychosocial interventions
In schizophrenia
• Groups to help with daily life
In depression
• Psychotherapy
Treatment
Antipsychotics
Typical versus Atypical agents
Adverse effect profile
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ExtraPyramidal symptoms (EPS)
Anticholinergic
Diabetes
Hyperlipidemia
Cardiac conduction
Increased risk of death
Treatment
Older typical agents
More pure dopamine blockers
Divided into high and low potency agents
• Both have adverse events associated with their use
High potency agents
• Haldol (haloperidol), Prolixin (fluphenazine)
• More EPS than anticholinergic side effects
Low potency agents
• Thorazine (chlorpromazine), Mellaril (thioridazine)
• More anticholinergic events than EPS
Treatment
Newer atypical agents
More serotonergic properties
• Less EPS
• Important for the elderly as they are more prone to
drug-induced parkinsonism (DIP) or tardive
dyskinesia (TD)
• Can lead to falls (fractured hip, subdural
hematomas), choking (aspiration pneumonia)
More likely used today across all ages
Treatment
Concerns with newer agents in the elderly
Diabetes
Hyperlipidemia
Cardiac conduction
Association with death in demented patients
• Study outcome issues
• CVA-related
 selection
• Pneumonia-related
 Monitoring
 EPS and sedation
Treatment
Atypicals
Clozaril (clozapine)
• Multiple side effects
Risperdal (risperidone)
• Dose dependent EPS
Zyprexa (olanzepine)
• Diabetes, hyperlipidemia
Geodon (ziprasidone)
• QTc prolongation
Seroquel (quetiapine)
• Reduces EPS
Abilify (aripiprazole)
• Little sedation or weight gain
Treatment
Atypicals
These medications can be used effectively in
the elderly, even in demented patients
In many cases there are no alternatives for
psychosis in this group
• Older typical agents can lead to severe morbidity
due to adverse events
The key is proper selection of patients and
continued monitoring of their condition
Treatment
Nonpharmacologic
Dementia with psychosis
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Environmental changes
Redirection
Prevent over or under stimulation
Emphasize caregiver, family participation
Maintain predictable routines
Diffuse restlessness with tasks
Feed hunger
Exercise
Music
Treatment
Nonpharmacolgic
Dementia with psychosis
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Evaluate and treat pain
Simplify the environment
Preform ADL’s and IADL’s as needed
Reassess for loneliness, fears, wishes, needs
Reevaluate sensory functioning
 Eye exams
 Audiology exams
 Check hearing aid batteries, ear canals
Treatment
Nonpharmacologic
Schizophrenia
• Cognitive behavioral skills training
 Helps mediate the effect of psychosis leading to untrue
cognitions about life and the environment
• Classes on medications, diagnosis
 Answer questions, understand their illness and treatment
• Functional adaptation group
 Problem-solving taught to help patients live in the world
 Maintain an apartment, job, relationship
Treatment
Depression with psychosis
Antidepressants important
• Must treat both sets of symptoms
May benefit from psychotherapy
• Especially supportive therapy
Consider ECT
• Very effective in the treatment of psychotic
depression
• Rapid turn around
Objectives
Define psychosis
Delineate common etiologies for psychosis
in the elderly
Describe treatment modalities for psychosis
in the geriatric patient
The End of the Modules
on
Psychosis in the Older Patient
Post-test questioned one
A 62-year-old man has schizoaffective disorder that has been
stable for 20 years. His early course was characterized by
multiple hospitalizations for manic episodes and treatment
with electroconvulsive therapy in his 20s and 30s. Current
medications are lithium carbonate, 1200 mg daily;
risperidone, 2 mg three times daily; and benztropine, 0.5
mg twice daily. This regimen has been stable for several
years, and he has taken the same dose of lithium for
approximately 20 years. Physical examination reveals
grimacing, chewing movements, and eyebrow raising. A
fine intention tremor also is noted in both hands. Which of
the following is the most likely diagnoses of the abnormal
movements?
Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
Which of the following is the most likely
diagnoses of the abnormal movements?
A. Tardive dyskinesia involving the orofacial
muscles and lithium-induced tremor of the hands
B. Tardive dyskinesia involving the hands and acute
dystonic movements of the face
C. Tardive dyskinesia involving the hands and
psychogenic movements of the face
D. Progressive supranuclear palsy affecting both the
face and hands
E. Parkinsonian effects secondary to antipsychotic
medication but partially treated with benztropine
Answer: A. Tardive dyskinesia involving the
orofacial muscles and lithium-induced tremor of the
hands
This patient displays classic symptoms of tardive
dyskinesia involving the orofacial muscles. These
may include facial twitches, grimacing, puffing of
the cheeks, chewing, eye blinking, and eyebrow
raising. Orofacial involvement is the most
common presentation of tardive dyskinesia in
older patients taking antipsychotic medications.
Abnormal movements of the trunk and extremities
also may occur. A fine intention tremor is
consistent with lithium use.
Acute dystonic reactions typically develops during initial exposure to
or after an increase in antipsychotic medication, usually in a younger
person. Dystonic reactions are characterized by acute muscle rigidity,
which may involve contortion of the facial or neck muscles, or
oculogyric crisis (ie, deviation and upward fixation of the eyes). These
symptoms reflect an acute reaction to the medication and do not occur
with chronic use at stable doses. Progressive supranuclear palsy (PSP)
involves degeneration of the basal ganglia and brainstem. It is
considered a Parkinson’s plus syndrome and frequently is diagnosed as
Parkinson’s disease initially. PSP is characterized by progressive gait
instability, dysphagia, and dysarthria; parkinsonian effects such as
muscle rigidity, pill-rolling tremor at rest, shuffling gait, mask-like
facies, and excessive salivation are not present. Although these may
occur with risperidone, they are more likely to occur with a traditional
antipsychotic agent, such as haloperidol or fluphenazine.
“Psychogenic” movements—those that are a direct manifestation of a
psychiatric syndrome—may be associated with conditions such as
hysterical paralysis or other “conversion” reactions in which a source
of psychologic stress manifests as bizarre motor symptoms. These
usually involve paralysis, paresthesia, or other loss of function. Go to
next question
Posttest question 2
A 60-year-old woman was diagnosed with late-onset
schizophrenia at the age of 55 years. Initially she
experienced the paranoid delusional belief that her home
was being monitored by a government agency. These
symptoms responded to mesoridazine for a number of
years, but because of her increasing gait instability and
concerns about falling, her physician changed her
medication to haloperidol 2 weeks ago. Since starting the
haloperidol she has felt more agitated, pacing around her
home and looking out the windows. She states that she
feels restless and uncomfortable.
What is the most likely source of this woman’s current
problem?
What is the most likely source of this
woman’s current problem?
A. The extrapyramidal side effect of akathisia
B. A relapse of the psychosis with increased
paranoia
C. An episode of mania secondary to
switching medications
D. Tardive dyskinesia with prominent limb
and truncal involvement
E. The anticholinergic side effect of confusion
Answer: A. The extrapyramidal side effect of
akathisia
The side effect experienced by the patient is that of akathisia, that is,
restlessness accompanied by pacing and an uncomfortable sensation of
needing to move about. This side effect typically is apparent shortly
after starting a high-potency antipsychotic medication such as
haloperidol. The presence of akathisia is particularly important to
recognize, as often in the face of increasing distress the clinician may
choose to increase the dose of antipsychotic medication. This decision
likely compounds the problem by increasing the severity of the
akathisia and other adverse effects. Whereas akathisia is likely to occur
typically within the first 4 weeks after starting or increasing an
antipsychotic medication, a relapse of psychosis may take several more
weeks to occur and tends to be more insidious. Although this woman
has motor restlessness, there is little else to suggest mania.
Although tardive dyskinesia is an important
consideration in the older population, it typically
does not have an acute presentation and is not
associated with subjective distress or agitation.
Rather, tardive dyskinesia represents a gradual
onset of abnormal movements (often unnoticed by
the patient), typically in the orofacial region, such
as grimacing, eye blinking, puffing the cheeks, or
chewing movements. Anticholinergic side effects
are also difficult for the older patient; however,
they would occur more commonly with the
thioridazine derivative than with haloperidol.
These side effects include urinary retention,
blurred vision, dry mouth, constipation, and
cognitive impairment.
In terms of treatment, akathisia may resolve
with a decrease in haloperidol dosage or the
addition of a ß-antagonist, benzodiazepine,
or anticholinergic agent. Interestingly,
akathisia has also rarely been associated
with the use of selective serotonin-reuptake
inhibitors.
end