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Everything You Need to Know About Geriatric Psychiatry in 75 Minutes Andrea Stewart, MD, FRCPC Writer of LMCC, 2002 Proportion of population aged 80 years (%) Aged 80 years in 1994 Aged 80 years in 2020 AGE DEPENDENCY RATIO Challenges of Late Life Co-morbid medical illness / cognitive disorders Sensory loss Financial worries Retirement Dependency Dying and death Bereavement OVERVIEW Dementia - BPSD Late Onset Psychosis Depression in late life Anxiety in late life Delirium Other types of dementia (Lewy Body, FTD) Case 2 Approach to Memory Loss Speaking to the person (safety first) Speaking to the family (safety first) History, physical examination Create a differential and then direct investigations (bloodwork, urinalysis, ECG, imaging) to firm up the diagnosis Investigations Follow-up Plan Differential Diagnosis Delirium Cognitive Impairment but not dementia/ Mild Cognitive Impairment/ Age Associated Memory Decline Dementia - subtypes Depression or other psychiatric illness Other CNS disease (cancer, demyelination, etc.) or a dementia secondary to GMC Alzheimer’s Dementia Memory Impairment One or more other cognitive impairment: Aphasia, apraxia, agnosia, executive functioning deficit Gradual onset and continual decline Impairments cause significant social or occupational functional decline compared to previous level of functioning Impairments are not delirium, substance-induced, or caused by another GMC or psychiatric illness Defining the Diagnostic Threshold Normal Cognition MCI/ CIND Dementia Screening Tools MMSE score <24/30 MOCA score <26/30 Mini-Cog (3 word registration & recall, CDT) 1 Work-up CBC, Cr, urea, electrolytes, TSH, vitamin B12 Neuroimaging if the onset is recent (<1 year), early (<65), or the presentation is atypical or suggestive of another neurological disease Other tests prn (VDRL, HIV, carotid U/S, EEG, chest Xray, urinalysis, LP) ECG prior to medication management 1Burns A, BMJ Activities of Daily Living Bars show 25th to 75th %ile of patients losing independent performance. EAT WALK CLEAR TABLE DISPOSE LITTER MAINTAIN HOBBY GROOM DRESS SELECT CLOTHES FIND BELONGINGS USE HOME APPLIANCES TRAVEL ALONE OBTAIN MEAL/SNACK TELEPHONE KEEP APPOINTMENTS MMSE 30 25 20 Mild AD 15 Moderate AD 10 5 Severe AD Adapted from Galasko. Eur J Neurol. 1998;5(suppl 4):S9-S17; Galasko et al. Alzheimer Dis Assoc Disord. 1997;11(suppl 2):S33-S39. 0 Cognitive Enhancers May improve: ADLs- activities of daily living, time to institutionalization Behaviour/Mood- decreased concomitant psychotropics Cognitive enhancement Types Acetylcholine-esterase inhibitors (boost ACh) NMDA antagonists (Block glutamate) Other Medications/ CAM Nimodipine (Ca channel blocker) at 90 to 180 mg/day General BP lowering Vitamin B12 Extract of Ginkgo biloba 761 Vitamin E no longer used due to bleeding risk DHEA may be harmful to memory Cognitive training, reminiscence therapy Case 2 Behavioural and Psychological Symptoms of Dementia ABC Approach A Antecedents B Behaviours C Consequences Physical: delirium, diseases, drugs, discomfort, disability Intellectual: dementia – cognitive abilities/losses Emotional: depression, psychosis Capabilities: environment not too demanding yet stimulating enough, balancing demands and capabilities Environment: noise, relocation, schedules… www.piecescanada.co m Social, cultural, spiritual: life story, relationships family dynamics, personality traits... Pharmacological Management of BPSD Atypical antipsychotics1 RSP & OZP reduce aggression, RSP reduces psychosis Higher risk CVEs, EPS, death Antidepressants2,3 db trials show CIT = RSP with fewer SEs Trazodone has trend of effectiveness in FTD Benzodiazepines 1Cochrane, 2008; 2Pollock, BG Am J Ger Psych; 3Cochrane, 2008 The following is NOT true of Alzheimer’s: a) Insidious, gradual and progressive decline b) Motor symptoms are absent until later in the disease c) A dramatic presentation is not the same as an abrupt onset d) Behavioural symptoms are often the most distressing symptom for families and caregivers e) The ‘head turning sign’ refers to sexual disinhibition f) Vascular events may co-occur and cause cognitive dysfunction Case 6 Psychosis in the 1 Elderly 4% in the community 15% presenting to a geriatric medicine clinic 10-38% of people in LTC (21% of new admissions to LTC) 1Holyrood S, Int J Ger Psych 1999 Approach Speaking to the family (safety first) Speaking to the person (safety first) History, physical examination Create a differential and then direct investigations (bloodwork, urinalysis, ECG, imaging) to firm up the diagnosis Investigations Follow-up Plan Differential Diagnosis Psychosis in People <45 MDE or Mania SZP/SZA/ delusional D/O 2 GMC/subs Delirium Personality disorder Psychosis in People >45 Cognitive Disorders (delirium, dementia) Differentiating the Dx Dementia Memory loss, impaired function, insidious onset & progress MDE Prominent mood and anxiety sx, past hx MDD, somatic/ guilt/ nihilistic delusions Delirium Mania LO SZP Acute, Delusions fluctuates, Mixed may be clouded states bizarre, no sensorium more dissleep common, orientation reversal, less baseline delusions grandiosity paranoid or from env., confusion schizoid vulnerable & irritability PD traits host Outcomes and Associated Factors Elderly with psychosis are more likely to have a history of psychosis, live in LTC, and have lower MMSE scores1 1Holyrood S, Int J Ger Psych 1999 Case 6 Which of the following is not true in LLP? a) Most paranoid disorders of old age are due to schizophrenia b) More women develop late onset schizophrenia c) With ageing, schizophrenia tends to give less severe positive symptoms d) Patients with schizophrenia live 10-30 years less on average Case 7 Approach to Mood Complaint History (with collateral) and physical examination Make the diagnosis considering the differential, assess severity (psychosis) and suicidality Thorough medication review Investigate causes (bloodwork, urinalysis, ECG, imaging) and remove promoting factors Review past episodes and treatments Differential Diagnosis Depressive Disorder (dysthymia, MDE, BP with MDE, personality disorder) Bereavement Dementia Delirium Substance (drug of abuse, medication) or GMC 1 Epidemiology Lifetime risk 11% Incidence in the general population: 4%/ year Incidence in people > 65: 1-3%/ year Incidence in hospitalized people: 11% Incidence in people in LTC: 12-22% 1Narrow WE, NIMH ECA prospective data Predisposers Precipitators Female gender, Recent widowed or bereavement, divorced, PHx moving to an MDD, CeVD, institution, Personality type, adverse life major physical or events disabling illness, (separation, loss, some meds, financial crisis), alcohol abuse, declining health, social relationship disadvantage, problems Caregiver stress Perpetuators Persistent sleep problems, chronic stress, social isolation, stigma, adverse effects of medication therapies Diagnostic Criteria Mood depressed/irritable or anhedonia for > 2 weeks and 4/8: Sleep change Concentration impaired Interests lost Guilty or worthless feelings Energy lost Appetite changed/ wt change Psychomotor symptoms Suicidal or deathrelated thinking DSM-IV-TR Late Life Depression Less More Complaints of sadness Somatic symptoms, Anxiety, Cognitive symptoms, Medical comorbidity CCSMH, Assessment and Treatment of Depression 2006 Subtypes With or without psychosis, graded severity, recurrent or first episode, bipolar depression Secondary to something else Dysthymia Co-morbid with dementia or substance abuse MDE vs Grief MDE Grief +/- onset after trigger Onset after death of loved one Symptoms worsen with time Symptoms improve with time SI/ preoccupation with death Passive wishes to have died 1st or with person Intense guilt & worthlessness Self esteem preserved Persistent mood state Sadness comes in waves Functional impairment Functional impairment <2 mo. Psychosis APA, 2000 Management Mild: bibliotherapy, exercise, close follow-up or supportive therapy Moderate: antidepressants +/- psychotherapy, or psychotherapy alone Severe: refer to psychiatry, +/- hospitalization for safety, ECT, antipsychotics with antidepressants, psychotherapy alone only effective for specific patients if done by experts otherwise in combination Suicide Risk Fixed RFs Modifiable RFs V. High Risk Behaviours Social isolation, Agitation Presence of chronic Giving away Old age pain (OR moderate possessions Male gender pain 1.9, severe pain Reviewing one’s will Widowed or divorced 7.5) Increase use alcohol Previous attempt Presence and severity Non-compliance with Losses (health, status, of MDE treatment role, independence, Hopelessness, Suicidal Taking unnecessary relations) ideation risks Access to means, Preoccupation with especially firearms death CCSMH, Assessment of Suicide Risk and Prevention of Suicide, 2006 Language of Treatment Antidepressants Meta-analysis of trials of 2nd generation antidepressants in people >60 with nonpsychotic depression and no dementia Medication Placebo Response 44% 35% Remission 33% 27% Discontinuation 24% 20% 1American Journal of Geriatric Psychiatry, 2008 Antidepressant Works >20% better Maintenance Go to 8 wks No change after 4wks Reassess diagnosis, increase dose, switch to escitalopram, sertraline, mirtazapine, effexor >20% better after above: Li, antipsychotic, psychotherapy Clinical Use of Antidepressants If anything protective for suicide in elderly Elderly more likely to die of overdose if taken Electrolytes pre and post (1 week to 1 month) Risk of GI bleed, especially with concurrent NSAID or ASA use - monitor, add gastroprotective agent Follow q2 weeks for the first 1-3 months, keep on medication >1 yr post remission Psychotherapy Cognitive Behavioural Therapy Problem Solving Therapy Interpersonal Therapy The following is true regarding depression: a) it is a treatable condition that with antidepressants has a remision rate of 30-40% and response rates of 67-90% b) the neurotransmitters serotonin and noradrenaline are involved c) Psychotherapy is effective in severe depression d) an association between early life trauma, hippocampal atrophy and depression can be seen e) it often presents with multi-system physical complaints f) it is associated with coronary artery disease, stroke, diabetes, cancer, Parkinson’s, and MS. g) ECT should be considered only when all other treatments have failed The following is true regarding depression: a) it is a treatable condition that with antidepressants has a remission rate of 70-80% and response rates of 67-95% b) the neurotransmitters serotonin and noradrenaline are involved c) Psychotherapy is effective in severe depression d) an association between early life trauma, hippocampal atrophy and depression can be seen e) it often presents with multi-system physical complaints f) it is associated with coronary artery disease, stroke, diabetes, cancer, Parkinson’s, and MS. g) ECT should be considered only when all other treatments have failed Which of the following are true of depression in old age: a) Is more prevalent in women than men b) Prevalence rates rise sharply with age c) Is accompanied by a much lower suicide risk than in younger adults d) Is unresponsive to treatment in half of cases. e) Is often precipitated by a loss f) Both b) and d) Which of the following are true of depression in old age: a) Is more prevalent in women than men b) Prevalence rates rise sharply with age c) Is accompanied by a much lower suicide risk than in younger adults d) Is unresponsive to treatment in half of cases. e) Is often precipitated by a loss f) Both b) and d) Which of the below options are true for psychotic depression: a) Is more frequent in elderly. b) Remits with antidepressants in 50% of cases c) Remits with antidepressants + antipsychotics in 75% of cases d) Responds and remits best with ECT e) Should prompt thorough search for symptoms of bipolar illness in pt and family members. f) All of the above except b) g) All of the above except b) and c) Which of the below options are true for psychotic depression: a) Is more frequent in elderly. b) Remits with antidepressants in 20% of cases c) Remits with antidepressants + antipsychotics in 45% of cases d) Responds and remits best with ECT e) Should prompt thorough search for symptoms of bipolar illness in pt and family members. f) All of the above except b) g) All of the above except b) and c) Which of the following are frequent “reasons for consultation” by elderly who have an episode of depression: a) “Nerves” b) Excessive fatigue c) Hypersomnia (sleeping too much) d) Digestive problems e) Fear of Alzheimer’s disease f) All of the above except C Which of the following are frequent “reasons for consultation” by elderly who have an episode of depression: a) “Nerves” b) Excessive fatigue c) Hypersomnia (sleeping too much) d) Digestive problems e) Fear of Alzheimer’s disease f) All of the above except C Which of the following would go against a diagnosis of normal grief: a) Active suicidal ideation b) Prominent psychotic symptoms c) Crying spells when she thinks of her deceased husband. d) Being less active socially e) Being unable to attend to her usual daily activities 3 months after the death of her husband Which of the following would go against a diagnosis of normal grief: a) Active suicidal ideation b) Prominent psychotic symptoms c) Crying spells when she thinks of her deceased husband. d) Being less active socially e) Being unable to attend to her usual daily activities 3 months after the death of her husband 81 year old widow, lives alone in her home, presents with 2 year history of insidious increase in worrying, indecisiveness, isolation, insomnia, and feeling tense. Her husband recently died in a NH after having dementia for 8 years. Her kids say she is increasingly dependent on them for running errands, and she has stopped doing her own taxes and driving. She appears nervous, with a smile that doesn’t match her words. Anxiety Disorder Mood Disorder ■ Depressed / irritable mood ■ Anhedonia ■ Euphoria ■ Weight gain/loss ■ Loss of interest ■ Fear ■ Apprehension ■ Panic attacks ■ Chronic pain ■ GI complaints ■ Excessive worry ■ Agitation ■ Difficulty concentrating ■ Sleep disturbances ■ Hypervigilance ■ Agoraphobia ■ Compulsive rituals APA 1994; Keller MB 1995; Clayton PJ et al 1991; Coplan JD, Gorman JM 1990 As many as 90% of depressed patients suffer from anxiety symptoms1-3 More severe illness at baseline More psychosocial impairment Greater likelihood of chronic illness Poorer, slower response to treatment Greater likelihood of committing suicide 1. Richou H. et al. Human Psychopharmacol 1995; 10:263-71 2. Coplan JD et al. J Clin Psych 190; 51(Suppl 10):9-13 3. Kasper S. et al. Primary Care Psych 1997; 3:7-16 Secondary anxiety disorders more elderly Anxiety Disorders incommon the inElderly Primary anxiety disorders generally do not have an onset in the elderly (same for personality disorders) High co-morbidity with depression Overall less common in the elderly. Phobias and GAD are the most common. Panic disorder is relatively rare, less than the 1-3% described in younger populations (Flint AJP 1994). Caution with anxiolytics can cause paradoxical disinhibition Diphenylhydramine (Benadryl), Dimenhydrinate (Gravol), Chlorpromazine, Amitriptyline, chloral hydrate and barbiturates are not good anxiolytics due to their side effects Elderly are more sensitive to benzodiazepines. Associated with an Cognition Anxiolytic Side Effects Amnesia (esp. alcoholics with benzos) Memory and visuospatial impairment Psychomotor Accentuate postural sway and incoordination Increase risk for MVAs and falls Paradoxical dysinhibition Respiratory Depression avoid benzos in sleep apnea Sleep Decreased sleep latency but also decreased stage 3 and 4 sleep with Benzos Which of the following is NOT true of anxiety disorders in old age a) It is more often secondary to another axis 1 condition like depression or medical condition b) Anxiolytics can worsen not only anxiety but can cause sleep disruption, falls, and MVAs. c) Benzodiazepines are safe in the elderly d) Benadryl, Gravol, Chlorpromazine, Amitriptyline and other anticholinergic medications can be dangerous in the elderly because of delirium and associated other receptor effects (orthostatic hypotension) e) Primary anxiety disorders and personality disorders, including dependent personality disorder, do not begin in MCQ#9 a) Prevalence rates increase with ageing. b) Phobias are the most common anxiety disorder c) Overall prevalence rates for all anxiety disorders in old age is around 10% d) Panic disorder affects approx. 5% of elderly. MCQ#9 a) Prevalence rates increase with ageing. b) Phobias are the most common anxiety disorder c) Overall prevalence rates for all anxiety disorders in old age is around 10% d) Panic disorder affects approx. 5% of elderly. Case 8 Differential Diagnosis Generalized Anxiety Disorder Dysthymia MDE Anxiety secondary to GMC, substance Bereavement Anxiety in Late Life Less common, 5-10% in the community F>M, peak onset adolescence Agoraphobia alone as having a second peak Late life onset usually heralds another condition: MDD, dementia, medication toxicity, withdrawal, GMC (cardio and cerebrovascular disease) Presentations of Anxiety 1 Disorders in Late Life Autonomic hyper-arousal pronounced: palpitations, dry mouth, dizziness, hot flashes, GI distress Low prevalence of panic disorder and OCD Onset after therapy with DA agonists, steroids, sympathomimetics, Beta-adrenergic agonists (salbutamol), theophylline, digoxin, thyroxine Flint AJ, Comprehensive Textbook of Geriatric Psychiatry: Anxiety Disorders, 2004 Agoraphobia Most prevalent anxiety disorder in the community1 Onset not uncommon after 601 Late onset related to abrupt onset physical illness or trauma (fall, being mugged)2 Associated with early parental loss3 1,3Lindesay J, Br J Psych, 1991; 2Burvill PW, Br J Psych, 1995 Depressive Disorder ■ Depressed / irritable mood ■ Anhedonia ■ Euphoria ■ Weight gain/loss ■ Loss of interest Anxiety Disorder ■ Fear ■ Apprehension ■ Panic attacks ■ Chronic pain ■ GI complaints ■ Excessive worry ■ Agitation ■ Difficulty concentrating ■ Sleep disturbances ■ Hypervigilance ■ Agoraphobia ■ Compulsive rituals APA 1994; Keller MB, 1995; Clayton PJ, 1991; Coplan JD,1990 Management Diagnose, initiate treatment or refer Investigate +/- treat co-morbid illness Psychotherapy: CBT Pharmacotherapy: SSRI (sertraline) Outcome More severe illness at baseline More psychosocial impairment Poorer, slower response to treatment Greater likelihood of committing suicide Greater likelihood of morbidity (cardiovascular, respiratory, GI diseases) and mortality (cardiovascular, COPD, neoplastic causes) Flint AJ, Comprehensive Textbook of Geriatric Psychiatry: Anxiety Disorders, 2004 Which of the following is NOT true of anxiety disorders in old age: a) It is more often secondary to another axis 1 condition like depression or medical condition b) Anxiolytics can worsen not only anxiety but can cause sleep disruption, falls, and MVAs. c) Benzodiazepines are safe in the elderly d) Benadryl, Gravol, Chlorpromazine, Amitriptyline and other anticholinergic medications can be dangerous in the elderly because of delirium and associated other receptor effects (orthostatic hypotension) e) Primary anxiety disorders and personality disorders, including dependent personality disorder, do not begin in old age Which of the following is NOT true of anxiety disorders in old age: a) It is more often secondary to another axis 1 condition like depression or medical condition b) Anxiolytics can worsen not only anxiety but can cause sleep disruption, falls, and MVAs. c) Benzodiazepines are safe in the elderly d) Benadryl, Gravol, Chlorpromazine, Amitriptyline and other anticholinergic medications can be dangerous in the elderly because of delirium and associated other receptor effects (orthostatic hypotension) e) Primary anxiety disorders and personality disorders, including dependent personality disorder, do not begin in old age Which of the following is true regarding anxiety disorders in old age: a) Prevalence rates increase with age b) Phobias are the most common anxiety disorder c) Overall prevalence rates for all anxiety disorders in old age is around 20% d) Panic disorder affects around 5% of elderly. Which of the following is true regarding anxiety disorders in old age: a) Prevalence rates increase with age b) Phobias are the most common anxiety disorder c) Overall prevalence rates for all anxiety disorders in old age is around 20% d) Panic disorder affects around 5% of elderly. Case 1 Approach History (with collateral) and physical examination Make the diagnosis considering the differential Thorough medication review Investigate causes (bloodwork, urinalysis, ECG, imaging) and remove promoting factors Consult prn (OT, PT, RD, SW, other MD) Differential Diagnosis Delirium Dementia Depression, Mania, Psychotic disorder Other CNS disease (cancer, demyelination, etc.) Delirium 20% of hospitalized patients >651 10-30% of people >65 it is the presenting symptom of a life-threatening illness1 LOS approximately doubled to 8 days2 Mortality doubled, morbidity increased3 Unrecognized in ~ 70%4 1Centers for Medicare and Medicaid Services, 2004 CMS Statistics; 2Agostini JV, Principles of Geriatric Medicine and Gerontology; 3McCusker J, Arch Intern Med; 4Gillis AJ, Can Nurse Delirium C - Consciousness fluctuates C - Course has an acute onset C - Cognition disturbed C - Cause is a GMC Subtypes of Delirium Meagher (1996), BJP Predisposers Precipitators Perpetuators Old age Med change Poor nutrition Visual loss Trauma (IV, Environmental Hearing loss restraints, foley, changes Hx delirium fall) Pain Dementia UTI, pneumonia IV/Foley Functional MI, CVA Dehydration dependence Low BP or O2 Sensory Medical AbN lytes deprivation/ morbidities GI or GU overstimulation Polypharmacy disease Poor sleep EtOH/ drugs Periop. factors Hypothermia Causes of Delirium I - Infections W - Withdrawal A - Acute metabolic Encephalopathy T - Trauma C - CNS pathology H - Hypoxia D - Deficiencies E - Endocrine Disorders Case 1 QuickTime™ and a GIF decompressor are needed to see this picture. Treatment of 1,2,3 Delirium Psychological/ Social/ Environmental Ensure pt wears glasses, hearing aid, dentures, encourage independence & regular activity, allow adequate sleep Support family, enlist their help in decreasing distress and providing frequent reorientation Place person near NS station in single room with adequate lighting, reorientation cues, and LIMIT RESTRAINTS Biological Treatment related to cause of delirium Manage sx (low dose neuroleptics) Ensure adequate hydration, stop unneeded lines 1Cole MG, J Geriatr Psychiatr Neurol; 2Simon I, Geriatr Nurs; 3Meagher DJ, Br J Psychiatry Antipsychotics in 1 Delirium Evidence suggests modest benefits in decreasing duration and severity of delirium with use of antipsychotic Low dose haldol (0.25-1.5 mg/24h) is equivalent to low dose risperidone (0.25 -1/24h) or olanzapine (1.25-5 mg/24h) in efficacy, but may cause more akathisia, definitely costs less Cochrane Collaboration, 2009 Delirium Outcomes Delirium in the elderly patient is associated with increased mortality, longer hospital stays, and increased risk of institutional placement It is a reversible syndrome, that improves or resolves with treatment of the precipitating illness and addressing precipitating and perpetuating factors MCQ: The following is true for delirium: a) It is characterized by problems and fluctuations with attention and consciousness b) In the elderly, it is most often completely reversible c) Hypoactive subtypes are more often missed d) Environmental interventions do not help e) It is a significant independent risk factor for death f) It can be superimposed on dementia or depression g) It is rare in the elderly h) It is better to use benzodiazepines than neuroleptics for psychotic and behavioural symptoms The following is true for delirium: a) It is characterized by problems and fluctuations with attention and consciousness b) In the elderly, it is most often completely reversible c) Hypoactive subtypes are more often missed d) Environmental interventions do not help e) It is a significant independent risk factor for death f) It can be superimposed on dementia or depression g) It is rare in the elderly h) It is better to use benzodiazepines than neuroleptics for psychotic and behavioural symptoms