Download Functional illness in elderly

Functional illness in elderly
Dr Seema Gupta
6.12.12
Overview
 As people age, some physiologic changes are
inevitable
 Older people - face unique psycho-social
challenges
 These changes and challenges can lead to a
variety of geriatric syndromes and issues
 These in turn can lead to poor health outcomes,
functional decline, frailty, disability and dependence
What is covered?
 Depression in old age
 Bipolar Affective disorder
 Anxiety disorder
 Psychosis
 Alcohol
Depression in old age
 In the population aged over 65 the prevalence -depression
is 10%
 Community-0.5-1.5%
 Clinical outpatients 5-10%
 Clinical Inpatients 10-15%
 Residential and nursing homes-15-30%
 Depressive disorders are at least 2 to 3 times more common
in hospitalized patients, nursing home residents, or
outpatients with chronic medical disorders.
Clinical presentation
 Depressed mood may be less prominent

Altered symptoms in late-life depression
Reduced
complaint of ‘feeling sad’
• Hypochondriasis and increased somatic concerns instead of
sadness
• Poor subjective memory - a dementia like picture
• Late onset anxiety Sx (Marked anxiety, obsessive-compulsive or
hysterical symptoms)
• Apathy and poor motivation

Symptoms that may be hard to interpret because of physical disorder
• Anorexia
• Weight loss
• Reduced energy
Clinical presentation- cont.
Late onset depression is associated more with
- Cognitive impairment: in upto 70% of cases
- Anhedonia
- Psychomotor changes -severe psychomotor retardation or
agitation seen in up to 30% of depressed elderly
patients
- Depressive delusions regarding poverty, physical illness or nihilistic
in nature
- Paranoia is also common and auditory hallucinations may
occur
in severe depression (Derogatory and Obscene)
- Weight loss
- Severe life stress : The frequency
and severity of life events
physical illness- cardiovascular disease, central nervous system
disorders (eg, strokes, dementia, Parkinson disease), cancer; loss of
a spouse) may be greater
Neuroimaging studies in late onset
depression:
CT: Cortical atrophy and ventricular enlargement
MRI: Atrophy, ventricular enlargement, lesions in basal ganglia and
white matter
SPECT: reduced cerebral blood flow, sparing the posterior parietal
cortex
Treatment
 General rules would include:
Low starting
Gradual increases
Prolonged trial periods (2-3 months)
Long maintenance period (up to 2 years; may be life-long)
 First line treatment :
SSRIs due to reduced side effects and relative safety in
overdose.
Others include Mirtazapine, SNRIs such as venlafaxine,
Trazadone, and occasionally Moclobemide.
Older patients take longer to recover, 6-8 weeks or more
Treatment cont.

Treatment-resistant depression:
 At least 30% of elderly patients- do not respond to antidepressenat
 If little or no response within the first 4 weeks at therapeutic dosages - change to an
antidepressant of a different class.
 If there is a partial response within 4 weeks- continue for a further 6 weeks as older
patients take a longer ( wait and support)
 Combination & augmentation strategies- lithium augmentation, antipsychotic
augmentation, adding Thyroxine, combining a tricyclic with an SSRI, combinations
such as SSRI and mirtazapine, high-dose venlafaxine hydrochloride.
 Sequential treatment programes have best outcome

Maintenance treatment:
 For a first episode of major depression, the patients should be kept on a continuation
treatment of at least 1 year
 For patients with three or more relapses or recurrences, long-term treatment is
recommended .
 Maintain the patient on the same medication regimen that led to remission.
Treatment- cont.


Electro convulsive therapy:

effective treatment available for severe depression, recovery rate – upto 80%. It is well
tolerated




particularly effective in psychotic depression
more likely- post ECT confusion and cognitive impairment
Memory impairment often worse with bilateral electrode placement
should be avoided in the first 3 months following a stroke or MI
Psychological Interventions:
 emerging evidence that for older adults with mild to moderate depressive episodes, a
psychological intervention is as effective as medication, combination with ADD better in sever
depression
CBT is the best established treatment and good evidence for its effectiveness in older adults
Interpersonal therapy - effective in Relapse prevention
 developing evidence for problem solving treatment
Family therapy
Prognosis

Good prognostic factors
1. Onset less than 70 years old
2. Short duration of illness
3. Absent physical illness
4. Good previous adjustment
5. Good previous recovery

Poor prognostic factors
1. Severe life events during follow up period
2. Poor medication adherence
3. Medical illness burden
4. Co-morbid (persistent) anxiety
5. Presence of psychotic symptoms

Remission rates of depression in patients in late life are similar to that in midlife, but
relapse rates appear higher
Prognosis

Mortality is higher because of concurrent physical disorder

A meta-analysis of outcomes in depressed older adults estimated that
at 2-year follow-up, 33% of subjects were well, 33% remained
depressed, and 21% had died.

Depression exacerbates the outcome of medical illnesses. Elderly
individuals with depression were almost four times more likely than
those without depression to die within 4 months of a myocardial
infarction.


Depression may increase the risk for cardiovascular disease.
Elderly patients have poor T-cell responses to mitogens and high
concentrations of plasma interleukin 6, which is indicative of
inflammatory activity that might increase the risk for bone resorption,
predisposing to fractures.
Depression scales

Geriatric depression Scale: Originally a 30-item test, it now has 15-items which
enables most subjects to be scored for depression in four or five minutes. It avoids
somatic questions and so good for older patients. An overall score of five or more
suggests the possibility of a depressive illness.

Hamilton rating scale: It has a number of somatic items, which render it less
appropriate for older subjects. It is a general adult scale that quantifies depression
but is not a diagnostic tool.

MADRS (Montgomery-Asberg Depression Rating Scale): It is sensitive to
change in depressive illness and is not reliably answered by patients with dementia

Depressive sign Scale: Nine items to help detect depression in people with
dementia

(Ref: Seminars in Old Age Psychiatry Pg 11-15)
Major Clinical Features Differentiating
Pseudo dementia from Dementia
Pseudodementia


Onset can be dated with some precision

Rapid progression of symptoms after
onset


Past psychiatric dysfunction common
Symptoms of short duration before
medical help is sought
Patients usually complain much of
cognitive loss


Nocturnal accentuation of dysfunction
uncommon

Attention and concentration often well
preserved


Don't know answers typical
Patients emphasize disability
Memory loss for recent and remote
events usually severe
Dementia



Onset can be dated only within broad limits


Past psychiatric dysfunction unusual

conceal disability & often appear
unconcerned.

Nocturnal accentuation of dysfunction
common



Attention and concentration usually faulty
Symptoms usually of long duration
Slow progression of symptoms throughout
course
Patients usually complain little of cognitive
loss
Near-miss answers frequent
Memory loss for recent events usually more
Bipolar Affective disorder


Mania accounts for 5-10% of mood disorders in the elderly.
The 1-year prevalence of BD among adults aged 65 and older is 0.4%, significantly
lower than in younger adults (1.4%).

Average age at onset is 55 years and female to male ratio is 2:1

Mania - similar clinical picture as in younger patients but- more often followed by
a depressive episode in older and mixed affective presentation more common.

First episode mania in late-life is uncommon; but these patients have lesser
familial loading and have more secondary mania than bipolar disorder.

Patients with first-episode mania in late life are twice as likely to have a comorbid
neurological disorder
Treatment

Acute mania and HypomaniaStop antidepressants



Antipsychotics and mood stabilisers effective ( monotherapy or combination )
Short
term benzodiazepines ay be added

Bipolar depression- NICE recommends
First line- SSRIs ( in addition to an antimanic drug) or quetiapine
Second line- switch to mirtazapine or venlafaxine or to add quetiapine, olanzapine or lithium to
antidepressant

Prophylaxis- NICE recommends


 after single manic episodethat was associated with significant risk
and adverse consequences
 In case of Bipolar I Disorder, after 2 or more acute episodes
 In case of Bipolar ii Disorder, if significant functional impairement,
frequent episodes or significant risk of suicide


Lithium is used as first line prophylaxis but usually lower dosages are indicated.
lower therapeutic range around 0.4 to 0.6mmol/L is suggested for prophylaxis
 Valproate, olanzapine, quetiapine, Carbamazepine, Lamotrigine
Anxiety disorders

Panic disorder, Phobias, OCD, GAD, acute stress
disorder,
PTSD





The estimated prevalence 1-10% with a female predominance.
most prevalent anxiety disorder – Phobic disorder.
least common anxiety disorder- panic disorder.
prevalence of anxiety disorders decreases with increasing age.
Non-specific anxiety symptoms, hypochondriacal and depressive
symptoms predominate.
Anxiety disorders

Signs and symptoms of phobia are
less severe but effects are equally
debilitating

Due to concurrent physical health problems- elderlt
to PTSD

OCD- egodystonic rituals, obsessions and compulsions. Usually demonstrated symptoms
when young but may begin late in life

Multiple factors may contribute to new anxiety symptoms include physical illness, major life
events, bereavement, social isolation, impaired self-care and insecure personality factors

Treatment


patients react more severely
Pharmacological – SSRI, Benzodiazepines
Psychological therapies- exposure therapy, behaviour therapy, anxiety management, CBT
Psychosis

Psychotic symptoms of acute onset- usually seen in delirium
secondary to a medical condition, drug misuse and drug-induced
psychosis.

Chronic and persistent psychotic symptoms may be due to a primary
psychotic disorder such as:
Schizophrenia
Late-onset schizophrenia
Delusional disorders
Mood disorders
Neurodegenerative disorders, such as Alzheimer’s disease, vascular
dementia, dementia with Lewy bodies or Parkinson’s disease
Psychosis cont.
 Kraepelin introduced the term ‘paraphrenia’ in 1913
 Late paraphrenia - expression of schizophrenia in the elderly
 current consensus- the late onset psychotic illness is subdivided into
 late onset (onset after 40 years of age)
 very late onset (onset after 60 years of age).
 late onset schizophrenia represent approximately 10% of the elderly





population of psychiatric hospitals
prevalence of the disorder in community- 0.1 to 4%
higher number of females affected than males
premorbid educational, occupational, and psychosocial functioning is
less impaired
patients have had premorbid schizoid or paranoid personality traits.
Social isolation and sensory deprivation are significantly associated
Diagnostic distribution in patients
with late onset psychosis
Paranoid
schizophrenia
61%
Delusional disorder
31%
Schizoaffective
disorders
8%
Clinical Features

Persecutory delusions are the most common symptoms- in up to 90% of
patients.



Auditory hallucinations – present in up to 75%

Negative symptoms ( affective flattening, alogia, avolition-apathy, anhedonia,
Visual hallucinations – in up to 60%
First rank symptoms ( thought insertion, thought broadcasting, thought
withdrawal, delusional perception, somatic passivity) - less common
attention) and thought disorder - extremely uncommon

Few patients – delusions only (10-20%). Partition delusions (attack through
the wall, neighbours spying via any ‘partition’) are common.

According to ICD patients – diagnosed as delusional disorder or
schizophrenia . No separate diagnosis exists for paraphrenia
Schizophrenia


Late onset schizophrenia is characterised by







Fewer negative symptoms
Better response to antipsychotics
Better neuropsychological performance
Greater likelihood of visual hallucinations
A lesser likelihood of formal thought disorder
A lesser likelihood of affective blunting
A greater risk of developing Tardive dyskinesia – up to 5-6 times
Similarities between early onset and late onset schizophrenia



Presence and severity of positive symptoms
Early psychosocial maladjustments
Subtle brain abnormalities revealed by imaging
Contributory factors for late onset
psychosis

Neurochemical changes associated with ageing








Age related deterioration of frontal and temporal cortices

Family history, albeit weaker than younger onset schizophrenia.
Cognitive decline
Social isolation
Sensory deprivation (hearing loss and visual impairment)
Polypharmacy
Paranoid and schizoid personality traits
Life events
Female sex
Treatment



Cochrane review- failed to identify studies ( no evidence)
atypical antipsychotics- better side-effect profile & considered more suitable
concerns raised- safety of atypical APD in psychosis due to dementia. The
CSM - olanzapine and risperidone were associated with a two-fold increase in
risk of stroke in elderly patients especially over 80 years and restriction
extended to other atypical APD

age-related changes affect pharmacokinetics & pharmacodynamics of
antipsychotic drugs- numerous, more persistent & disabling side effects

principle ‘Start low and go slow ’

clozapine for treatment-resistant schizophrenia is well established but –
toxicity , need for monitoring white cell counts - limited use in older patients &
used in treatment resistance & severe tardive dyskinesia.
Recommended doses of atypical
antipsychotics for elderly people
 Starting dose (mg/day) , Maximum dose (mg/day)
 Amisulpiride 25-50 mg, 200-400 mg
 Olanzapine 1-5mg, 5-15mg
 Risperidone 0.25-0.5mg , 2-3mg
 Quetiapine fumarate 12.5-25mg, 100-200mg
 Clozapine 6.25mg, 50-100mg
 Psychological treatment
involves – integration of
 social
skills training

cognitive behavioural techniques and
aims to reduce their cognitive vulnerabilities and improve their
ability to cope with stress and to adhere to other forms of
treatment
 psychosocial interventions-
combination of interpersonal and
independent skills training together with standard occupational
therapy found to be associated with improved social functioning
and independent living.
Alcohol use in the elderly:

Alcohol use disorders in elderly people are a common but under-recognised
problem which is assocaited with major physical and psychological health
problems. In UK, according to the Office for national statistics, 2001 nearly 17% of
men aged 65 and above drank more than the weekly guidelines of 21 units and 7%
of women aged 65 and above drank more than the weekly guidleine of 14 units per
week

Alcohol use disorders may be deccribed as being early onset or late onsetEarlyonset category: These patients have had a life long pattern of problem drinking and
have probably been alcoholics for most of their lives. These individuals had drinking
problems in their 20s or 30s and there is a family history of alcoholism. They are
more likely to have physical and psychiatric illness.

Late-onset category: These patints first develop drinking problems at 40-50 years
of age. They have fewer physical and mental helalth problems. Often a stressful life
event precipiates or exacerbates their drinking. This group is more receptive to
treatment and more likely to recover sponatneously from alcoholism.
Key factors associated with heavy
drinking
 Gender
>2 times as women likely to exceed sensible
 Men
guidelines for weekly drinking.
 Women - more with late onset of alcohol problems
 Socio-economic group
Higher levels of drinking were more prevalent among the
 higher
social classes and the most affluent.
 Living arrangements and partnerships
Widowed, divorced or never married men more likely to
 engage
in heavy drinking.
older women those married had the highest level of
 Among
alcohol consumption.
 Ethnic and religious origins
In general African-carribean, muslims and hindu women reporetd
 drinking
less than their white counterparts.
 Genetic factors
Some studies suggest that in men, genetics might play a greater
 part
in early than in late onset alcohol misuse.
 Physical ill-health and psychiatric illness
 Precipitating life events
 Neurotic personality
 Substance-seeking behaviour, crime , manipulativeness,
antisocial behaviour rare
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