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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 This is to certify that: ......................................... Has reviewed/completed ..........Functional Illness................. Date ........................................