Download Basics Geriatric Psychiatry 2012_Dr Lau

Review Of Geriatric
Psychiatry
T. Lau, MD, FRCPC [psych], MSc.,
Director Undergraduate Education,
Faculty of Medicine,
UNIVERSITY OF OTTAWA
Royal Ottawa Mental Health Centre
Geriatrics
Why is it important to know
something about the elderly
Geriatrics Overview
• 3 D’s
– Depression
– Dementia
– Delirium (check the pee, poop etc)
• 2 Extra D’s
– Drugs
– Delusional sx (Psychosis in the
Elderly)
• Overview and cases of
–
–
–
–
–
–
DEPRESSION
MANIA
ANXIETY
PSYCHOSIS
DELIRIUM
DEMENTIA
“I want to die in my sleep
like my grandfather, not
like the people kicking
and screaming in the
backseat of his car.”
Sue McKay Geriatric
Psychiatrist
Case 1
• 73 year old woman who presents with 2 month
history of tearfulness, loss of energy, apathy,
inability to get out of bed in the morning, and
insomnia with early morning awakenings.
• She describes increasing anxiety, an inability to
cope, forgetfulness, problems reading or even
watching TV, a 30 lb weight loss and feels very
constipated.
• She expresses a concern that something is
wrong with her stomach. Her lower back has
also been bothering her more.
Case 1
• She lost her husband 8 months ago and one of
her children a little over 1 year ago.
• She has a remote history of resected breast
cancer and a more recent history of thyroid
cancer which was resected 3 years ago. She
also has a history of atrial fibrillation.
• She has no past psychiatric history and has
always been able to cope with difficulties until
recently.
• She is on coumadin and a beta blocker.
Case 1
Questions
1. What is in your differential diagnosis?
2. What kind of investigations would you order?
3. Assuming you believe her to be depressed what
would be your plan of treatment?
4. Is there a reason for suggesting one
antidepressant over another?
Case 1
Questions
5. Assuming she does not have any response to
6.
7.
8.
9.
treatment after 3 weeks what would you do?
How effective are antidepressants?
Does duration of sx or number of previous
episodes effect remission rates?
Are they less effective in the elderly?
What is different about the depressed elderly
compared to younger adults?
MDD Tx: Summary
BIO:
• SIMILAR EFFICACY
– Choose antidepressants based on expected side effects
– Consider serotonergic agents for anxious, sleep depressed
– Consider noradrenergic agents for psychomotor retarded, excessive
sleepiness
• ADEQUATE TRIALS
– Adequate trial 4-6 weeks (look for some response @ 2 weeks as a
predictor of success). Switching amongst the same class may also
work. Effective (Response: 70% w 1st, 70% w 2nd, 90% overall). BUT
50% discontinue in first 3/12, <30% complete full course of tx. Watch
for adherence.
MDD Tx: Summary
BIO:
• SPECIAL POPULATIONS
– Recurrent & FHx of BAD consider Li.
– Psychotic features: ECT vs add AAP to antidepressant.
• ECT (particularly psychotic depression 95% RR).
– Consider especially if situation is urgent, not eating.drinking,
taking medication, suicidal, medication intolerance
• MEDICALLY UNWELL
– Comorbid medical conditions, consider stimulants, which are
relatively safe and work faster. Methylphenidate,
dextroamphetamine, and modafinil
MDD Tx Resistance: Summary
• AUGMENTATION
– Lithium, T3, Ritalin, Tryptophan, Dopamine agonists
– Atypical antipsychotics [Risperidone, Olanzapine, Aripiprazole]
– COMBINATIONS
– SSRI/SNRI + Wellbutrin
– SSRI/SNRI + Remeron
– QUETIAPINE MONOTHERAPY
Depression in the Elderly: Tx
 More likely to have somatic complaints, anxious,
melancholic and psychotic features. Therefore ECT
often used and is effective.
 Similar response rates (although may take longer to
tx), high relapse rates. Only 10-20% are tx resistant.
With aging, more frequent episodes and longer
untreated episodes (duration to spontaneous
remission is longer) or may change to chronic course.
 May have comorbid cognitive impairments. Noncompliance and physical disability often lead to
chronicity.
 More often confronted by death, grief may be a
complicating feature
Depression in the Elderly
• Controversy exists still about whether depression
in late life is assoc with poorer outcome
• Post Hoc analysis of the Sequenced Treatment
Alternatives to Relieve Depression (STAR*D).
• Early onset age<55. Late onset age 55-75. (n=574)
with non psychotic MDD with baseline HAMD>14.
Citalopramx14 weeks. Outcome: 16 item Quick
Inventory of Depressive Sx-self rated score.
• Time to remission, remission rates did not differ
between the groups. Am J Geriatr Psychiatry
2008
• (Next slide for details….)
Grief vs. depression
• Depression
– Persistent mood state
– Poor self esteem (from Mourning and Melancholia,
Freud: introjected lost object w negative assoc
feelings experienced as part of self)
– Fxnal impairment beyond 2/12
– Suicidal thoughts with desire to die
• Grief
– Dysphoria, sadness comes in waves with marked
fluctuation, often w triggers
– No fxnal impairment > 2/12
– No psychomotor retardation, active suicidality,
psychosis (although transient phen may occur)
Grief vs. depression
• Kubler Ross
– 1) Shock/denial, 2) anger, 3)
bargaining, 4) depression, 5)
acceptance
• Grief in Children
– Protest, Despair, Detachment
MCQ # 1
The following is true regarding depression
a) With the first antidepressant patients feel
completely well 1/3 of the time and feel better
2/3 of the time
b) the neurotransmitters acetylcholine and
adrenalin are involved
c) Psychotherapy is effective in severe depression
d) it rarely presents with multi-system physical
complaints
e) ECT should be considered only when all other
treatments have failed
a
MCQ #2
Depression in old age:
a) Does not respond as well to antidepressants
b) Is accompanied by a much lower suicide risk than
in younger adults
c) Are more likely to have anxious, somatic and
psychotic features
d) Is a normal part of aging
e) Is not associated with the death of a loved one
C
MCQ # 3
Which of the following are infrequent
“reasons for consultation” by elderly who
have their first depressive episode:
a)
b)
c)
d)
e)
“Nerves”
Excessive fatigue
Hypersomnia (sleeping too much)
Digestive problems
Fear of Alzheimer’s disease
C
MCQ# 4
Which of the following would be more
consistent with normal grief?
a) Active suicidal ideation
b) Prominent psychotic symptoms
c) Crying spells when she thinks of her deceased
husband.
d) Profound feelings of guilt
e) Being unable to attend to her usual daily
activities 3 months after the death of her
C
husband
Anxiety disorders and the Elderly
• Secondary anxiety disorders more common in elderly
– Primary anxiety disorders, like personality disorders, generally do
not have an onset in the elderly
– High comorbidity with depression
• Overally 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 for older patients due to their side effects
– Elderly are more sensitive to benzodiazepines. Associated with an
increased risk for falls and MVAs
Potential Anxiolytic Side Effects and the
Elderly
 Cognition
 Amnesia specially in alcoholics with benzos
 Memory and visuospatial impairment
 Psychomotor
 Accentuate postural sway and coordination
 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
Case 2
• 85 year old woman who lives alone, never married
and has no children. She is hard of hearing and
visually impaired.
• She has become increasingly seclusive and
withdrawn. Her hydro and water stopped being paid
and was cut off.
• A nephew who was concerned called the CCAC to
ask if someone could check in on her and help her at
home. She refused to allow anyone in and talked
about a how people were trying to break into her
house and kill her. She was convinced the mail man
was delivering messages from the devil.
Case 2 Questions
1. What is your DDx?
2. How is late life psychosis different than
the younger population?
3. What is the natural history of
schizophrenia?
Differential Diagnosis
In younger patients
In the Elderly
• Psychosis
 PRIMARY PSYCHOTIC DISORDERS
– Substance - GMC
– Mood D/O (MDD or
BAD)
– SCZ, SCZ-A
– BPE
– Dissociative D/O
– Delusional disorder
– Delirium
– Personality disorders
 Schizophrenia
 Late onset 25%
 Early onset grown old 75%
 Delusional Disorder
 0.03% but 1-2% of hospital admissions
 Paraphrenia
 MOOD DISORDERS
 Depression
 (33% of severe subtype cf 15% mild to moderate)
 Mania
 COGNITIVE DISORDERS
 Dementia
 (~50% have psychotic symptoms)
 Delirium
 Substance-GMC
Biphasic in the women
MCQ#5
Regarding psychosis in late life, which is the best
answer?
a)
b)
c)
d)
e)
Paranoia is most often due to schizophrenia.
More men develop late onset schizophrenia.
Psychosis is often associated with mood and cognitive
disorders
Psychosis is often caused by illicit drugs of abuse
Patients with schizophrenia live 5-10 years less on
average
c
Case 3
• 68 year old woman who you, as her family physician have
followed over many years, presents with increasing confusion,
gait instability, falls, and incontinence. The change appears
abrupt. She is now sleeping much of the day and is up at
night.
• She is on several medications including beta blockers,
diuretics and Mobicox for arthritis. She continues to have
some brandy after supper. When she last came to the clinic
you were away and a locum prescribed some clonazepam to
help her sleep better and relieve some of her anxiety.
• She is admitted to the hospital under your care.
– What is in your differential diagnosis?
– What tests would you order?
Case 3
• A urine C&S and CT head were normal.
• Routine blood work was also normal.
• She is now extremely agitated at night. Falling
frequently and is distressed with the belief that
people are trying to kill her and she has to escape
out of this prison. The nurses on the floor are
requesting sedation or restraints for safety.
– What are your next steps and why?
Delirium
• Disturbance of 4Cs
–C
–C
–C
–C
Consciousness (focus, sustain or shift
attention)
Cognition (memory, disorientation,
language) or perceptual disturbance
Course
Consequence of GMC
• Why is it important?
– Delirium in the elderly patient is associated with
increased mortality, longer hospital stays, and
increased risk of institutional placement.
Delirium
• DSM IV Subcategories:
– due to GMC, substance intoxication/withdrawal,
multiple etiologies
• Prevalence: 10-15% of those hospitalized.
• Under recognized. in those >65 higher (1040%).
• Independent risk factor for mortality 40% @
one yr.
• Lab features: EEG generalized slowing
Delirium
Meagher (1996), BJP
• Hypo:
• dec Ach in nucleus basilis & RAS, associated with CVA, metabolic
disorders, late sepsis, aspiration, pulmonary embolism, decubitus ulcers
and other complications related to immobility. Characterized by:
Unawareness, inattention, decreased alertness, sparse or slow speech,
lethargy, decreased motor activity, staring, apathy. Liptzin (1992) BJP
• Hyper:
•
•
•
–
mediated by LC-NA.
withdrawal states, acute infection,
Etiology: Hyper and hypactive delirium
Ach in RAS (dorsal tegmental pathway).
• Risk factors
– Medical illness, sensory impairment, hx of delirium, ETOH, preexisting brain damage (eg. Dementia), malnutrition
INDEPENDENT PRECIPITATING
FACTORS (n=196)
• Precipitating factor
•
•
•
•
Use of physical restraints
Malnutrition
>3 medications added
Use of bladder catheter
Adjusted Relative
Risk
4.4 (2.5-7.9)
4.0 (2.2-7.4)
2.9 (1.6-5.4)
2.4 (1.2-4.7)
Delirium: Treatment
• Biological
– Determine cause if possible and treat (eg. infection,
med ASE’s, metabolic d/o, pain, renal/hepatic failure,
drug intoxication/withdrawal, SOL, CVA, NPH, etc).
– Manage sx (low dose neuroleptics), watch for AC ASE of
meds (Breitbart AJP 1996).
• Psychological
– Establish calm and safe environment. Develop trust and
provide reassurance
– Place near NS station with adequate lighting,
reorientation, familiar faces, voices.
• Social
– Support family, may be helpful in decreasing distress
and reorientation
Delirium
• Environmental interventions
–
–
–
–
–
Noise reduction
Diurnal variation in noise and lighting
Frequent reorientation
Day/date in room, big clock in room
Keep familiar items in room e.g., family
pictures
– Early mobilization, physical therapy
– Limit use of restraints
– Early recognition and treatment of
dehydration
MCQ #6
The following is true of delirium
a) In the elderly, it is rare and most often completely
reversible
b) Hyperactive subtypes are more often missed
c) It is a significant independent risk factor for death
d) It can be superimposed on dementia or
depression
e) It is better to use benzodiazepines than
neuroleptics for psychotic and behavioural
symptoms
C
Case 4
• A 78-year-old widow who lives alone and whom you have seen
infrequently is brought to your office by her daughter.
• Although the patient has no complaints, her daughter indicates
that for the past 2 years she has become more forgetful. Her
behaviour is repetitive, and she sometimes calls her daughter
several times a day to ask the same question.
• The quality of her housework is beginning to decline (her house
is untidy, food is left to spoil in the refrigerator, she is limiting
food preparation to simple, familiar items, and she has to check
recipes even for easy dishes).
• Her personal hygiene is also declining, and some bills are not
being paid on time.
Case 4
•
•
•
•
What is in your differential diagnosis?
What tests would you order?
What are your next steps?
You see her several years later in a nursing home.
She is more confused and no longer recognizes you.
She is frequently exit seeking and is resistive with
care at times. She has injured staff and co residents
during periods of anger and agitation.
• What would you do?
Defining the Diagnostic Threshold
Dementia
• What is Dementia?
– Memory problems with difficulties in another
cognitive area (aphasia, apraxia, agnosia,
executive dysfunction) together with a loss of
function
Projected number of dementia, AD,
and VaD cases in Canada from 19912031
No. of cases (x1000)
800
600
x3
400
x2
200
Dementia
AD
VaD
0
1991
2001
2011
2021
2031
Canadian Study of Heath and Aging Working Group.
CMAJ 1994;150:899-913.
What are the Different Types:
Frequencies…
•
•
•
•
•
Alzheimer’s
Vascular
Dementia with Lewy Bodies
Frontotemporal Dementia
Others
– Parkinson’s with dementia
– PSP
– Prion
– Huntington’s
Progression of AD
Mild cognitive
impairment
• Memory
impairment
• Absence of ADL
deficits
• Apathy, anxiety,
irritability
AD Progression
Mild - MMSE >20
• Forgetfulness
• Problems with shopping, driving and hobbies
• Depression
Moderate - MMSE 10-20
• Marked memory loss
• Require help with ADLs
• Wandering
• Insomnia
• Delusions
Severe - MMSE <10
Adapted from Galasko D. Eur J
Neurol. 1998;5:S9-S17.
• Very limited language
• Loss of basic ADLs
• Incontinence
• Agitation
Nursing home
placement,
death from
pneumonia
and/or other
comorbidities
THERAPEUTIC STRATEGIES
Detection
Latency
.Traumatisms
. Vascular risk factors
Symptoms
Induction
.Genetic/hereditary
Pathogenesis
Disease
Primary
Prevention
Vaccine
Estrogen
NSAID
Ginkgo
Secondary
Prevention
(“Mild cognitive
Impairment”)
Antioxydants
Anti-inflammatories
Neurotrophic factors
Estrogens
Vascular Prevention
Symptomatic
Treatment
Cholinergic replacement
Therapy
Glutamate Modulation
Mood and Behaviour
Management
Original Case Report
B-Behaviours
• 51 y-old ♀ with cognitive
impairment and: delusions of
sexual infidelity, paranoid
delusions, hallucinations, hiding
objects inappropriately,
screaming and agitation, physical
aggression
Alois Alzheimer 1906
PIECES
P
S
I
E
E
• 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…
• Social, cultural, spiritual: life story,
relationships family dynamics, personality
traits……
C
Pharmacologic Management of BPSD
 Herrmann and Lanctot
Canadian Journal of Psychiatry Oct 2007
 Atypicals
 Remain the best studied and most effective but side effects limit their
use
 Antidepressants
 Some evidence for Trazadone and Celexa but effect size may limit use
in urgent situations
 Anticonvulsants
 Tegretol can be effective but poorly tolerated. Negative studies with
Epival. Not as thoroughly studied as atypicals
 Benzodiazepines
 Short term use only
MCQ #7
The following is true of Alzheimer’s
a) Motor symptoms are present early in the disease
b) There is usually a step wise decline
c) The ‘head turning sign’ refers to sexual
disinhibition
d) Behavioural symptoms are often the most
distressing symptom for families and caregivers
e) Vascular events may co-occur but play no role in the
pathophysiology
D
Case 5
• 65 year old woman who presents with a two year
history of strange behaviour and sleeping
problems and one year history of resting tremor,
falls and increasing mental and physical slowness.
• As her family physician you diagnosed
Parkinson’s disease and initiated L-Dopa. The LDopa helped with her motor symptoms.
• Periods of confusion became evident as were well
formed visual hallucinations. Because of your
suspicion of delirium and some urinary symptoms
you treated her for a UTI.
Case 5
•
Despite this, the fluctuations and
hallucinations continue. Her daughter
who is the primary caregiver feels she is at
her wits end and is asking you what to do.
QUESTIONS
1. What is your differential?
2. What is the difference between DLB and
PDD?
Lewy Body Dementia
McKeith Neurology 96 updated 2006
•
Diagnosis
– Dementia
– Plus >2/3 (probable, 1/3 possible)
• Clinical Features
• Fluctuating cognition
• VH’s well formed + delusions
• Parkinsonism
– Pathologically
•
•
• identified with Ubiquitin Stain. LB seen in
PD in SN. a-synnuclein stain better ie.
No NFT staining
LBD and Delirium
– Fluctuating LOC/attention. LBD has attn
to do months in reverse
Parkinson’s and DLB
– wrt to PD hallucinations and depression
but not delusions suggesting cortical
pathology for delusions.
– Louis’97 reported rest tremor lower in
DLB but myoclonus higher.
–
–
–
–
–
–
–
–
–
–
Repeated falls
Syncope w transient LOC
Neuroleptic sensitivity
Systematized delusions (>50%)
Hallucinations in other modalities
Increased rates of depression (4050%)
Misidentification syndrome v.
common
Tx
Seems to respond well to AchEI
Extreme caution with
neuroleptics
MCQ #13
Which of the following is true regarding
Dementia with Lewy Bodies
a)
b)
c)
d)
e)
It is rare
It is associated with severe neuroleptic sensitivity, REM
sleep disorders, and falls
PET/SPECT shows increased Dopamine uptake in the
basal ganglia
Can occur in patients who have had the motor
symptoms of Parkinson’s for over one year
Response to Acetylcholinesterase inhibitors is POOR
B
Case 6
 82 year old married man who you have followed over
several years having treated him for hypertension,
diabetes and peripheral vascular disease.
 He has a history of paroxysmal atrial fibrillation and is
on Coumadin. He has not been as steady while
walking lately and had some recent falls. His wife
and family have become increasingly concerned that
something is wrong.
 He is forgetful and needs constant reminders even to
change and get dressed.
 The family have also observed that he seems very
emotional at times. He has been getting lost while
driving.
Vascular Dementia
•
Memory problems + one of:
– Agnosia, Apraxia, Aphasia
– Executive dysfxn
•
Vascular
– Focal si/sx or lab evidence
– Impairment
– Not during delirium
•
Clinical features:
•
•
•
– Cognitive changes: executive dysfxn with few language impairments, often motor,
gait abnormalities. Memory problems often retrieval related: working memory.
Neurological: dizziness, focal motor, pseudobulbar palsy
Subtypes: Multiinfact&Bingswanger-small vessel subcortical deep white matter
Risk Factors: M, age, apo E4, race=black / asian, HTN, CAD, DM, Hyperchol, smoking
MCQ#8
All of the following is true regarding Vascular
Dementia
a)
b)
c)
d)
e)
Lateralizing findings are common
Gait changes are uncommon
Gradually progressive decline is typical
Neuroimaging or clinical evidence of CVA is necessary
for the diagnosis
Retrieval < encoding deficits on neuropsych testing
D
Case 7
•
•
60 year old married mother of 2 who
presents with a 2 year history of
increasingly strange and
uncharacteristic behaviour.
She was caught shoplifting and has
become surprisingly disinhibited. Her
awareness of her social
inappropriateness was negligible and
quite embarassing for her family who
feel she seems like a different person.
Case 7
•
Her language also has changed where she has
experienced increasing difficulties speaking clearly.
She often mutters and has been persisting in rigid
patterns of behaviour, for instance, ruminating over a
routine of watching TV and eating.
•
1.
2.
3.
QUESTIONS
What is your differential?
What differentiates FTD from AD?
Are there any differences in treating this condition?
MCQ #9
Frontotemporal Dementia is characterized by
a)
b)
c)
d)
e)
Memory and visual spatial impairment early on
Personality changes later with disinhibition
Early loss of insight, decline in social interpersonal
conduct with impaired regulation, emotional blunting,
executive skills deficits, frontal signs
Characteristic functional neuroimages with occipital
cerebral hypometabolism
Low rates of family history
C
Differentiating them...
• AD
– insidious onset, gradual
progression
– memory, language, and
visuospatial defects
– indifference, delusions
– Normal B/W
• Subcortical Vascular
– CVS risk factors, step wise
decline
– Gait changes, EP signs
– Recall, executive skills deficits
– Depression, apathy
– MRI subcortical lacunes or
hyperintensities
 DLB
 visual hallucinations
 fluctuating course
 parkinsonism
 Frontotemporal
Degeneration
 Personality changes early,
disinhibition
 Executive skills deficits, frontal
signs, preserved visuospatial early
on
 Characteristic functional
neuroimages
Lau, T. Canadian Journal of Diagnosis Nov/Dec 2009
Lau, T. Canadian Journal of Diagnosis Dec 2009