Download DELIRIUM, DEMENTIA, DEPRESSION AND COMPETENCY

DELIRIUM, DEMENTIA,
DEPRESSION AND
COMPETENCY
COMMON ISSUES IN GERIATRIC
AND CONSULTATION
PSYCHIATRY
Paul B. Rosenberg, M.D.
Geriatric and Consultation-Liaison Psychiatry
Department of Veterans Affairs Medical Center
Washington, DC
DELİRYUM
• Bilinç ve dikkatte bozulma
• Bilişsel işlevlerde (bellek, dil, yönelim)
veya algıda bozulma
• Hızla gelişir ve dalgalı seyreder
• Tıbbi bir durum nedeniyle olur
Deliryumun Klinik Özellikleri
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Bilişsel bozulma
Tıbbi hastalıktır
Akut/ani başlar
Yönelim bozulur
Varsanılar
Sanrılar
Görsel-uzamsal bozulma
• Apraksiler
• Sözcük bulmada güçlük
• Anlama ve
değerlendirmede güçlük
• Uykulu (hepatik, üremik,
ilaç nedenli)
• Ajite (alkol yoksunluğu)
Deliryumun Eşanlamları
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Akut konfüzyonel durum
Toksik-metabolik ansefalopati
Organik beyin sendromu
ICU psychosis
EPIDEMIOLOGY AND RISK
FACTORS
• Dahiliye servislerinde
yatan hastaların
%25’inde
• Elderly
• Dementia
• Renal failure
• Liver failure
• Immobilization
• Foley catheter
• Infected
• Anticholinergic
medications
• Polypharmacy
• Narcotics
• Benzodiazepines
METABOLIC CAUSES
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Hypernatremia
Hypercalcemia
Hypo-, hyper-glycemia
Hyperosmolar state
Uremia (uremic encephalopathy)
Liver failure (hepatic encephalopathy)
INFECTIOUS CAUSES
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Urinary tract infection
Pneumonia
Sepsis
Delirium may be the first sign of infection,
predating fever, leukocytosis, CXR findings
MEDICATIONS
• Anticholinergics (Cogentin, Artane)
• Psychotropic medications (Thorazine,
Mellaril, TCAs, Paxil, benzodiazepines)
• Lithium toxicity
• Steroids
• Narcotics
ANTICHOLINERGIC EFFECT
AND DELIRIUM
• Cholinergic transmission declines with age
• Cerebral cortex widely innervated by cholinergic
neurons in basal forebrain
• Risk of delirium correlates with serum
anticholinergic levels
• Anticholinergic levels associated with diminished
ability to perform ADLs
• Anticholinergic levels normalize as delirium
resolves.
ANTICHOLINERGIC
EFFECTS OF MEDICATIONS
Usual
• Cogentin, Artane
• TCAs
• Mellaril, Thorazine
• Paxil
• Narcotics
• Antihistamines
• OTC cold medications
Surprising
• Furosemide
• Digoxin
• Theophylline
• Ranitidine
• Cimetidine
• Isordil
• Nifedipine
CNS CAUSES OF DELIRIUM
• Alcohol withdrawal (delirium tremens) -- very
agitated delirium
• Barbiturate/benzo withdrawal (rare)
• Post-ictal
• Increased intracranial pressure
• Head trauma
• Encephalitis/meningitis
• Vasculitis
DIAGNOSTIC STUDIES IN
DELIRIUM
• Metabolic studies (CBC, Chem-18, TFT’s)
Urinalysis
• CXR
• EEG = diffuse slowing; normal EEG makes
delirium less likely
• CT/MRI to r/o bleed, tumor (coagulopathies, head
trauma)
• LP to r/o infection (febrile, leukocytosis)
• ‘Fish where the fish are’
MANAGEMENT OF
DELIRIUM
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Find the cause(s)
Usually multifactorial
Look for medication toxicity
Re-orient patient
Quiet, unstimulating environment
Antipsychotic medications for agitation
Benzodiazepines often makes delirium worse
1:1 observation/restraints only when needed
DEMENTIA
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Pathognomic deficit is in short-term recall
Deficits in at least three cognitive areas
Insidious onset
Stable level of consciousness, not fluctuating
Major cause of institutionalization in the elderly
Current treatment is largely for psychiatric
complications, not underlying dementia
AGING AND DEMENTIA
50
45
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25
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15
10
5
0
60-69
70-79
Incidence (per 1000)
80+
Prevalence (%)
90+
COMMON DEMENTIAS
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Alzheimer’s disease
Vascular dementia
AIDS dementia
Alcoholic dementia (Korsakoff’s)
Frontotemporal dementia
PSYCHIATRIC ASPECTS
OF DEMENTIA
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Agitation
Wandering
Pacing
Insomnia
Hoarding
Catastrophic reactions
Capgras’ syndrome
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Psychosis
Depression
Anxiety
Agnosia
Aphasia
Apraxia
Deficits in abstract
thinking
EVALUATION OF DEMENTIA
• Interviewer caregiver
and patient together
and separately
• Clinical course
• ADLs, IADLs
• Premorbid level of
function
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B12
TSH
RPR
Brain imaging (CT,
MRI)
• EEG/LP only when
indicated
PSYCHOSIS IN DEMENTIA
• Prevalence of hallucinations is
about 30%
• Hallucinations may be
selectively associated with
more rapid decline in
Alzheimer’s
• 25% of patients have
misperceptions
• May be due to recall problems
or agnosia
• Delusions are often fixed
confabulations
• May be associated with more
rapid neuronal loss
• Particularly common in
Dementia with Lewy Bodies -fluctuating cognition with
recurrent VH that are detailed,
contain formed elements.
• Dementia with Lewy Bodies -very sensitive to parkinsonian
effects of medications
• Psychosis is a major source of
caregiver stress
ALZHEIMER’S -NEUROSCIENCE
• Amyloid plaques
(extraneuronal)
• Neurofibrillary tangles and tau
protein (intraneuronal)
• Loss of cholinergic innervation
(nucleus basalis of Meynert)
• Cerebral atrophy (nonspeciific)
• Decreased perfusion and
metabolism in temporoparietal
cortex and hippocampus
• Deficits may predate cognitive
impairment
• Abnormal extraneuronal
processing of b-amyloid
precursor protein (b-APP) to
42- a.a. instead of 40-a.a.
fragment
• Familial AD -- single-point
mutations in b-APP
• Transgenic mice
• Presenilins (chromosome 14
and 1) may be b-APP secretases
• Apolipoprotein E4 -- risk factor
for sporadic AD.
• Subtle deficits in younger life decreased “idea density”
ALZHEIMER’S -TREATMENT
Cholinergic
Neuroprotective
• Aricept (donepizil) start 5 mg,
increase to 10 mg
• Modest but consistent effect at
all stages of AD
• No effect on MMSE, but ADLs,
memory, attention, and
neuropsychiatric symptoms
often improve
• Suggest 3-month trial
• Exelon (rivastigmine)
• Reminyl (galantamine)
• Antioxidants (Vitamin E, LDeprenyl)
• Anti-inflammatories (steroids,
NSAIDs)
• Inhibitors of secretases
• Vaccines against b-amyloid
• Need to find pre-morbid
markers of AD
NEW IDEAS IN
ALZHEIMER’S TREATMENT
Idea
Treatment
Inflammation is part of NSAIDs, steroids
AD pathology
Elevated homocysteine Folate
associated with AD
Comments
Steroids not safe (ulcers),
Vioxx not effective, ?
ibuprofen may be best
May be associated with
vascular dementia
Abnormal lipoprotein
metabolism in AD
Statins
Statins decrease b-amyloid
expression in vitro
Vaccine against bamyloid
Intrathecal or intranasal
vaccine
Adverse event (meningencephalitis)
BEHAVIORAL INTERVENTIONS IN
DEMENTIA
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Calm consistent environment
Cuing and reminding
Emphasize cognitive strengths
Music
Light therapy
Safe environment for wandering
Daytime exercise, minimize naps
TREATING AGITATION WITH
MEDICATIONS
Haldol
2-3 mg
2-3 mg better than .5-.75 mg for
paranoia/suspiciousness, but (+) EPS
Risperdal 1-2 mg Largest study (n=625) , particularly
good for paranoia/suspiciousness, (+)
EPS at 2 mg
Olanzapine 5 mg
5 mg better than higher doses, good for
paranoia/suspiciousness, minimal side
effects
Seroquel
25-50mg No published studies but my clinical
experience has been very (+)
Depakote Level = Some response for generalized
50-100 impulsivity, but nausea/sedation is a
problem in elderly
OTHER MEDICATIONS IN
DEMENTIA
• Antidepressants -- watch for agitated depression, need
caregiver’s assessment
• Use benzodiazepines sparingly -- watch for sedation,
paradoxical agitation/stimulation
• Benzos best saved for last except for restless
legs/myoclonus
• Trazodone is good for sleep in demented as well as nondemented patients -- 25 mg q hs
• Buspirone -- a drug looking for a use
VASCULAR DEMENTIA
• Risk factors of HTN, diabetes,
hyperlipidemia, smoking (same
as CVA)
• Stepwise deterioration
• Preserved personality
• Multi- or large single-infarct
• Lacunar state -- basal ganglia,
thalamus, internal capsule
• Subcortical dementia -psychomotor slowing
• Binswanger’s -- ischemic injury
of frontal hemisphere white
matter -- preserved visuospatial
functions
• No specific treatment
• Quit smoking
• Control BP
• Platelet inhibition
ALCOHOLIC DEMENTIA
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Prevalence of 6-25% in elderly alcoholics
Often termed Korsakoff’s dementia
Overlap with AD
Associated with peripheral neuropathy
Speech functions often preserved
Confabulatory
Relatively subtle to diagnose
Case reports of improvement with cholinesterase
inhibitors
FRONTOTEMPORAL
DEMENTIA
• Degeneration of frontal and
temporal lobes
• Apathetic and disinhibited
personality changes predate
cognitive deficits
• Executive functions and naming
selectively impaired
• Visuospatial skills preserved
• These patients are often initially
misdiagnosed as depressed,
manic, or psychopathic
• Subtypes include Pick’s disease,
dementia of ALS.
• Decreased serotonin
• Decreased metabolism in
frontal and temporal lobes
• Familial type with mutations in
tau gene on chromosome 17
WHAT DO CAREGIVERS DO
 Cognitive supervision
 IADLs
 Bathing
 Dressing
 Feeding
 Transfer
 Monitoring medical condition
WHAT KEEPS CAREGIVERS GOING
 Love
 Money
 Habit
 Cultural beliefs
 Spirituality
STRESSES ON CAREGIVERS
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24-hour supervision
Lack of appreciation
Implied or overt criticism
Feeling conflicted regarding changes in roles and power
relationships
Feeling uncared-for
Worry about when they need caregiving later on
Perseveration and aggression
Best laymen’s resource The 36-hour day, by Peter Rabins
ASSESSMENT OF AGITATION
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“Incidents”, “episodes”, and other euphemisms
“Tell me the worst part”
Nature of agitation
Wandering
Disordered day-night cycle
Verbal aggression
Physical aggression
Perseveration, stimulus-seeking
Inappropriate disrobing and sexual advances
COGNITIVE SUPERVISION
• For many demented patients,
the greatest need is to have a
non-demented person present
• Remembering to take
medications
• Remembering to perform timedependent IADLs (cooking,
shopping, bills, home
maintenance)
• Caregiver supplies an intact
sense of time passing and shortterm recall
 Spouses often approach
subtly and
diplomatically, avoiding
confrontation regarding
cognitive deficits
 Biggest stresses is
perseveration and
verbal/physical
aggression
 Adult Day Health Care
supplies respite for
cognitive supervision
HOW CAN WE HELP CAREGIVERS
 Treat sundowning and agitation – most important pragmatic
intervention
 Treat depression when you can – but apathy/amotivation is
more cognitive than mood and may be hard to treat
 Education re dementia – insidious onset, progressive nature,
limited efficacy of treatments.
 Tell them what they already know (“clarification”)
 Support groups
 Anticipatory grief – i.e., the demented person is slowly leaving
us
 Empathy with anger, fear, anxiety, “wishing him dead”
RESPITE
 Home health aides
 Other family members
 Adult Day Health Care (“daycare”)
 Respite Care
 Nursing home
CAREGIVER BURNOUT
 Burn-out often determines the timing of nursing
home placement, despite our supposedly explicit
(“DelMarva”) criteria
 Physical limitations – poor health of caregiver
 Depression
 Dementia
 Financial limitations
 May need permission to “give up”
THE RELUCTANT CAREGIVER
 Loss of freedom
 Financial constraints
 Change of role
 No respite
 Cultural beliefs
 Habit
 Feeling forced into caregiving (and most people are)
COUNTERTRANSFERENCE
 The feelings caregivers arouse in us
 Sympathy
 Depression
 Hopelessness
 Admiration
 Frustration
 Anger
 Suspicion of abuse
DEPRESSION IN THE
MEDICALLY ILL
• Fewer than 1/2 of depressed patients are
identified and treated in primary care clinics
• Prevalence of 10-15% in medical inpatient
and outpatient populations
• Must be distinguished from dementia,
delirium, effects of substance abuse
CLINICAL FEATURES OF
DEPRESSION
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Depressed mood
Diminished interest/pleasure (anhedonia)
Significant weight loss (or gain)
Insomnia (or hypersomnia)
Psychomotor retardation or agitation
Fatigue, loss of energy
Feelings of worthlessness, guilt
Diminished concentration, indecisveness
Suicidal ideation
UNDERDIAGNOSIS OF
DEPRESSION
• Emphasis on somatic rather than cognitive/mood
complaints
• Belief that depression is a natural reaction to
circumstance (countertransference)
• Reluctance to stigmatize patient with psychiatric
diagnosis
• Nonspecific symptoms, overlap with medical
illness
• Time limitations in primary care
MORBIDITY AND
MORTALITY
• Depression signficantly increases morbidity and
mortality
• Increased risk of MI, angioplasty, and death
following cardiac cath
• Independent risk factor for mortality post-MI
• Increased mortality post-CVA
• Similar results in dialysis, cancer, and general
acute illness
• Possible neuroendocrine mind-body connection
DEPRESSION AS A MEDICAL
SYMPTOM/SIGN
• Up to 20% of major depressive episodes turn out to be
initial manifestation of medical illness
• Cushing’s
• Addison’s
• Hypo-, hyper-thyroidism
• Huntington’s
• Parkinson’s
• Similar overlap as in delirium
MEDICAL CONSIDERATIONS
• Anorexia -- GI illness,
chronic disease, cancer,
side effects of
chemotherapy.
• Weight loss with normal
appetite -hyperthyroidism, DM,
malabsorption.
• Insomnia -- sleep apnea
(daytime somnolence),
nocturnal myoclonus.
• Early morning awakening
is more typical of
depression
• Pain
• Delirium
• Anxiety
• Mania
PSYCHOSOCIAL FACTORS
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Death and dying
Disfigurement
Disability
Pain
Loss of role
Family conflict
Lifelong issues
CARDIAC DISEASE
• 20% of patients with CAD or post-MI are
depressed
• Risk factors female, prior depression, disabled
• Frasure-Smith followed depressed patients postMI.
• 6-month mortality was 17% for depressed, 3%
non-depressed
CANCER
• About 50% of cancer
patients feel depressed
• Uncontrolled pain
• Delirium
• Brain metastases
• Death and dying
• Disability and
independence
• Disfigurement
• Life cycle issues -dying young,
unfinished business
• Chemotherapy -steroids, procarbazine,
l-asparaginase, ARAC, vinca alkaloids,
interferon
STROKE
• 30-50% depressed,
about half with major
depression
• More common with
left anterior lesions
• Not merely secondary
to neurological
disability
• Antidepressant
treatment is effective
• High-risk period is 1st
2 years post-stroke
• Depression associated
with higher morbidity
and mortality
• Treatment probably
improves
rehabilitation
OTHER DISEASES
ASSOCIATED WITH
DEPRESSION
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Parkinson’s
Huntington’s
Multiple sclerosis
ALS
Epilepsy
AIDS
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Hypothyroidism
Hyperthyroidism
Hyperparathyroidism
Cushing’s
Chronic fatigue
syndrome
MEDICATIONS CAUSING
DEPRESSION
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Reserpine
Methyldopa
Inderal (rare)
High-dose (older) oral
contraceptives
• Corticosteroids
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Benzodiazepines
Alcohol
Opioids
Opiate analgesics
Cocaine withdrawal
PSYCHOSOCIAL
TREATMENTS
• Supportive
psychotherapy
• Listen!
• Clarification
• Fight stigma
• Family issues
• Substance abuse rehab
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Optimize level of care
Home health aides
Meals on wheels
Adult Day Health
Care
• Partial Hospitalization
ANTIDEPRESSANT
MEDICATIONS
• Tricyclics
• Selective serotonin
reuptake inhibitors
(Prozac, Paxil, Zoloft,
Celexa)
• Effexor (venlafaxine)
• Wellbutrin
(buproprion)
• Remeron
(mirtazapine)
• Reboxetine
• Ritalin
• Thyroid supplement
• MAO inhibitors
• ECT
CAPACITY
• Cognitive capacity to understand the
risks/benefits of decisions
• Patients are competent until proven
otherwise
• Psychiatric consultation can help with
medical competency to make current
medical decisions
• Consent passes to next-of-kin
LEGAL ISSUES IN CAPACITY
• Medical incompetence now included in DC, MD,
Virginia statutes; no court order needed.
• Guardianship is legal competency over funds
alone or all medical/legal decisions (court order)
• Fiduciary refers to control of VA disability check
(VA hearing).
• Payee refers to control of Social Security
disability check (Soc. Security hearing).
ELEMENTS OF
COMPETENCY
• Capacity to understand risks/benefits
(dementia)
• Capacity to appreciate consequences
(psychosis)
• Capacity to come to a decision (delirium)
• Capacity to communicate a decision
(aphasia, intubation, ENT surgery)
PSYCHOSTIMULANTS
• FDA-approved for ADD, narcolepsy
• Not approved for mood disorders
• However, widely used for depressed medically ill
patients
• Advantages -- well tolerated, rapid onset (1-2
days)
• Disadvantages -- not well studied, probably don’t
work in severe mood disorders
PSYCHOSTIMULANTS - II
• Ritalin (methylphenidate) is most popular
• Dexedrine (dextroamphetamine) less so
• Modafinil + several long-acting methylphenidate
preparations available
• I prefer short-acting drugs (Ritalin) for safety and close
titration
• Used more in medically ill patients than in routine
psychiatric care
PSYCHOSTIMULANTS -- III
Day
Breakfast
Lunch
1
5 mg
None
2
5 mg
5 mg
3
10 mg
5 mg
4
10 mg
10 mg
Watch for
Tachycardia
Insomnia
Agitation
Dyskinesia
PSYCHOSTIMULANTS -- IV
• Target symptoms
– depressed mood
– lack of motivation for therapies (particularly
PT, speech therapy)
– anorexia (paradoxical)
– attention
SIDE EFFECTS AND
CONTRAINDICATIONS
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Tachycardia
Insomnia
Anorexia
Mania
Contraindications
– unstable cardiac condition
– history of cocaine or stimulant abuse
NEW USES FOR
PSYCHOSTIMULANTS
• Difficult-to-wean ventilator patients
• Fatigue and cognitive slowing in AIDS
• Cognitive impairment and poor rehab effort after liver
transplant
• Post-stroke rehabilitation
• Depression in very fragile elderly patients
• Palliative care -- motivation, energy, alertness, improving
tolerance to opioids
• Augmentation of antidepressants in major depression