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David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

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MAP-N 13 th March 2012 Old Age Psychiatry Study Morning T he Older Patient with Psychotic Symptoms. David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta Associate Professor, Faculties of Medicine and Health Sc, UoM - PowerPoint PPT Presentation
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David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta Associate Professor, Faculties of Medicine and Health Sc, UoM Associate Professor of Psychiatry, University of Toronto
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Page 1: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

David Mamo

Consultant Psychiatrist, MCH, Malta

Clinical Lead, Geriatric Psychiatry, MCH, Malta

Associate Professor, Faculties of Medicine and Health Sc, UoM

Associate Professor of Psychiatry, University of Toronto

Page 2: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Learning Objectives

• Be familiar with the common causes of psychosis in the elderly

• Understand the importance of Secondary vs. Primary Psychotic Disorders in the Elderly

• Build confidence in the systematic triage including physical and mental state examination, and initial management of a an older person presenting with psychotic symptoms

• Appreciate that aging is best considered as a dynamic course than as a cross-sectional state, making psychosis in the elderly “a moving target”.

• Introduce the new and evolving geriatric mental health services being developed in Malta

Page 3: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta
Page 4: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta
Page 5: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

What is Psychosis?

Generally defined as “Hallucinations and Delusions”

..but, often accompanied by

(a) Disorganized Thinking, and(b) Disorganized Behavior

Page 6: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Hallucinations and Delusions≠

Schizophrenia

Page 7: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Primary & Secondary Psychosis

Primary Psychotic Disorders

(a) Schizophrenia and Related Disorders(b) Affective Psychosis

Secondary Psychotic Disorders

(a) Dementia: Alzheimer’s, Vascular, LBD, other dementias(b) Delirium: (I WATCH DEATH in PAIN)(c) Substance-Induced (including medication!)(d) General Medical Conditions (MINES)

Page 8: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Etiologies of Pychosis in Older Adults(in order of frequency)

1. Alzheimer’s & other dementias2. Depression3. Medical / Toxin / Substance-Induced4. Delirium5. Bipolar Disorder6. Delusional Disorder7. Schizophrenia8. Schizoaffective Disorder

Differential Diagnosis of the Older Patient with Psychotic Symptoms. Manepalli et al; Primary Psychiatry, 2007.

Page 9: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Etiologies of Pychosis in Older Adults(in order of frequency)

1. Alzheimer’s & other dementias2. Depression3. Medical / Toxin / Substance-Induced4. Delirium5. Bipolar Disorder6. Delusional Disorder7. Schizophrenia8. Schizoaffective Disorder

Differential Diagnosis of the Older Patient with Psychotic Symptoms. Manepalli et al; Primary Psychiatry, 2007.

Page 10: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Psychosis: A Common Clinical Presentation in the Elderly

Community: 1-4%

Acute Psychogeriatric Hospital/Ward: 10%

Nursing Homes: up to 60%

Elderly without dementia > 85 years: 10%

VERY HIGH PREVALANCE OF ANTIPSYCHOTIC USE IN NURSING HOMES Chen et al, Arch Internal Med, 2010

Page 11: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Psychosis: Risk Factors in the Elderly

1. Sensory Deficits2. Social Isolation3. Cognitive Decline4. Medical Comorbidities5. Polypharmacy

Page 12: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 1: Psychosis – The Great Chameleon

Page 13: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 1: As your community’s psychogeriatric resource nurse, you are asked to call on Mrs. Borg, a 92 year old widowed lady with no past medical or psychiatric history living on her own with some support from a home help worker 1 hour per day. You are told that she has been acting strangely over the past few months, talking of little people visiting her at night and observing unusual images on her walls. You are told that her memory has declined over the past few months and needs support in most iADL’s but is independent of ADL’s. At this time your primary/working diagnosis is:

A. Late-Onset Schizophrenia

B.Psychosis Secondary to a Medical Illness

C.Dementia

D.Depression with Psychotic Symptoms

E.Boredom of Old Age

Page 14: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 1: As your community’s psychogeriatric resource nurse, you are asked to call on Mrs. Borg, a 92 year old widowed lady with no past medical or psychiatric history living on her own with some support from a home help worker 1 hour per day. You are told that she has been acting strangely over the past few months, talking of little people visiting her at night and observing unusual images on her walls. You are told that her memory has declined over the past few months and needs support in most iADL’s but is independent of ADL’s. At this time your primary/working diagnosis is:

A. Late-Onset Schizophrenia

B.Psychosis Secondary to a Medical Illness

C.Dementia

D.Depression with Psychotic Symptoms

E.Boredom of Old Age

Page 15: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 1 continued: The most critical aspect of your assessment of Mrs. Borg involves:

A. Obtaining detailed history from reliable informant

B.Establish Personal and Developmental History

C.Checking her Vital Signs and Doing a MMSE

D.Rule out Schizophrenia

E.A & C

F.All the Above

Page 16: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 1 continued: The most critical aspect of your assessment of Mrs. Borg involves:

A. Obtaining detailed history from reliable informant

B.Establish Personal and Developmental History

C.Checking her Vital Signs and Doing a MMSE

D.Rule out Schizophrenia

E.A & C

F.All the Above

Page 17: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 1 continued: Having established your provisional diagnosis, you consider your next step. As a thorough clinician accustomed to deal with severe mental illness and trained to maintain calm and use emergency resources carefully given current constraints on emergency medical resources and hospital beds, you decide to:

A. Arrange an urgent Crisis Team Appointment the Next Day

B.Arrange Appointment at POP next week and involve Outreach Services in the Meanwhile

C.Inform your supervisor and document your discussion

D.Counsel the Caregiver about Dementia

B.None of the Above

Page 18: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 1 continued: Having established your provisional diagnosis, you consider your next step. As a thorough clinician accustomed to deal with severe mental illness and trained to maintain calm and use emergency resources carefully given current constraints on emergency medical resources and hospital beds, you decide to:

A. Arrange an urgent Crisis Team Appointment the Next Day

B.Arrange Appointment at POP next week and involve Outreach Services in the Meanwhile

C.Inform your supervisor and document your discussion

D.Counsel the Caregiver about Dementia

B.None of the Above

Page 19: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Medical Causes of Psychosis with or without delirium (MINES)

Page 20: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 2: The Hidden Pain

Page 21: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 2: As the local psychogeriatric resource nurse, you are called on a 70 year old man recently admitted to a nursing home who has recently been getting increasingly intermittently agitated, pacing the halls all day, and getting very confused, paranoid, and physically abusive at night. You learn that he has been recently discharged from your local rehab facility where he was treated for a urinary tract infection. You are told that he suffers from hypertension which has been managed with medication, and a history of dementia, but you note that his recent discharge summary does not indicate a diagnosis of dementia, and that he was previously living fairly independently at his own home. You find the patient seated in a chair. He is very pleasant, but fidgety. He starts a conversation about his past involvement with a local soccer team, and you are impressed by how articulate he is. Yet, he is also very distractible, often loosing track of the conversation. You conduct an MMSE scoring 21/30, yet his clock drawing is surprisingly good. His vitals reveal a pulse rate of 110 bpm, and BP 145/90. He appears uncomfortable but is unable to tell you why. Your plan involves:

A. Getting a verbal order for risperidone 1 mg stat

B.Counsel the staff about the management of BPSD

C.Arrange for a physical examination to be done

Page 22: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 2: As the local psychogeriatric resource nurse, you are called on a 70 year old man recently admitted to a nursing home who has recently been getting increasingly intermittently agitated, pacing the halls all day, and getting very confused and verbally abusive at night. You learn that he has been recently discharged from your local rehab facility where he was treated for a urinary tract infection. You are told that he suffers from hypertension which has been managed with medication, and a history of dementia, but you note that his recent discharge summary does not indicate a diagnosis of dementia, and that he was previously living fairly independently at his own home. You find the patient seated in a chair. He is very pleasant, but fidgety. He starts a conversation about his past involvement with a local soccer team, and you are impressed by how articulate he is. Yet, he is also very distractible, often loosing track of the conversation. You conduct an MMSE scoring 21/30, yet his clock drawing is surprisingly good. His vitals reveal a pulse rate of 110 bpm, and BP 145/90. He appears uncomfortable but is unable to tell you why. Your plan involves:

A. Getting a verbal order for risperidone 1 mg stat

B.Counsel the staff about the management of BPSD

C.Arrange for a physical examination to be done

Page 23: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Delirium

• A sudden and significant decline in mental functioning not better accounted for by a preexisting or evolving dementia

• Disturbance of consciousness with reduced ability to focus, sustain, and shift attention

Page 24: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

4 major causes

• Underlying medical condition• Substance intoxication• Substance withdrawal• Combination of any or all of these

Page 25: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Causes of Delirium (I WATCH DEATH)

Infections Deficiencies

Withdrawals Endocrinopathies

Acute Metabolic Acute Vascular

Trauma Toxins or Drugs

CNS Pathology Heavy Metals

Hypoxia

Page 26: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Causes of Delirium (I WATCH DEATH PAIN)

Infections Deficiencies

Withdrawals Endocrinopathies

Acute Metabolic Acute Vascular

Trauma Toxins or Drugs

CNS Pathology Heavy Metals

Hypoxia PAIN

Page 27: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Prevalence

• Hospitalized medically ill: 10-30%

• Hospitalized elderly: 10-40%

• Postoperative patients: up to 50%

• Near-death terminal patients : up to 80%

Page 28: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Clinical features

Prodrome

Fluctuating course

Attentional deficits

Arousal /psychomotor disturbance

Impaired cognition

Sleep-wake disturbance

Altered perceptions

Affective disturbances

Page 29: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Beware of the “quiet” delirium…

• Hyperactive (agitated, hyperalert)

• Hypoactive (lethargic, hypoalert)

• Mixed

Page 30: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Outcome

• Elderly patients 22-76% chance of dying during that hospitalization

• Several studies suggest that up to 25% of all patients with delirium die within 6 months

Page 31: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Management

• Environmental interventions

- “Timelessness”

- Sensory impairment (vision, hearing)

- Orientation cues

- Family members

- Frequent reorientation

- Nightlights

Page 32: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Management

• Pharmacologic management of agitation

- Low doses of high potency neuroleptics (i.e. haloperidol) – po, im or iv

- Atypical antipsychotics (risperidone)

Benzodiazepines generally restricted to withdrawal situations as they may cause paradoxical reactions

Page 33: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 3: Je Me Souviens

Page 34: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 3: An 81 year old man has been seeing his dead wife and dead sister for the past three months. He has a 4 year history of declining memory and difficulties with iADL’s. His daughter reminds you that he has a history of recurrent bouts of depression, and you note that he has been crying and having difficulty sleeping, and calling her incessantly and getting very anxious when she is about to leave. You are a seasoned nurse and recognize the importance of a physical and cognitive evaluation in such situations, and note that his BP is 165/90, PR normal, afebrile, but appears mildly rigid in his upper and lower extremities, and he shuffles somewhat when he walks. MMSE is 17/30, and his attention span during your assessment is excellent. His daughter shows you results from recent tests done in hospital stating that his CT brain was unremarkable except for mild atrophy The most likely explanation of this presentation is:

A. Parkinson’s Disease with Dementia

B.Severe Depression with Psychotic Symptoms

C.Alzheimer’s Disease

D.Late-Onset Schizophrenia

E.Lewy-Body Dementia

Page 35: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 3: An 81 year old man has been seeing his dead wife and dead sister for the past three months. He has a 4 year history of declining memory and difficulties with iADL’s. His daughter reminds you that he has a history of recurrent bouts of depression, and you note that he has been crying and having difficulty sleeping, and calling her incessantly and getting very anxious when she is about to leave. You are a seasoned nurse and recognize the importance of a physical and cognitive evaluation in such situations, and note that his BP is 165/90, PR normal, afebrile, but appears mildly rigid in his upper and lower extremities, and he shuffles somewhat when he walks. MMSE is 17/30, and his attention span during your assessment is excellent. His daughter shows you results from recent tests done in hospital stating that his CT brain was unremarkable except for mild atrophy The most likely explanation of this presentation is:

A. Parkinson’s Disease with Dementia

B.Severe Depression with Psychotic Symptoms

C.Alzheimer’s Disease

D.Late-Onset Schizophrenia

E.Lewy-Body Dementia

Page 36: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Psychosis in Alzheimer’s Dementia

Very Common (20% in Early; 50% by Years 3 & 4)

Most Common in Early to Moderate Stages

Delusions and/or HallucinationsHallucinations (Visual > auditory > others)

Delusions (Commonly “understandable” false beliefs – e.g. delusions of theft, house is not home, persecution); these decrease in later stages.

? Psychosis associated with more rapid decline

Page 37: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

http://www.alzheimers.org.uk

Page 38: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta
Page 39: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

‘Management of Behavioural Changes in Individuals with Dementia’ by Dr Carmelo Aquilina Wednesday 14th March 2012Time: 6:30pm-7:30pmVenue: 5, Lion Street, Floriana

Page 40: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 4: Slow, Unsteady, and Scared

Page 41: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 4: A 75 year old woman reports hallucinations of children and small animals when she is alone in her room. Her family describe her getting very agitated when this happens. On your functional inquiry they respond that she has been having more difficulty walking, and at times has some tremor in her hands. Aware that dementia is a a very common cause of hallucinations in the elderly, you inquire about her memory. Her daughter acknowledges that she noted a small but noticeable decline in recent memory over the past year, with a tendency to repeat questions, difficulties with finding the right words, getting lost when shopping, and preparing meals. The daughter also noticed that her state tends to fluctuate somewhat, having some “good days” in which she seems quite well in terms of her memory and even her tremor. Your examination is unremarkable except for some rigidity in her arms and mild resting tremor. The most likely explanation of this presentation is:

A. Parkinson’s Disease with Dementia

B.Severe Depression with Psychotic Symptoms

C.Alzheimer’s Disease

D.Late-Onset Schizophrenia

E.Lewy-Body Dementia

Page 42: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 4: A 75 year old woman reports hallucinations of children and small animals when she is alone in her room. Her family describe her getting very agitated when this happens. On your functional inquiry they respond that she has been having more difficulty walking, and at times has some tremor in her hands. Aware that dementia is a a very common cause of hallucinations in the elderly, you inquire about her memory. Her daughter acknowledges that she noted a small but noticeable decline in recent memory over the past year, with a tendency to repeat questions, difficulties with finding the right words, getting lost when shopping, and preparing meals. The daughter also noticed that her state tends to fluctuate somewhat, having some “good days” in which she seems quite well in terms of her memory and even her tremor. Your examination is unremarkable except for some rigidity in her arms and mild resting tremor. The most likely explanation of this presentation is:

A. Parkinson’s Disease with Dementia

B.Severe Depression with Psychotic Symptoms

C.Alzheimer’s Disease

D.Late-Onset Schizophrenia

E.Lewy-Body Dementia

Page 43: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Psychosis in Lewy Body Dementia

Very Common (visual hallucinations up to 80%; often an early sign)

Auditory hallucinations (20%) and paranoid delusions (65%) also common

Therefore, overall at least as common (if not more) compared with psychosis in AD

Important to recognize due to (a) high sensitivity to even low doses of antipsychotics (especially high potency), (b) greater risk of falls, (c) sleep disorders, (d) fluctuating and more rapid course.

Page 44: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Psychosis in Parkinson’s Disease

Also very Common (20 – 60%, more so in later stages with dementia)

Hallucinations more common than delusions (often vivid visual hallucinations)

Hallucinations most commonly secondary to dopaminergic medication (rather than due to PD per se).

Onset of Sx vis-à-vis medication dosing times / new treatment can give clues to etiology.

Page 45: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 5: The Intruder

Page 46: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 5: You conduct a home visit for a a very pleasant and seemingly cognitively intact 69 year old woman who has become a local nuisance with the police and neighbors over the past 7 months, making frequent reports about “the woman next door entering” her home. She cites a number of pieces of “evidence” for her case, including lights and noises she hears at night, and a “fallen toothpick” which she placed in her key hole to check whether anyone has tried to force her door open. She has no psychiatric history, has been generally well physically except for a declining hearing and vision. You call her son from her home and he informs you that his mother was never unwell, though in hindsight she always tended to be somewhat “sensitive” and suspicious of others’ motives. He confirms that she has never abused alcohol or drugs. She has evidently been taking very good care of herself and her house, and while she has tended to avoid going out, she has no difficulty walking. On your examination you notice that except for very mild forgetfulness (MMSE 27/30) she is physically intact and her mental status is otherwise unremarkable. The most likely explanation of this presentation is:

A. Bipolar Disorder

B. Alzheimer’s Disease

C. Delusional Disorder

D. Paranoid Personality Disorder

Page 47: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 5: You conduct a home visit for a a very pleasant and seemingly cognitively intact 69 year old woman who has become a local nuisance with the police and neighbors over the past 7 months, making frequent reports about “the woman next door entering” her home. She cites a number of pieces of “evidence” for her case, including lights and noises she hears at night, and a “fallen toothpick” which she placed in her key hole to check whether anyone has tried to force her door open. She has no psychiatric history, has been generally well physically except for a declining hearing and vision. You call her son from her home and he informs you that his mother was never unwell, though in hindsight she always tended to be somewhat “sensitive” and suspicious of others’ motives. He confirms that she has never abused alcohol or drugs. She has evidently been taking very good care of herself and her house, and while she has tended to avoid going out, she has no difficulty walking. On your examination you notice that except for very mild forgetfulness (MMSE 27/30) she is physically intact and her mental status is otherwise unremarkable. The most likely explanation of this presentation is:

A. Bipolar Disorder

B. Alzheimer’s Disease

C. Delusional Disorder

D. Paranoid Personality Disorder

Page 48: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Delusional Disorder

• Relatively uncommon (0.03%) but more common in older adults

• Different from Schizophrenia in lack of hallucinations, absence of deterioration of function, and generally absence of disorganization of behavior and certainly of thought.

• Different from Dementia in absence of Cognitive Decline

• Different from Mood Disorder: No preceding mood component

• Often find premorbid history of paranoid and schizotypal personalities

• Difficult to manage/treat as they deny illness and refuse medication (but AP’s are effective, if taken..); CBT approaches can be helpful.

Page 49: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 6: Looming Death

Page 50: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 6: A previously healthy 70-year old woman is admitted to KGH for failure to thrive. She has lost 20 Kg in the past 7 months, has difficulty swallowing solids and liquids, and has lost her appetite entirely. Previously the life of her family, she no longer enjoys visits from her children, and would rather be left alone. Physical examinations, laboratory tests, imaging and endoscopy have yielded no positive results. You are part of a psychogeriatric consultation service and asked to see patient to rule out a “psychosomatic illness”. You find a cachectic woman seated in her chair. She is difficult to engage, makes little eye contact, and shows marked latency of speech. When you ask her why she is not eating she points to her throat and says that the “feeding tube is clogged”. Her affect is dysphoric but blunted in reactivity and shows very limited range. When asked what she believes is the root of her problem she indicates that she has a terminal cancer. You note that she has resigned herself to dying, and sees no scope for living any further. Mention of her large family elicits no emotion from her. Cognitively she is difficult to assess fully as her ability to focus and persist on tasks is limited. However she is clearly alert, well-oriented to exact place, and oriented to time o the year. Recent memory appears mildly impaired, though formal testing not done. The most likely explanation of this presentation is:

A. Major Depressive Episode with Psychotic Symptoms

B. Schizoaffective Disorder, Depressed State

C. Occult Gastric Carcinoma

Page 51: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Case 6: A previously healthy 70-year old woman is admitted to KGH for failure to thrive. She has lost 20 Kg in the past 7 months, has difficulty swallowing solids and liquids, and has lost her appetite entirely. Previously the life of her family, she no longer enjoys visits from her children, and would rather be left alone. Physical examinations, laboratory tests, imaging and endoscopy have yielded no positive results. You are part of a psychogeriatric consultation service and asked to see patient to rule out a “psychosomatic illness”. You find a cachectic woman seated in her chair. She is difficult to engage, makes little eye contact, and shows marked latency of speech. When you ask her why she is not eating she points to her throat and says that the “feeding tube is clogged”. Her affect is dysphoric but blunted in reactivity and shows very limited range. When asked what she believes is the root of her problem she indicates that she has a terminal cancer. You note that she has resigned herself to dying, and sees no scope for living any further. Mention of her large family elicits no emotion from her. Cognitively she is difficult to assess fully as her ability to focus and persist on tasks is limited. However she is clearly alert, well-oriented to exact place, and oriented to time o the year. Recent memory appears mildly impaired, though formal testing not done. The most likely explanation of this presentation is:

A. Major Depressive Episode with Psychotic Symptoms

B. Schizoaffective Disorder, Depressed State

C. Occult Gastric Carcinoma

Page 52: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Affective Psychosis

Psychotic Depression present in up to 50% of hospitalized elderly patients with depression, and 25% of community dwelling elderly with depression

Delusions (mood-congruent) much more common than hallucinations.

Catatonia in severe depression

Bipolar mania also generally presents with mood-congruent delusions (e.g. erotomanic)

Page 53: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

The Older Patients with Schizophrenia

Page 54: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Schizophrenia and Aging

• Rate of Cognitive Decline not different from general population (but they often start from a lower baseline and “appear” demented early!!)

• Aud Halluc and Delusions may decrease

• Negative Symptoms may increase

• Older patients with schizophrenia have a worse functional outcome than patients with HIV-AIDS

Page 55: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Prescribed Antipsychotic Dose and AgePrescribed Antipsychotic Dose and Age1,418 patients in Tokyo1,418 patients in Tokyo

Uchida H et al. Am J Geriatr Psychiatry (2008)

Inpatients

Outpatients

Page 56: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Dean F Wong et al Uchida et al

Age and D2

Page 57: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Antipsychotic Dosing RecommendationsAntipsychotic Dosing Recommendationsin Older Patients with Schizophreniain Older Patients with Schizophrenia

Up to 40 % reduction in dose > 45yrs (Harris 1997)

Up to 60 % reduction in dose (mixed age) (Inderbitzin 1994; Smith 1994)

Expert Consensus (Alexopoulos GS et al 2004)

Risperidone 1.25 – 3.5 mg Olanzapine 7.5 – 15 mgQuetiapine 100 – 300 mg

Page 58: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

Classical pharmacokinetics does not address variability

Page 59: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

MaintainMaintainWellnessWellness

Population Pharmacokinetics

∆ ∆ DoseDose

Striatal D2 Occupancy

<65% > 65%

Per

cent

Res

pon

der

s (C

GI)

0

20

40

60

80

100

Non RespondersResponders

Therapeutic Window

LAST PIECE OF THE PUZZLE

Page 60: David Mamo Consultant Psychiatrist, MCH, Malta Clinical Lead, Geriatric Psychiatry, MCH, Malta

“Grow old with me! The best is yet to be,

the last of life, for which the first was made..”

Robert Browning


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