Geriatric PsychiatryGeriatric Psychiatry

Marie Cecilia Y. Tan, MD, DPBPMarie Cecilia Y. Tan, MD, DPBP Section of PsychiatrySection of Psychiatry

Optimal Aging CenterOptimal Aging Center

Makati Medical CenterMakati Medical Center

Story of Mr. BStory of Mr. B• 80-yr old married Filipino, retired lawyer;

with visual impairment• CC: sudden and escalating psychomotor

agitation, confusion, and psychosis of 2 weeks

• HPI:– 3 wks: family squabble over sale of property;

wife threatened to leave him– Before this, they said he was “normal”– s/sx: nervous, irritable, paranoid, irrelevant

remarks, restlessly pacing, very repetitive, repetitively dialing house no. while at home, confused

– 3 days: hardly slept

Questions…Questions…How do we manage How do we manage Mr. B holistically?Mr. B holistically?

• 1. How do we explain his sudden behavioral problems?

• 2. What are the possible causes of his behavioral problems?

• 3. What are the aspects that need to be assessed?

• 4. How do we manage his problem behaviors?

Outline of Lecture

I. Geriatric Psychiatry definition and

History

II. Second Half of Life Developmental

Phases

III. Medical Assessment of the

Elderly Psychiatric Patient

IV. Common Psychiatric Illnesses of

Old Age

V. Management

Question.Question. How do we explain his How do we explain his behavioral problems?behavioral problems?

• 3 yrs: forgetful, lost, quiet, less interactive, repetitive, non-specific words (“it” and “thing”)

• (+) for Warning Signs/Red Flags for Probable Dementia

Story of Mr. BStory of Mr. B

• Lawyer, retired 5 yrs ago

• His likes: – gardening, playing golf, meeting up with

friends, bringing grandchildren out

• 3 yrs: – less motivated to do things; less

interactive in conversations; he said, he would rather stay home as he felt easily tired

Initial Impression?Initial Impression?

• Probable Dementia

– Behavioral and Psychological Symptoms of Dementia [BPSD]

• DSM-IV: Dementia, with delusions and behavioral disturbance

Outline of Lecture

I. Geriatric Psychiatry definition and

History

II. Second Half of Life Developmental

Phases

III. Medical Assessment of the

Elderly Psychiatric Patient

IV. Common Psychiatric Illnesses of

Old Age

V. Management

Geriatric Psychiatry defined…

• Initially called Old Age Psychiatry• Branch of medicine concerned with:

– Promoting longevity– Preventing, diagnosing, treating physical and

psychological disorders in older adults• Mental disorders of these patients often differ in

clinical manifestations, pathogenesis, and pathophysiology from d/o of younger adults

• Older people may have:– Coexisting chronic medical illnesses and disabilities,

many medications, cognitive impairments

Geriatric Psychiatry -- History

• The growth of the field began in the US, in 1978, at the annual American Psychiatric Association (APA) meeting in Atlanta, GA

• American Association for Geriatric Psychiatry (AAGP)– American Journal of Geriatric Psychiatry

(AJGP)

Cognition defined…• Memory- remote and recent• Attention- ability to focus, shift, and sustain• Language- speaking, understanding, reading,

writing• Orientation to space and time• Visuospatial function• Praxis- ability to carry out motor activities with

intact motor functions• Executive functions

– ability to respond to information in the environment and execute a logical, goal-directed plan

– Initiate, organize, plan; concepts of insight and judgment

Functional Capacity

Activities of Daily Living [ADLs]

• Elemental activities necessary for an individual to care for oneself within a limited environment

• Eating, bathing, dressing, toileting, grooming, transferring, walking

Instrumental Activities of Daily Living [IADLs]

• Complex tasks that require a higher level of functional independence; abilities necessary to function in the community

• Driving, using public transportation, managing meds, managing finances, doing laundry, cooking, cleaning, using appliances, using the telephone, shopping, attending to hobbies

Outline of Lecture

I. Geriatric Psychiatry definition and

History

II. Second Half of Life Developmental

Phases

III. Medical Assessment of the

Elderly Psychiatric Patient

IV. Common Psychiatric Illnesses of

Old Age

V. Management

Human Development in the Second Half of Life

• Little attention has been paid to the developmental stages in the 2nd half of life—as if by then, everything is programmed, locked in motion, and ready to decline.

• Work of Erik Erikson– Different stages in life framed in terms of dichotomies– 6 of the 8 developmental stages occur in the 1st half of life– 5 occur by adolescence– Only 1 addresses later life

Erikson’s 8 Developmental Stages

Stage

• Infancy [birth to abt. 1 year]

• Early childhood [1-3 yrs.]

• Play age [3 - 5]

• School age [6-11]

• Adolescence• Young adult [21-40]

• Adulthood [40-65]

• Mature age [>65]

Psychosocial Issue or Crisis

• Trust vs. mistrust• Autonomy vs. shame,

doubt• Initiative vs. guilt• Industry vs. inferiority• Identity vs. identity

diffusion• Intimacy vs. isolation• Generativity vs.

stagnation• Integrity vs. disgust,

despair

Newly Described Developmental Potential in the 2nd Half of life– Biological Considerations

• The 1st 3 yrs of life are NO longer seen as the period when hard-wiring or development of the central nervous system is completed.

• Those who study human development are finding more evidence that learning and psychological development are LIFELONG and greatly influenced by the ongoing diversity of human experience.

• Findings from biological research reveal that brain plasticity and creative potential continue to unfold through new phases of adult physical and emotional development.

Newly Described Developmental Potential in the 2nd Half of life– Biological Considerations

• Fascinating findings of ongoing capacity for learning and creative development in the 2nd half of life– Challenge the mind, the brain biologically responds in

positive ways – anatomically and physiologically– regardless of age

– A stimulating environment results in individual neurons sprouting new dendritic branches, affecting neurotransmission

– Nerve cell bodies and nuclei increase in size

• Latest findings from research on neuroplasticity point strongly to the remodeling effects that lifelong experiences and constructive challenges have on the brain, especially in modifying synapses.

Newly Described Developmental Potential in the 2nd Half of life– Psychological Considerations

• Developmental growth: changes at different points in the life cycle—changes in how we view and experience life in a combined psychological, emotional, and intellectual sense– Wisdom: developmental mix of age, knowledge,

emotional and practical life experience, and brain function which allows us to integrate those pieces to achieve insight that we can apply to a variety of life circumstances.

– Creativity: bringing something new into existence that is of value, be it a great work of art, innovative volunteerism, or a fabulous new recipe

Newly Described Developmental Potential in the 2nd Half of life– Psychological Considerations

• Dr. Gene Cohen– Research has demonstrated the significant influence

on mental health – even in the midst of mental disorder– of accessing what he has referred to as Human-Potential Phases in the second half of life.

• Represent the combination of neurobiological, cognitive, and emotional development with the passage of time

• Expressed in the positive push from within us toward new perspectives, new impetuses for change, and new forms of creative expression from mid-to-later life

• Inner orientations toward mental wellness that continue throughout the life cycle, right to the end.

Four 2nd Half of Life Developmental Phases [Human-Potential Phases]– by Dr. Gene Cohen

• Mid-Life Re-Evaluation Phase [Mid-to-late 30s through the Mid-60s]

– Developmental impetus– internal drive for re-evaluation, exploration, and transition

– Typically occurring in 40s and 50s– Midlife crisis?– Quest energy rather than crisis anxiety– Motivated by a new developmental inner push to re-

evaluate their lives and work in order to make them more gratifying

– Combines the capacity for insightful reflection with a powerful desire to create meaning in life.

Four 2nd Half of Life Developmental Phases [Human Potential Phases]

• Liberation Phase [Mid-50s to Mid-70s]– Developmental impetus– internal drive for liberation,

experimentation, and innovation

– Typically occurring in 60s to early 70s

– Creative endeavors are charged with the added energy of a new degree of personal freedom that comes both psychologically from within us, and externally through retirement

– Creative expression often includes translating a feeling of “If not now, when?” into action.

– People tend to feel comfortable about themselves by this time

– A new comfort level for experimentation and innovation

– Retirement often provides a new feeling of finally having time to try something new

– New comfort and confidence is accompanied by a desire to do the right thing and a feeling of “what can they do to me?”

Four 2nd Half of Life Developmental Phases [Human Potential Phases]

• Summing-Up Phase [Late-60s into the 90s]

– Developmental impetus– internal drive for recapitulation, resolution, contribution

– Typically occurring in 70s and older– The desire to find larger meaning in the story of their lives

through a process of looking back, summing-up, and giving back

– Creative expression includes a recapitulation and review of one’s life through personal story-telling, memoirs, and autobiography.

– Wanting to contribute to society---volunteerism, community activism, philanthropy

– Reflection on what remains unresolved or unfinished

Four 2nd Half of Life Developmental Phases [Human Potential Phases]

• Encore Phase [Late-70s to the end of life cycle]

– Developmental impetus– internal drive for reflection, continuation, and celebration of self, family, community, culture, and spirituality

– Typically during late-70s, becoming more pronounced during one’s 80s to the end of life

– Plans and actions are shaped by the desire to restate and reaffirm major themes in one’s life, but also to explore novel variations on those themes.

– Continues to be motivated by life’s energy and the audience of others.

– Celebrate one’s place in family, community, and in the spiritual realm

– Celebratory reunions promote solidarity by bringing families together

Outline of Lecture

I. Geriatric Psychiatry definition and

History

II. Second Half of Life Developmental

Phases

III. Medical Assessment of the

Elderly Psychiatric Patient

IV. Common Psychiatric Illnesses of

Old Age

V. Management

Medical Assessment of the Elderly Psychiatric Patient

• Medical issues are important considerations in the management of the elderly person with mental illness.

• Acute illnesses and chronic comorbidities may be confused with psychiatric disease, exacerbate behavioral symptoms, or interfere with therapy.

• Any abrupt changes in an older person’s mental or physical health is a problem, and is due to a disease or external factors and should NOT be considered as part of normal aging.

Medical Assessment of the Elderly Psychiatric Patient

• Often, the problems are the result of multiple rather than single causes.

• It is important for older people to have a thorough medical and neurological evaluation when psychiatric problems present acutely.

• Importance of close attention to details of the patient’s history, which may uncover the existence of a medical problem.

• Attention to physical examination and screening laboratory tests.

Medical Assessment of the Elderly Psychiatric Patient

• As individuals grow older, maintaining social independence, functional mobility, and cognitive abilities becoming increasingly important.

• Functional decline is often the presenting symptom of medical illness in older people, and in some instances, may be the only symptom.

• Functional assessment must be part of the evaluation of any geriatric patient.

• Good health in old age entails the maintenance of optimal function, stability in chronic disease, and adequate support systems.

Common Medical Illnesses in the Elderly

Diseases• Eye diseases [cataracts,

glaucoma]• Hypertension• Arthritis• Dementia• Cerebral vascular dse.• Coronary artery dse.• Peripheral vascular dse• Diabetes mellitus• Ear disease [hearing

loss]• Depression/anxiety

Prevalence53%

52%

50%

42%

35%

30%

25%

25%

24%

23%

Medical History—History of Present Illness

• Be aware of the atypical presentation of illness common in the elderly. – Falls, incontinence, or functional loss can be the

initial sign of an underlying illness, and may be the only sign.

– Geriatric syndromes!!!-• Visual /hearing impairment, dementia, delirium,

depression, frailty, gait impairment• May be the only sign of an underlying depression or

delirium

– Psychiatrist should view the onset of geriatric syndrome as a flag, warranting further cognitive and behavioral assessment.

Medical History—History of Present Illness

• Get the list of medications!!!– Rx for daily and as needed medicines– Over-the-counter medications, vitamin

and nutritional supplements, herbal preparations

– Ask the px what she uses of pain; any sleeping pills?

• Use of alcohol?

Medical History—Past Medical History, Family Hx

• Past operations/Confinements– Occurrence of delirium during hospital

stays or after surgery?

• Family history– Presence of longevity,

neurodegenerative diseases e.g. dementias, parkinson’s; mood d/o

Medical History—Social History

• Living environment– Living independently? Assisted living?– Capability to continue this arrangement?– Driving?– Is home environment safe? Safe access

to the bathroom? Are there stairs?– Living environment suitable for his

disability?

Medical History—Social History

• Support systems– Do patients have family who can give support?– Friends and other social supports they can see on a

regular basis?– Religious or spiritual guidance? Attend regular

church/worship?– Involvement in social, civic, or religious groups?– Experience of significant losses of family and friends who

provided support? How have the losses impacted mood and level of functioning?

– Good relationship between the px and identified caregiver? Neglect or abuse?

– If no family, what other resources are available for px to maintain independence? Nursing home be considered?

Medical History—Social History

• Daily Activities– What does the person do with his time?

• “What do you do all day?”• “What is your typical day?”

– Is px still employed– Are the involved in other activities– What did px enjoy doing in the past?– Is px able to see and hear well enough

to enjoy reading, television, radio, etc?

Functional Assessment

• Assessment of independent functional status-- IADLs & ADLs

• This is essential because impairment cannot be predicted by the number or severity of medical diagnoses in an individual patient.

• Identifying functional impairments allows the clinician to attempt to modify those factors that may contribute to any disability and can affect other treatment decisions.• Impairments in ability to purchase or cook food, or even

to feed oneself, can have enormous nutritional consequences.

• Impairments in ADLs have also been identified as risk factors for falls and institutionalization

Physical Examination

• First impressions are telling.– Observations of grip strength when shaking hands– Deformities, skin rash, or pallor– Muscle tremor– Speech character and content– Use of eyeglasses, hearing aids– Use of cane or walker– Mobility, gait

• Vital signs– Addition of pain

Neurological Exam

• Testing of mental status, vision, hearing• Falls are a serious problem among older adults,

with potentially devastating consequences, including institutionalization and death

• Test the gait and balance---let px walk– Posture, pace, steps, arm swing, turn,– Do romberg’s maneuver [testing px’s balance]

• Stand with eyes closed and arms held out in front of the body

• Test postural reflexes– Tap px from the back and ask px to keep his balance

Neurological Exam

• Test for cognition– Mini-Mental Status Examination

• 30 items• Orientation- 5; Immediate recall- 3; attention

and calculation- 5; delayed recall- 3; language- 9

– Draw a clock [Clock-drawing test]

Outline of LectureI. Geriatric Psychiatry definition and

History

II. Second Half of Life Developmental

Phases

III. Medical Assessment of the

Elderly Psychiatric Patient

IV. Common Psychiatric Illnesses of

Old Age

V. Management

Common Psychiatric Illnesses in the Elderly

• 1. Depression

• 2. Delirium

• 3. Dementia

Depression in Old Age

• There are many faces of depression in the elderly.

• Devoid of classic signs and symptoms of depression

• Very common

• One of the most most underdiagnosed conditions in old age

• Often inadequately treated

I am depressed…

ASK…ASK…

“What do you mean by depressed?”

Major Depression-- Criteria

• 5 or more of the symptoms:

– 1. 2- week period– 2. Change from previous functioning– 3. Clinically significant impairment in

social or occupational functioning

Major Depression-- Criteria

• Depressed mood

• Anhedonia (loss of interest)

• Appetite change/weight change

• Sleep disturbance

• Psychomotor agitation or retardation

• Feeling of worthlessness or guilty

• Poor concentration

• Suicidal thoughts

Major Depression-- Lack of Recognition?

• Reluctance to acknowledge symptoms

• Symptoms may mislead clinicians– Fatigue may be seen as medical

problem– Sleep difficulty seen as primary problem– Depression seen as “normal reaction.”– Functional disability regarded as

inevitable

Depression: Red Flags!!!

• 1. Persistently low mood

• 2. Disinterest in previously pleasurable activities

• 3. Low energy/lethargy

• 4. Clear change from previous disposition

• 5. Interferes in daily functioning

Language of Depression in the Elderly

• True or false?

– Growing older causes mental disease. It is not possible to live to a ripe old age without having experienced significant mental disorder of any kind.

False

• Growing older does NOT cause mental disease.

• It is possible to grow old without experiencing significant mental disorder

• REMEMBER!!! Depression or any other mental conditions are NOT part of the normal aging process.

Language of Depression in the Elderly

• “I am a little bit down…”• I have been feeling a bit sad since my wife

died…”• “I have been worried lately…”• Physical and somatic nature of complaint:

– Multiple pains [headache, neck tension, backache]– Preoccupied with bowel functions or gastrointestinal

complaints [constipation, sense of bloatedness]– Unexplained health worries– Prominent cognitive symptoms [memory and

concentration problems]– Fatigue/tires easily; interrupted sleep; loss of appetite

Language of Depression in the Elderly

• Social withdrawal or avoidance of social interaction• Prominent loss of interest and pleasure [anhedonia]• Irritability without subjective complaints of sadness• Concurrent experience of nervousness• Signs of functional impairment or otherwise

unexplained functional decline• Expressing a sense of helplessness or hopelessness• Expressing a sense of emptiness• Expressing feelings of uselessness

True or False???

• In the elderly, being depressed is normal and acceptable as long as it is mild.

False

• Even minor depression is NOT acceptable in older adults.

• It causes functional disability similar to major depression.

True or False?

• As long as the person says that he/she is not depressed, then, clinical depression cannot be present.

False

• Masked depression shows a unique face of elderly depression, This form can be easily missed with devastating consequences in the elderly.

Masked Depression

• Pearls!!!– Older adult makes repeated visits to a

doctor with lists of vague physical complaints unsupported by clinical findings. BEWARE!

Depression and Medical Illness

• Reciprocal or bidirectional relationship between medical illness and depression

• Increased medical burden---increase depressive symptoms

• Long-term depressive symptoms---increase medical burden and even mortality

• Depression within the context of medical illness needs attention and warrants treatment

Depression and Medical Illness

• Depression in pxs with neurological disorders are very common

• Most common:– Parkinson’s Disease (50%)– Alzheimer’s Disease (17-24%)– Vascular Dementia (21-32%)– Cerebrovascular disorder (25-50%)

Depression and Medical Illness

• Medical disorders associated with higher rates of depression:– Diabetes– Coronary artery disease– Cancer

• Others:– Hypothyroidism – Autoimmune disease [e.g. SLE]– Connective tissue disease [e.g. rheumatoid arthritis]– Infections [e.g. pneumonia]– Obstructive sleep apnea

Depression and Medical Illness

• Medications associated with depression:– Corticosteroids– Sedative-hypnotics– Propranolol

• Alcohol: causes depression

How is Depression in Late-life Managed? Management has to be holistic!!!

• Treat…Not delay

• Unnecessary delay can easily tip the balance for the elderly

• Treatment options: – Medications (“Start low…go slow”),

and/or– Psychotherapy, and/or– Psychosocial intervention (physical,

social, and cognitive stimulation)

How is Depression in Late-life Managed?

• Psychosocial Issues:– Bereavement– Other losses: economic status/financial

status, social status, health, mobility, independence

– Relational issues– Recent life changes– Personality problems

Common Psychiatric Illnesses of in the Elderly

Dementia

Story of Mr. B

• 3 yrs: forgetful, lost, quiet, less interactive, repetitive, non-specific words (“it” and “thing”)

• (+) for Warning Signs/Red Flags for probable dementia

Story of Mr. B

• Lawyer, retired 5 yrs ago

• His likes: – gardening, playing golf, meeting up

with friends, bringing grandchildren out

• 3 yrs: – less motivated to do things; less

interactive in conversations; he said, he would rather stay home as he felt easily tired

RED FLAGS!!!

• Forgetting appointments• Relying more on notes• Not taking medications correctly• Unusual grooming or behaviors• Confusion, forgetfulness, or

repetition during interview/conversations

• Inability to follow instructions• Lost (especially in familiar places)

DSM-IV Diagnosis of DementiaDSM-IV Diagnosis of Dementia

• The development of multiple cognitive deficits manifested by BOTH:– Memory impairment

• Impaired ability to learn new information or• To recall previously learned information

– One or more of the ffg cognitive disturbances:• Aphasia, apraxia, agnosia, or disturbance in

executive functioning– These deficits cause significant impairment in social

or occupational functioning AND represent a significant decline from a previous level of functioning.

– The deficits do NOT occur exclusively during the course of a delirium

Remember!!!Remember!!! DementiaDementia……

• Clinical diagnosis• Clinical history and mental status

exam are the MOST important tools• Vital elements in history-taking:

– Cognitive impairment– Functional decline

• Cannot be diagnosed based on radiological, biochemical, genetic, or psychological tests alone

Types of Dementia Alzheimer’s Disease

• Most common form; 70% of all cases• Cortical dementia characterized by a

slow, progressive loss of cognitive functions

• In addition to those stated on Dementia, the multiple cognitive deficits should NOT:– Be due to other CNS, systemic, of

substance-induced conditions– Better accounted for by another

psychiatric disorder

Types of Dementia Alzheimer’s Disease

• RISK FACTORS:– Advanced age: MOST dramatic

• Incidence doubles every 5 yrs after 65 yrs old– Post-menopausal state– Genetic factors

• Increases risk of AD by 3.5x– Brain injury

• Head injury increases risk of AD by 2-4x– HPN, hypercholesterolemia, DM,

atherosclerotic dse– Major depressive disorder– Lower intelligence, less education

Types of Dementia Vascular Dementia

• 25% of all cases

• Resembles AD clinically, but with distinct etiology

• Caused by focal or diffuse cortical or subcortical brain damage as a result of CVD

• May complicate AD

Types of Dementia: Vascular Dementia

• DSM-IV diagnostic criteria

– With regard to etiology: focal neurological signs & symptoms or laboratory evidence indicative of CVD, is judged to be etiologically related to the disturbance

Types of Dementia: Vascular Dementia

• Diagnosis as defined by Roman et al. 1993– Presence of Dementia– Presence of CVD defined by: focal

neurological signs AND evidence of relevant CVD by CT or MRI (either of these or combination):

• Multiple large-vessel infarcts• A single strategically placed infarct• Multiple basal ganglia & white matter lacunae• Extensive periventriuclar white matter lesions

– Temporal relationship between onset of dementia & CVD• Onset of dementia is within 3 months

after a recognized stroke

BPSD BPSD defined…defined…

80-yr old married Filipino, retired lawyer; with visual impairmentCC: sudden and escalating psychomotor agitation, confusion, and psychosis of 2 weeksHPI:

3 wks: family squabble over sale of property; wife threatened to leave himBefore this, they said he was “normal”

s/sx: nervous, irritable, paranoid, irrelevant remarks, restlessly pacing, very repetitive, repetitively dialing house no. while at home, confused

3 days: hardly slept

Story of Mr. B

1996 International Psychogeriatric Association Consensus Conference on the

Behavioral Disturbances of Dementia• A heterogeneous group of psychological

reactions, psychiatric symptoms, and behaviors occurring in people with dementia of any etiology

• Symptoms of disturbed perception, thought content, mood or behavior that frequently occur in patients with dementia - Finkel and Burns, 1999

• BPSD is NOT a diagnostic entity but is instead a term that describes a clinical dimension of dementia. - Lawlor, 2004

• The multiple cognitive impairments of dementia are often associated with these disturbing NONCOGNITIVE symptoms of behavioral and psychological disturbances

Behavioral Symptoms• Usually identified on the basis of

observation of the patient

• Include:– Physical aggression– Screaming– Restlessness, agitation– Wandering– Culturally inappropriate behavior– Sexual disinhibition– Hoarding– Cursing– shadowing

Psychological Symptoms

• Assessed on the basis of interviews with patients and relatives

• Include– Anxiety– Depressive mood– Hallucinations– Delusions

• Although cognitive deficits are the clinical hallmark of a dementing illness…

Noncognitive symptoms can dominate disease presentation and can present as therapeutic dilemma.

Untreated BPSD is associated with…

• Decreased quality of life for both the caregiver and the patient

• Significant patient and caregiver suffering• Caregiver stress and depression• Accelerated functional and cognitive decline

– There is excess disability caused by BPSD– they function at a lower level than those without

• Reduced caregiver employment and income• Increased hospital lengths of stay• Increased overall financial cost• Premature institutionalization

As BPSD are disabling to both patient and caregiver, accurate and early recognition and treatment are vital.

Question.Question. What are the causes of What are the causes of his behavioral problems?his behavioral problems?

• Major causes of acute agitation and psychosis in dementia:– Dementia itself– Medical illness– Medications– Pain and/or physical discomfort– Psychiatric illness– Stress (psychological and environmental)

Cause: Dementia ItselfCause: Dementia Itself

• BPSD is …

• A result of the underlying impairment in brain circuitry and/or neurochemistry critical to the control of expression and behavior.

Cause: Medical IllnessCause: Medical Illness

• Remember!!!– The compromised brain of a patient

with dementia is especially vulnerable

to metabolic changes - Any added insult to it, e.g. impaired

oxygen/blood flow, will commonly result

in acute agitation, psychosis, or

delirium.

Medical Problems associated with Medical Problems associated with Agitation, Psychosis, or DeliriumAgitation, Psychosis, or Delirium

• Infection– Urinary tract infections: Most common– Rule of Thumb:

• Order urinalysis and urine culture• Obtain a medical consultation

• Acute Renal, Hepatic, or Thyroid Dysfunction

• Sensory impairment [blindness, deafness]• Acute neurologic events [seizure, ischemic event e.g. stroke]• Acute cardiac events

Medical Problems associated with Medical Problems associated with Agitation, Psychosis, or DeliriumAgitation, Psychosis, or Delirium

• Acute pulmonary events• Occult malignancies [esp. in the CNS]

• Occult bone fracture

• Post-operative states

• Substance intoxication or withdrawal– Alcohol is the MOST commonly abused

drug in the elderly

Cause: Medications!!!

• Medications that are common causes of psychosis, agitation, or delirium:

– Anticholinergics [biperiden, diphenhydramine; includes H2-receptor blocker e.g cimetidine]– Narcotics [esp. meperidine]– Antihistamines [diphenhydramine, hydroxyzine]– Tricyclic antidepressants [imipramine, clomipramine]– Benzodiazepines– Corticosteroids– Antibiotics (some)

[The ones in bold are clinically important and are based on sufficient information.]

Cause: Environmental and Cause: Environmental and Psychological Stress Psychological Stress

• Common environmental stresses:– Uncomfortable surroundings

• Excess heat, cold, or noise, lighting

problems, etc.

– Moves from familiar to unfamiliar

settings• Transfer of homes, room changes

– Caregiver’s approach• Impatient in caregiving, inattentive,

confrontational/argumentative,

demanding, etc.

Mr. BMr. B

• Causes of his acute agitation and psychosis:– Dementia [probable AD]– Sensory impairment [legally blind]– Sudden psychological stress

– Not delirium---it was acute but No fluctuations

Assessment: Medical Work-upAssessment: Medical Work-up

• Medical work-up is always indicated:– Suspicion of delirium– Sudden changes in behavior– Treatment-resistant problems

• Includes the ffg:– Careful history– Physical and neurological exams– Brief baseline cognitive screen– Review of medications– Review of intraoperative data

Assessment: Medical Work-upAssessment: Medical Work-up• First-line investigations:

– Electrolytes [plus Ca++ and Mg++]– CBC – Glucose– Renal function [bun/crea]– Liver function test [SGOT/SGPT, bilirubin, alk phosphatase]– Thyroid function test [TSH, FT4]– Erythrocyte sed rate– Urinalysis [consider culture]– EKG– CXR– Pulse oximetry [and blood gas, if w/ signs of hypoxemia]

[The ones in BOLD were done on our patient.]

Assessment: Medical Work-upAssessment: Medical Work-up

• Second-line investigations:– Drug screen– Blood cultures– Cardiac enzymes– Serum folate/B12– Brain CT or MRI– CSF examinations– EEG [if highly suspicous of sz]– Others [as case may be]

[The ones in BOLD were done on our patient.]

Question.Question. How do we manage his How do we manage his behavior problems?behavior problems?

• Target symptoms?

• What nonpharmacological interventions do we employ?

• What medications do we give to control her agitation and psychosis?

Mr. BMr. B

• Started her on:– Quetiapine 12.5mgBID and PRN for

agitation– Donepezil 2.5. mg

• With good control of agitation and psychosis

Common Psychiatric Illnesses in the Elderly--- Delirium

• A diagnosis of Superimposed Delirium on top of an underlying Dementia is very common.• Syndrome characterized by acute change in cognition, attention, perception, thinking, and

consciousness that fluctuates over time. • Always has a medical cause!!

REMEMBER!!!– Pxs with dementia: 3-5x risk– Dementia: MOST significant predisposing factor for delirium development

DSM-IV Diagnosis of Delirium

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

• A change in cognition (memory deficits, disorientation, language disturbance) or the development of a perceptual disturbance that is NOT better accounted for by a pre-existing, established, or evolving dementia.

• The disturbance develops over a short period of time (hours to days) and tends to fluctuate during the course of the day

• There is evidence from the hx, PE, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.

Take Home Pointers!!!Take Home Pointers!!!

• Learning and psychological development are lifelong.

• Fascinating findings that ongoing capacity for learning and creative development continue in the second half of life.

• Depression in old age has many faces; it is under recognized and undertreated. Treatment is necessary to decrease morbidity and mortality.

• BPSD are very common in those with dementia. Up to 50-90% of pxs with dementia experience

them at one point in the course of their illness.• BPSD impair the quality of life of both patients

and caregivers.

Take Home Pointers!!!Take Home Pointers!!!

• Delirium superimposed on dementia is also very common in the elderly. Dementia is the most significant predisposing factor for the development of delirium.

• It is important to check on the list of medications!!!

• “Start low and go slow.”

““Beautiful young people are accidents Beautiful young people are accidents of nature. But, beautiful old people are of nature. But, beautiful old people are works of art.”works of art.”

-- Eleanor Roosevelt

“ “In the past few years, I have made a In the past few years, I have made a

thrilling discovery…that until one is thrilling discovery…that until one is over 60, one can never really learn over 60, one can never really learn the secret of living. One can then the secret of living. One can then begin to live, not simply with the begin to live, not simply with the intense part of oneself, but with intense part of oneself, but with one’s entire being.”one’s entire being.”

-- Ellen Glasgow -- Ellen Glasgow

(Pulitzer Prize winner at age 67)(Pulitzer Prize winner at age 67)

Thank you

for your

kind attention!!!