66
T. Lau, MD, FRCPC [psych], MSc., Director Undergraduate Education, Faculty of Medicine, UNIVERSITY OF OTTAWA Royal Ottawa Mental Health Review Of Geriatric Psychiatry
T. Lau, MD, FRCPC [psych], MSc.,Director Undergraduate Education,
Faculty of Medicine, UNIVERSITY OF OTTAWA
Royal Ottawa Mental Health CentreGeriatrics
Review Of Geriatric Psychiatry
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 treatment after 3 weeks what would you do?
6. How effective are antidepressants?7. Does duration of sx or number of previous
episodes effect remission rates?8. Are they less effective in the elderly?9. 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. Non-compliance 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 # 1The following is true regarding depressionThe 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 depressiond) it rarely presents with multi-system physical
complaintse) ECT should be considered only when all other
treatments have failed
a
MCQ #2
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 aginge) Is not associated with the death of a loved
one
Depression in old age:
C
Which of the following are infrequent Which of the following are infrequent “reasons for consultation” by elderly who “reasons for consultation” by elderly who have their first depressive episode:have their first depressive episode:
a) “Nerves” b) Excessive fatiguec) Hypersomnia (sleeping too much)d) Digestive problemse) Fear of Alzheimer’s disease
MCQ # 3
C
Which of the following would be more consistent with normal grief?
a) Active suicidal ideationb) Prominent psychotic symptomsc) Crying spells when she thinks of her
deceased husband.d) Profound feelings of guilte) Being unable to attend to her usual
daily activities 3 months after the death of her husband
MCQ# 4
C
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 DiagnosisIn the Elderly PRIMARY PSYCHOTIC 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
In younger patients
• Psychosis– Substance - GMC
– Mood D/O (MDD or BAD)
– SCZ, SCZ-A
– BPE
– Dissociative D/O
– Delusional disorder
– Delirium
– Personality disorders
Biphasic in the women
MCQ#5
Regarding psychosis in late life, which is the best Regarding psychosis in late life, which is the best answer?answer?
a) Paranoia is most often due to schizophrenia. b) More men develop late onset schizophrenia.c) Psychosis is often associated with mood and cognitive
disordersd) Psychosis is often caused by illicit drugs of abusee) 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 Consciousness (focus, sustain or shift attention)
– C Cognition (memory, disorientation, language) or perceptual disturbance
– C Course– C 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 (10-40%).
• Independent risk factor for mortality 40% @ one yr.
• Lab features: EEG generalized slowing
Delirium
• 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, pre-existing brain damage (eg. Dementia), malnutrition
Meagher (1996), BJP
INDEPENDENT PRECIPITATING FACTORS (n=196)
• Precipitating factor Adjusted RelativeRisk
• Use of physical restraints 4.4 (2.5-7.9)• Malnutrition 4.0 (2.2-7.4)• >3 medications added 2.9 (1.6-5.4)• Use of bladder catheter 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 deliriumThe following is true of deliriuma) In the elderly, it is rare and most often completely
reversibleb) Hyperactive subtypes are more often missedc) It is a significant independent risk factor for deathd) It can be superimposed on dementia or depressione) 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 1991-
2031
0
200
400
600
800
1991 2001 2011 2021 2031
No.
of c
ases
(x10
00)
DementiaADVaD
Canadian Study of Heath and Aging Working Group. CMAJ 1994;150:899-913.
x 2
x 3
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
Adapted from Galasko D. Eur J Neurol. 1998;5:S9-S17.
• Forgetfulness• Problems with shopping, driving and hobbies• Depression
Mild - MMSE >20
• Marked memory loss• Require help with ADLs• Wandering• Insomnia• Delusions
Moderate - MMSE 10-20
• Very limited language• Loss of basic ADLs• Incontinence• Agitation
Severe - MMSE <10
Mild cognitive impairment• Memory impairment• Absence of ADL deficits• Apathy, anxiety, irritability
Nursing home placement, death from pneumonia and/or other comorbidities
AD Progression
THERAPEUTIC STRATEGIES
Pathogenesis
Symptoms
Disease
Induction.Genetic/hereditary
Latency.Traumatisms. Vascular risk factors
Detection
Primary PreventionVaccineEstrogenNSAIDGinkgo
SecondaryPrevention(“Mild cognitive Impairment”)AntioxydantsAnti-inflammatoriesNeurotrophic factorsEstrogens
Symptomatic Treatment
Cholinergic replacementTherapy
Glutamate ModulationMood and Behaviour
Management
Vascular Prevention
Original Case ReportB-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
• 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……
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 #7The following is true of AlzheimerThe following is true of Alzheimer’’s s a) Motor symptoms are present early in the
diseaseb) There is usually a step wise declinec) The ‘head turning sign’ refers to sexual
disinhibitiond) 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 L-Dopa 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.
QUESTIONS1.What is your differential?2.What is the difference between DLB and PDD?
Lewy Body DementiaMcKeith Neurology 96 updated 2006
• Diagnosis– Dementia– Plus >2/3 (probable, 1/3 possible)
• Fluctuating cognition• VH’s well formed + delusions• Parkinsonism
– Pathologically• identified with Ubiquitin Stain. LB
seen in PD in SN. 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.
• Clinical Features– Repeated falls– Syncope w transient LOC– Neuroleptic sensitivity– Systematized delusions (>50%)– Hallucinations in other modalities– Increased rates of depression (40-
50%)– Misidentification syndrome v.
common– Tx– Seems to respond well to AchEI– Extreme caution with
neuroleptics
MCQ #13Which of the following is true regarding
Dementia with Lewy Bodies a) It is rareb) It is associated with severe neuroleptic
sensitivity, REM sleep disorders, and fallsc) PET/SPECT shows increased Dopamine uptake in
the basal gangliad) Can occur in patients who have had the motor
symptoms of Parkinson’s for over one yeare) 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#8All of the following is true regarding
Vascular Dementia a) Lateralizing findings are commonb) Gait changes are uncommonc) Gradually progressive decline is typicald) Neuroimaging or clinical evidence of CVA is
necessary for the diagnosise) 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.
• QUESTIONS1. What is your differential?2. What differentiates FTD from AD?3. Are there any differences in treating this condition?
MCQ #9Frontotemporal Dementia is characterized
by a) Memory and visual spatial impairment early onb) Personality changes later with disinhibitionc) Early loss of insight, decline in social
interpersonal conduct with impaired regulation, emotional blunting, executive skills deficits, frontal signs
d) Characteristic functional neuroimages with occipital cerebral hypometabolism
e) 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
