Geriatric Psychiatry

Geriatric Psychiatry Anita S. Kablinger MD Associate Professor Psychiatry and Pharmacology

Objectives:
Differentiate between the various cognitive disorders
Know aspects of normal aging
Gain knowledge of the best treatment options for geriatric psychiatric illnesses

Why is it a subspecialty?
Mental disorders may have different manifestations, pathogenesis, and pathophysiology from younger adults
Coexisting chronic medical illness
More medicines
Cognitive impairments
Increased risk for social stressors, including retirement and widowhood

Geriatric population increasing
2000, estimated that 1 in 5 Americans were over 55 years of age, and 13% over 65 years of age
By 2050, estimates are that 22% will be over the age of 65, and 5% over age 85.

Aging and the Life Cycle (Erickson)
Young adulthood--intimacy versus isolation
Middle-aged--generativity versus self-absorption
Elderly--Integrity versus despair (Acceptance of mortality, satisfaction with one’s meaning in the world)
Fear of death is usually a mid-life issue

Other tasks of elderly
Reminiscence is normative
Loss
On-time normative incidents do not usually result in crisis
Fears are usually pain, disability, abandonment, and dependency

Cognition and aging
Cognition includes learning, memory, & intelligence
Learning is the ability to gain new skills and information. It may be slower in elderly, especially verbal learning.

Cognition and aging (continued)
Memory is divided into immediate, short- and long- term memory. Immediate memory remains intact.
Short-term memory is also intact, however, it is affected by concentration which may be less in older adults.
Long-term memory is most affected by aging. Retrieval is less efficient; the elderly need more cues

Intelligence
Ability to use information in an adaptive way or to apply knowledge to specific circumstances
Crystallized intelligence includes vocabulary, verbal skills, and general information can continue to increase throughout life.
Fluid intelligence consists of recognizing new patterns and creative problem solving. This peaks in adolescence.

Benign senescent forgetfulness
Age associated mild memory problems. May also have cognitive problems due to anxiety.
Examples are forgetting names, misplacing items, and experiencing difficulty with complex problem-solving.
(aging-associated cognitive decline)

Psychiatric Evaluation
See patient alone to assess for suicidal/homicidal ideation even if cognitively impaired
May need info from caretaker
May take extended time due to slower response time

Other important aspects of history
Family history--Alzheimer’s disease is transmitted as an autosomal dominant trait in 10-30% of the offspring of parents with Alzheimer’s disease
Review of all meds, over the counter, prescribed, herbal
Alcohol and substance abuse history

MSE
General description
mood, feelings, affect
witzelsucht is caused by frontal lobe dysfunction and is the tendency to make puns and jokes and laugh aloud at them

MSE (continued)
perceptual disturbances
may be transitory resulting from decreased sensory acuity
types of agnosia (the inability to recognize and interpret the significance of sensory impressions: the denial of illness (anosognosia), the denial of a body part (atopognosia); or the inability to recognize objects (visual agnosia) or faces (prosopagnosia)

MSE (continued)
Language output
nonfluent or Broca’s aphasia--understanding intact but can not speak, speech may be telegraphic
fluent or Wernicke’s aphasia
global aphasia
ideomotor apraxia--can not demonstrate use of simple objects
Visuospatial functioning--some decline is normal with age

MMSE affected by educational level
median score for 9-12 yrs of school is 26, high school diploma 28
less sensitive in those with high intelligence, and less specific with those below average intelligence

Neuropsychological Assessment
MMSE is not used to make a formal diagnosis
WAIS-R vocabulary holds up with age. Performance part is a more sensitive indicator of brain damage than the verbal part.
Depression can impair psychomotor performance, especially visuospatial functioning and timed motor performance. The Geriatric Depression Scale is a useful screening instrument that excludes somatic complaints from its list of items.

Mental Disorders of old age
Most common: depressive disorders, cognitive disorders, phobias, and alcohol use.
High risk of suicide
Risk factors include loss of social roles, loss of autonomy, deaths, declining health, increased isolation, financial constraints, and decreased cognitive functioning.

Cognitive Disorders
Include:
Delirium
Dementia
Amnestic Disorders
Psychiatric disorders due to a Medical Condition
Postconcussion Syndrome
Replaces the term “organic disorders”

Note that major psychiatric illnesses may also have changes in cognition, but they are not called cognitive disorders

Delirium
Usually acute and fluctuating
Altered state of consciousness (reduced awareness of and ability to respond to the environment)
Cognitive deficits in attention, concentration, thinking, memory, and goal-directed behavior are almost always present

Features of delirium
May be accompanied by hallucinations, illusions, emotional lability, alterations in the sleep-wake cycle, psychomotor slowing or hyperactivity
Usually abrupt

Causes of Delirium— I WATCH DEATH
Infectious Deficiencies
Withdrawal Endocrinopathies
Acute metabolic Acute vascular
Trauma Toxins/drugs
CNS Pathology Heavy Metals
Hypoxia
Note that prescribed medicines may cause delirium

Treatment of delirium
Look for underlying cause “always be suspicious”
Close supervision, especially by family
Reorient frequently
Adequate lighting

Treatment of delirium (continued)
Use consistent personnel
Try not to use restraints, as it can worsen confusion.
Medication only if behavioral attempts fail
Avoid polypharmacy
Low dose neuroleptic is treatment of choice, unless the delirium is due to withdrawal. If due to withdrawal, use a short-acting benzodiazepine.

ICU Syndrome
May be multifactorial
Postcardiotomy delirium occurs 3 or 4 days after surgery

Changes in dementia
Cognition, memory, language
Personality change, abstract thinking, aphasias
Visuospatial functioning
However, level of awareness and alertness usually intact in early stages (differentiates dementia from delirium)
Chronic, versus acute

Amnestic Disorders
Differs from delirium and dementia because major problem is short-term memory only.
Impairment may be due to hemorrhage in mamillary bodies, or degenerative changes in the dorsal medial nucleus of the thalamus
Most common cause is alcoholism

Transient global amnesia
Transient inability to learn new info
Variable retrograde amnesia that “shrinks” following recovery
Level of conscousness and personal identity intact
Due to transient vascular insufficiency of the mesial temporal lobe, or medicines, tumors, arrhythmias, cerebral embolism
Also have risk problems for stroke

Postconcussion syndrome
Follows a history of head trauma resulting in cerebral concussion
LOC, posttraumatic amnesia, less commonly, post-traumatic seizures
Impairment in attention, concentration, performing simultaneous cognitive tasks, and in learning new information, or recalling information shortly after the injury
Not a form of dementia

Dementing Disorders
Only arthritis more common in geriatric population
5% have severe dementia, and 15% mild dementia in those over 65
Over 80, 20% have severe dementia
Most common causes: Alzheimer’s disease, vascular dementia, alcoholism, and a combination of these 3
Risk factors are age, family history, and female sex

Noncognitive symptoms accompanying dementia
Mood disorders--dementia and depressive symptoms can coexist and the depression responds to treatment
Pathological laughter and crying occurs
Irritability and explosiveness

Other noncognitive symptoms in dementia
Excessive emotional outbursts that occur after task failure are “catastrophic reactions” and can be avoided by educating family members to avoid confrontation
Delusions or hallucinations occur during the course of dementias in nearly 75%

Behavior problems in dementia
Agitation, restlessness, wandering, violence, shouting
Social and sexual disinhibition, impulsiveness
Sleep disturbances

Dementia and treatable conditions
10-15% from:
heart disease, renal disease, and congestive heart failure
endocrine disorder, vitamin deficiency,
medication misuse
primary mental disorders

Subcortical dementia
Subcortical dementias are associated with movement disorders, gait apraxia, psychomotor retardation, apathy, akinetic mutism.
Alert, but slowly responsive and inactive
Not fluent in language, but comprehends
Often dysarthric, difficulty with forming complex sentences
Difficulty with executive function

Subcortical dementia
Causes:
Huntington’s disease, Parkinson’s disease, NPH, multi-infarct dementia, Wilson’s disease

Cortical dementias--
Ex: Alzheimer’s, CJD, and Pick’s disease
Involve aphasia, agnosia, apraxia
Fluent, moderately attentive, normally responsive to questions, and normally active in his environment

Human prion disease
result from dicing mutations of the prion protein gene and may be inherited, acquired, or sporadic.
They include familial CJD, Gerstmann-Straussler-Scheinder syndrome, and fatal familial insomnia.
Autosomal dominant

Sporadic CJD
Accounts for 85% of human prion diseases
Occurs world-wide with a uniform distribution and incidence of around 1 in 1 million per annum
A mean age of onset of 65
Rare in those less than 30

Dementia of the Alzheimer’s Type (DAT)
50-60% of patients with dementia
5% of those who reach 65 have DAT
15-25% of those 85 or older
More common in women
Occupy 50% of all NH beds

DAT
General sequence is memory, language, then visuospatial functions
Death occurs in about 7 yrs
On autopsy: neurofibrillary tangles and neuritic plaques with an amyloid core and deposition of amyloid in blood vessels
Involves cholinergic system arising in basal forebrain, nucleus basalis of Meynert--reductions in brain acetylcholine, and the adrenergic system

DAT (Genetics)
Chromosome 21
Most severe form associated with chromosome 14
Genetically heterogeneous disease caused by 2 or more genes located on 2 or more chromosomes (14, 19, 21)
Slow virus?
Deposition of aluminum

PET Scans of DAT
Decreased metabolic rate of glucose in temporoparietal area, and in frontal regions in more severe cases

Pick’s Disease
Slowly progressive
Focal cortical lesions, primarily frontal that produce aphasia, apraxia, and agnosia.
Lasts 2-10 yrs., average duration 5 yrs

CJD
Usual course one year
Not associated with aging
Incidence decreases after age 60
Terminal stage: severe dementia, generalized hypertonicity, and profound speech disturbance
Typical burst pattern on EEG

Vascular Dementia
Second most common type
Can reduce known risk factors: hypertension, diabetes, cigarette smoking, and arrhythmias

Huntington’s
Basal ganglia and cerebral cortex
Progressive dementia, muscular hypertonicity, and bizarre choreiform movements
Death in 15-20 yrs
On the G8 fragment of chromosome 4
Screening test available

NPH
Dementia
Ataxia
Incontinence

Dementia due to Parkinson’s Disease
Motor dysfunction, frontal lobe symptoms, and memory deficit
Nearly 1/2 are depressed, and depression is most common mental disturbance in Parkinson’s
Increased risk for anxiety
Levodopa, amantadine, and bromocriptine can cause psychosis and delirium

HIV (AIDS)-Related Dementia
Involvement of CNS is a primary symptom of the illness and may occur before signs of systemic infection
In later stages may be result of fungal, parasitic, viral, or neoplastic disease
Initial infection involves the brain--headache, bells palsy, seizures, flu symptoms, or aseptic meningitis
Later stages may show abnormal reflexes

Other types of dementia
Multiple sclerosis is characterized by multifocal lesions in the white matter. May show early mood lability
Vitamin B12 deficiency--neurologic changes may occur before megaloblastic changes
Hypothyroidism
Wilson’s disease

Diagnostic evaluation of dementia
B12 and folate
VDRL and FTA
CT/MRI
EEG is sensitive for delirium
Consent and counseling for HIV

Treatment of behavior problems
Neuroleptics should not be first choice, unless the patient is psychotic and should be on a “prn” basis
Consider the likelihood of depression and anxiety first
Consider using behavioral methods if at all possible

Medicines for behavioral problems
Valproic acid, trazodone, and buspirone may be of benefit
BZD’s may aggravate confusion

Social Recommendations
Refer to Alzheimer’s group or other support groups
Continue preventive care--vision, dental, etc.
Consider caregiver stress

Drug treatment for DAT
Most current ones affect acetylcholine
Tacrine
Aricept
Exelon
Reminyl
Early intervention may prevent or slow decline

Depression
15% of all older adult community residences and nursing home patients
Accounts for 50% of older adult admissions to a psychiatric facility
Age is not a risk factor, but widowhood and chronic medical illness are

Depression
May have more somatic complaints such as decreased energy, sleep problems, pain, weakness, GI disturbances
Increases use of primary care medical resources
For those with a medical condition, depressive symptoms significantly reduce survival
Increases risk of suicide

Depression in medical illness
Medicines or the medical illness may cause depression
Rule out medical causes
Use psychological symptoms such as hopelessness, worthlessness, guilt
Pseudodementia occurs in about 15% of depressed older patients, and 25 to 50% of patients with dementia are depressed

Depression in older adults
May have delusions which are usually persecutory or hypochondriacal in nature
Need treatment with both an antidepressant and an antipsychotic
ECT may be treatment of choice

Bereavement
Normal grief starts with shock, proceeds to preoccupation, then to resolution
May be prolonged in elderly, but consider major depression if there is marked psychomotor retardation, lasts over 2 months, marked impairment, or if suicidal ideation

Bipolar Disorder
Episodes persist into old age
Do organic workup if onset is over 65
Usually more irritable than euphoric, and paranoid rather than grandiose
May have dysphoric mania , with pressured speech, flight of ideas, and hyperactivity, but thought content is morbid and pessimistic

Treatment of bipolar
Lithium is an effective treatment, but decreased renal clearance and neurotoxic effects may be more common
Valproic acid is also helpful for behavioral disturbances

Schizophrenia
Usually before 45, but there is a late onset type beginning after age 65
More likely in women
Paranoid type more common
Psychopathology less marked with age
Residual type occurs in 30% of those affected: Emotional blunting, social withdrawal, eccentric behavior, and illogical thinking predominate

Delusional Disorder
Onset between 40 and 55
Persecutory or somatic delusions most common
In one study of people older than 65, 4% had pervasive persecutory ideation
May be precipitated by stress, loss, social isolation , visual impairment, deafness, immigrant status

Anxiety Disorders
Very common in elderly
May occur first time after age 60, but not usually
Most common are phobias, especially agoraphobia
Elderly more likely to use anxiolytics
May be due to medical causes or depression

Somatoform Disorders
More than 30% over age 65 have at least one chronic disease. After 75, 20% have diabetes mellitus and an average of 4 diagnosable chronic illnesses

Hypochondriasis
Hypochondriases peak incidence in 40-50 yr range. Repeat exams, but not invasive and high risk tests
Hypochondriasis may be a secondary symptom of depression

Alcohol and substance abuse
20% of nursing home patients have alcohol dependence
Sudden onset delirium in hospitalized patients usually from withdrawal
Consider in patients with GI problems
May misuse OTC
35% use analgesics, and 30% use laxatives

Alcohol
Brain more sensitive as ages
Due to changes in metabolism, a given amount may produce a higher blood alcohol level than in a younger individual
May worsen normal changes in sleep and sexual functioning
Interacts with other medicines

Alcohol detoxification
Use lorazepam and oxazepam if needed for detox in elderly because of rapid metabolism

Personality disorders
Borderline, narcissistic, and histrionic personality disorders may become less intense
Before diagnosing a personality disorder, verify that it is not an improperly treated Axis I disorder
Some personality traits may become more pronounced

Sleep disorders
Advanced age is single most important factor associated with increased prevalence of sleep disorders
REM sleep behavior disorder occurs almost exclusively among elderly men
Advanced sleep phase--go to sleep early, and awaken during night
Alcohol can interfere with sleep
Dementia associated with more arousals, increased stage I sleep; decreased stages 3/4

Other disorders of old age
Vertigo--antivert may be of benefit. Usually has psychological component
Syncope
Elder abuse--about 10% over age 65 abused

Psychopharmacology
Evaluate physically first, including EKG
Bring in all meds
Should give meds 3-4 times over 24 hrs.
Washout of psychotropic meds sometimes beneficial
Major goals are to improve quality of life, maintain in community, and delay or avoid nursing home placement
start at lower doses

Psychopharmacology
Watch for all drug interactions
Compliance may be a problem
Cognitive dysfunction may require help with medication regimen

Metabolism changes
Decrease in lean body mass and total body water
Increase in body fat, prolongs half life
Hepatic metabolism decreases, as well as production of albumin
Decreased renal function

25% of all prescriptions are for people over 65
40% of all hypnotics are for over 65
75% of older people use OTC

Psychostimulants
May be of benefit in depressed older patients
Amphetamines may augment analgesia for patients on pain meds

Antipsychotics
Used for psychosis and behavioral disturbances
Can have side effects at lower doses
Give a 4 week trial at least
No need to use prophylactic antiparkinsonian agents, but the risk of EPS increases with age

Antipsychotics
Low potency agents (mellaril, thorazine) have increased effects such as orthostatic hypotension, sedation, cognitive impairment
Atypicals may be of most benefit (clozapine, olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole)

Anxiolytics
Rate of use high
May cause anterograde amnesia
May accumulate in tissues if long acting so may increase ataxia, insomnia, and confusion
If necessary, oxazepam and lorazepam are drugs of choice
Buspirone may be of benefit. Takes several weeks to work

Geriatric psychotherapy
Goals are to have minimal complaints, make and keep friends of both sexes, have sex if interested and capable
Grief and loss are central issues
Example: retirement and self-esteem
Group therapy directly lessens the elder’s sense of isolation
Family support is crucial

Institutional Care
50% stay less than 3 months
Skilled nursing facilities vs. intermediate-care facilities
70% proprietary, 30% governmental
State hospitals now exclude people with dementia

Restraints
40% nursing home patients placed in restraints last year
Without restraints, have better muscle tone, less rage, greater sense of mastery

Competence
Legal decision
May be competent for some procedures, and incompetent for others

Pearls
Evaluate any change in cognition. It is not normal
Rule out drug interactions, alcohol abuse, or medical problems if depressed or anxious
The dose of antidepressant that gets the patient well is the dose that keeps the patient well

Pearls
The elderly generally require less medication for the same symptoms--start low, and go slow

Geriatric Psychiatry

by cardiacinfo on Dec 06, 2010

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