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Geriatric Psychiatry
 

Geriatric Psychiatry

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    Geriatric Psychiatry Geriatric Psychiatry Presentation Transcript

    • 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