Assessing Behavioral Disorders in the Geriatric Population

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					Assessing Behavioral Disorders in the Geriatric Population

What Are the Most Common Psychiatric Disorders in the Elderly?
Outpatient Care  Dementia 10% > age 65 45% > age 85  Depression 4-5%  Substance abuse 1-5%  Psychosis 0.1-4% Long Term Care  Dementia 50-70%  Affective disorders 10-15%  Schizophrenia 0-4%  Mental retardation/ Developmental disabilities 1-5%

Prevalence of Dementia in the US
50 Prevalence of Dementia (%) 40 30 20 16 2 65-70 4 70-75 8 32

10
1 0 60-65

75-80

80-85

>85

Age (year)
    

>65 years: 10% >85 years: 32% to 47% Today: About 4 million have Alzheimer’s Disease (AD) 2050: Greater then 14 million will have AD Economic burden associated with AD approaches $100 billion annually

Nursing Facilities Demographics


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Currently, there are 17,176 nursing homes in the US There are more than 1.5 million residents Hospitals are releasing patients sooner; nursing homes are taking a larger role in sub acute care



Over age 65
– 5% live in nursing homes now – 25% to 50% will live in nursing

homes at some point in their lives
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Over age 85
– 25% live in nursing homes – Prevalence of mental disorders

in nursing homes is estimated to be more than 75%

Rovner BW, et al. Am J Psychiatry. 1986;143:1446-1449. American Health Care Association. 1998. Available at: http://www.ahca.org

Dementia: A Diagnostic Workup
       

Medical history
Medication history Social history

Psychiatric history
Neurological exam Mental status exam

Blood test
Imaging studies (eg, optional CT without contrast, MRI, PET, SPECT)

Differential Diagnosis of Dementia
     

Alzheimer’s disease (AD) Dementia with Lewy bodies (DLB) Frontotemporal dementias Dementia with Parkinson’s disease Vascular dementia Other degenerative dementias

Required Laboratory Studies
       

Complete blood count
Serum electrolytes (including calcium) Glucose

BUN and creatinine
Liver function tests TSH and free thyroid index

Vitamin B12 level
Syphilis serology

Lumbar Puncture


  

Early onset, rapidly progressive or unusual features Metastatic carcinoma Suspicion of normal pressure hydrocephalus Increased tau, decreased beta-amyloid (sensitivity/specificity unknown)

Examples of Imaging Techniques


Structural
– CT – MRI



Functional
– QEEG – SPECT – PET – fMRI – MRS

What Functional Imaging Can Show
   

Alzheimer’s disease Vascular dementia Parkinson dementia Depression





 

Parietal/temporal deficits Focal, asymmetric, cortical subcortical deficits Parietal deficits Frontal/global deficits

IPA Consensus Statement
Behavioral signs and symptoms of dementia are  Common  Morbid  Classifiable  Treatable

Finkel SI, et al. Int Psychogeriatr. 1996;8(suppl 3):497-500.

Behavioral Scales Used to Assess Neuropsychiatric Symptoms in Dementia
    

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Behavioral Pathology in AD Scale (BEHAVE-AD) ADAS non-cognitive subscale (ADAS-non-cog) Behavioral Rating Scale for Dementia (BRSD) Cohen-Mansfield Agitation Inventory (CMAI) Columbia University Scale for Psychopathology in Alzheimer’s Disease (CUSPAD) Brief Psychiatric Rating Scale (BPRS) Neuropsychiatric Inventory (NPI)

Behavioral Disturbances Associated With Dementia
% of Patients Range Disturbed affect/mood Disturbed ideation Altered perception Hallucinations Misperceptions Agitation Global Wandering 0-86 10-73 Median 19 33.5

21-49 1-49

28 23

10-90 0-50

44 18

Tariot PN, et al. Am J Psychiatry. 1993;150:1063-1069.

Behavioral Disturbances Associated With Dementia (cont.)
(% of Patients) Range Aggression Verbal Physical Resistive/uncooperative Anxiety Withdrawn/passive behavior Vegetative behaviors Sleep Diet-appetite 0-47 12.5-77 27 34 11-51 0-46 27-65 0-50 21-88 Median 24 14.3 44 31.8 61

Tariot PN, et al. Am J Psychiatry. 1993;150:1063-1069.

Neurobiology of Behavioral Disturbances in Dementia
Ach  Cholinergic function, related to neural mechanisms of emotion  Controversial link between dementia severity and agitation  Mixed findings regarding role in mood disorders


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Decreased activity associated with psychotic features Some behavioral benefit associated with cholinergic treatment

Neurobiology of Behavioral Disturbances in Dementia (cont.)
5HT  Decreased 5HT more pronounced in behavior disturbances  Depression associated with decreased activity  Psychosis history associated with decreased activity  Agitation associated with decreased activity and agonist challenge  Serotonergic agents show mixed results

Neurobiology of Behavioral Disturbances in Dementia (cont.)
NE


Increased NE responsivity may contribute to behavioral disturbances Increased NE turnover in depression and psychosis Decreased NE in depression?

 



May suggest avoiding noradrenergic agents in treatment
May support use of -blockers



Neurobiology of Behavioral Disturbances in Dementia (cont.)
DA  Relative preservation in aggression  No relationship to mood disturbance  No relationship to psychosis  Agitation correlated with plasma HVA  Antipsychotics may be more effective in decreased aggression than psychotic features in AD  Significant deficit in LBD

Neurobiology of Behavioral Disturbances in Dementia (cont.)
GABA
 

GABA deficit well established in AD Little known about changes in behavioral disturbances Decreased activity associated with aggression in animals GABA modulators and benzodiazepines have moderate effect Role of anticonvulsants

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Neurobiology of Behavioral Disturbances in Dementia (cont.)
Corticotropin Releasing Factor (CRF)  Decreased activity in neurodegenerative disorders  Relevant to stress response  Many pharmacotherapies modulate CRF Glutamate  Imbalance between glutamate and dopamine may lead to psychosis

What Is Agitation?


Any inappropriate verbal, vocal, or motor activity that is not an obvious expression of need or confusion

Cohen-Mansfield J, Deutsch LH. Semin Clin Neuropsychiatry. 1996;1:325-339.

Agitation
Physical
Pacing Inappropriate robing/disrobing Trying to get to a different place Handling things inappropriately Restless Stereotypy

Verbal
Complaining Requests for attention Negativism Repeated questions, phrases Screaming

Cohen-Mansfield, et al. 1988.

Aggression
Range Verbal 11% to 15% Median 24% Characteristic Threats Accusations Name-calling Obscenities Hitting Kicking Pushing Scratching Tearing Biting Spitting

Physical

0% to 46%

14%

Sexual

18% in 1 report

General Approach to Behavioral Complications of Dementia
 

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Characterize target symptoms Standard medical evaluation to identify possible medical disorder If medical disorder, treat and monitor target symptoms Standard psychiatric evaluation If psychiatric disorder, treat and monitor target symptoms

Flow Chart for Management of Agitation in Dementia
Agitation

Acutely manageable?

No

Short-term sedation with antipsychotics, benzodiazepines

Medical workup

Yes

Effective?

No
Specific medical disorder • Treat specifically • Monitor agitation • Employ nonpharmacologic principles Hospitalize • Restraints? • Seclusion?

Delirium

Yes Yes

Discrete psychiatric disorder

No

Tariot, et al. Tariot and Leibovici.

Flow Chart for Management of Agitation in Dementia (cont.)
Employ nonpharmacologic principles Continue treatment as appropriate

Yes No
Develop psychobehavioral metaphor, match to relevant class, continue attempting nonpharmacologic approaches

Successful?

Depressive features

Manic features

Anxious features

Psychotic features

Nonspecific

Antidepressants Anticonvulsants

Anticonvulsants

Antidepressants Anticonvulsants Anxiolytics

Antipsychotics

Empirical trials of appropriate agents

Effective? • Continue as appropriate • Consider eventual empirical withdrawal

No
Tariot, et al. Tariot and Leibovici.

Yes

Nonpharmacologic Approaches
      

Modify environment Optimize stimulation Use consistent routines Assess/adapt to aggravating factors Behavior management principles Education Support of patient and caregivers

General Approach to Pharmacotherapy
 

   

Use psychotropics where appropriate Empirical trials of symptomatic pharmacotherapy for remaining symptoms Start low, go slow Assess target symptoms and toxicity Increase dose until benefit or toxicity Hold at nontoxic efficacious dose or subtoxic dose; levels may help

General Approach to Pharmacotherapy (cont.)


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If effective, continue for weeks to months, taper and re-evaluate If ineffective, taper and re-evaluate; consider second agent Medications do not always work