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Geriatric Psychiatry

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					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