Assessing behavioral disorders in the geriatric population
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Assessing Behavioral Disorders in the Geriatric Population. Long Term Care Dementia50-70% Affective disorders10-15% Schizophrenia0-4% Mental retardation/ Developmental disabilities1-5%. What Are the Most Common Psychiatric Disorders in the Elderly?. Outpatient Care

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Assessing Behavioral Disorders in the Geriatric Population

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Assessing behavioral disorders in the geriatric population

Assessing Behavioral Disorders in the Geriatric Population


What are the most common psychiatric disorders in the elderly

Long Term Care

Dementia50-70%

Affective disorders10-15%

Schizophrenia0-4%

Mental retardation/Developmental disabilities1-5%

What Are the Most Common Psychiatric Disorders in the Elderly?

Outpatient Care

  • Dementia 10% > age 65 45% > age 85

  • Depression4-5%

  • Substance abuse1-5%

  • Psychosis0.1-4%


Prevalence of dementia in the us

50

40

30

20

10

0

Prevalence of Dementia in the US

  • >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

32

Prevalence of Dementia (%)

16

8

4

2

1

60-65

65-70

70-75

75-80

80-85

>85

Age (year)


Nursing facilities demographics

Over age 65

5% live in nursing homes now

25% to 50% will live in nursing homes at some point in their lives

Over age 85

25% live in nursing homes

Prevalence of mental disorders in nursing homes is estimated to be more than 75%

Nursing Facilities Demographics

  • 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

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

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

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

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

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

Functional

QEEG

SPECT

PET

fMRI

MRS

Examples of Imaging Techniques

  • Structural

    • CT

    • MRI


What functional imaging can show

Parietal/temporal deficits

Focal, asymmetric, cortical subcortical deficits

Parietal deficits

Frontal/global deficits

What Functional Imaging Can Show

  • Alzheimer’s disease

  • Vascular dementia

  • Parkinson dementia

  • Depression


Ipa consensus statement

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

Behavioral Scales Used to AssessNeuropsychiatric Symptoms in Dementia

  • 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

Behavioral Disturbances Associated With Dementia

% of Patients

Range

Median

0-86

19

Disturbed affect/mood

Disturbed ideation

10-73

33.5

Altered perception

Hallucinations

21-49

28

Misperceptions

1-49

23

Agitation

Global

10-90

44

Wandering

0-50

18

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


Behavioral disturbances associated with dementia cont

Range

Median

11-51

24

Resistive/uncooperative

0-46

14.3

27-65

44

Anxiety

31.8

Withdrawn/passive behavior

21-88

Sleep

0-47

27

Diet-appetite

12.5-77

34

Behavioral Disturbances Associated With Dementia (cont.)

(% of Patients)

Aggression

Verbal

Physical

0-50

61

Vegetative behaviors

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


Neurobiology of behavioral disturbances in dementia

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

  • Decreased activity associated with psychotic features

  • Some behavioral benefit associated with cholinergic treatment


Neurobiology of behavioral disturbances in dementia cont

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 cont1

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 cont2

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 cont3

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


Neurobiology of behavioral disturbances in dementia cont4

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

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

Agitation

Physical

Verbal

Pacing

Inappropriate robing/disrobing

Trying to get to a different place

Handling things inappropriately

Restless

Stereotypy

Complaining

Requests for attention

Negativism

Repeated questions, phrases

Screaming

Cohen-Mansfield, et al. 1988.


Aggression

Aggression

Range

Median

Characteristic

Verbal

11% to 15%

24%

Threats

Accusations

Name-calling

Obscenities

Physical

0% to 46%

14%

Hitting

Kicking

Pushing

Scratching

Tearing

Biting

Spitting

Sexual

18% in 1 report


General approach to behavioral complications of dementia

General Approach to Behavioral Complications of Dementia

  • 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

Flow Chart for Management of Agitation in Dementia

Agitation

No

Acutely manageable?

Short-term sedation with antipsychotics, benzodiazepines

Yes

Effective?

Medical workup

No

  • Hospitalize

  • Restraints?

  • Seclusion?

Specific medical disorder

  • Treat specifically

  • Monitor agitation

  • Employ nonpharmacologic principles

Yes

Delirium

Yes

Discrete psychiatric disorder

No

Tariot, et al. Tariot and Leibovici.


Flow chart for management of agitation in dementia cont

Flow Chart for Management of Agitation in Dementia (cont.)

Employ nonpharmacologic

principles

Continue treatment as appropriate

Yes

Develop psychobehavioral metaphor, match to relevant class, continue attempting nonpharmacologic approaches

No

Successful?

Depressive features

Anxious features

Nonspecific

Manic features

Psychotic features

Antidepressants

Anticonvulsants

Anticonvulsants

Antidepressants

Anticonvulsants

Anxiolytics

Empirical trials of appropriate

agents

Antipsychotics

No

Effective?

  • Continue as appropriate

  • Consider eventual empirical withdrawal

Yes

Tariot, et al. Tariot and Leibovici.


Nonpharmacologic approaches

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

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

General Approach to Pharmacotherapy (cont.)

  • 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


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