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Overview of Dementia, Depression and Schizophrenia in the Elderly. Peter Betz, M.D. Hierarchical Levels of Human Mental Life. Components of Modes of Treatment Psychological Life Mental Disorder Initiatives Personal Chronicle Disruptive Life Stories Rescript

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hierarchical levels of human mental life
Hierarchical Levels of Human Mental Life

Components of Modes of Treatment

Psychological Life Mental Disorder Initiatives

Personal Chronicle Disruptive Life Stories Rescript

Constitutional Problematic Dispositions Guide

Dimensions

Motivational Rhythms Behavior Disorders Interrupt

Cerebral Faculties Psychiatric Diseases Remedy

McHugh and Slavney

dementia is now neurocognitive disorder ncd
Dementia is now ‘Neurocognitive Disorder’(NCD)

Further Defined as ‘Major’ or ‘Minor’

what s in a name
What’s in a name?
  • Greater phenomenological correctness – especially with the growing base of literature defining specific aetiologies
  • Broader term - can include syndromes with only one cognitive domain affected (e.g. ‘amnestic d/o’)
  • NCD is often the preferred term in the literature and in practice – such as in younger individuals or those with TBI
  • Dementia is ok to still use if it helps communicate the nature of the illness
neurocognitive disorder
Neurocognitive Disorder

Major

Minor

Concern of the individual, informant or clinician

‘modest’ cognitive decline – preserved IADLs but needs compensatory strategies or accommodation

Not due to delirium or another mental disorder

  • Concern of the individual, informant or clinician
  • ‘significant’ cognitive decline – needs IADL assistance
  • Not due to delirium or another mental disorder
alzheimer disease
Alzheimer Disease
  • Probable – all 3
    • 331.0 +
    • 294.10 or 294.11
  • Possible – not all 3
    • 331.9
    • No coding +/- behavioral disturbance
  • Insidious onset and gradual progression without plateaus
  • Impairment in Memory/Learning and one other area
  • No mixed etiologies
vascular ncd
Vascular NCD
  • *Onset temporally related to cerebrovascular event(s)

-or-

  • Prominent impairment in complex attention (processing speed) or executive function (planning, organizing, sequencing, abstraction)
  • Hx, PE &/or *Imaging shows evidence of sufficient vascular disease
  • Probable (290.4) if * is present in your decision tree
  • Possible (331.9) if no *
  • No coding +/- behavioral disturbance for either possible or probable
ncd with lewy bodies
NCD with Lewy Bodies
  • Core Features
    • Fluctuating cognition
    • Well defined VH
    • Parkinsonism onset subsequent to cognitive decline
  • Suggestive Features
    • REM sleep disorder
    • Severe neuroleptic sensitivity
  • Probable
    • 2+ bullets including at least one core feature
    • 331.82 + 294.10/294.11
  • Possible
    • 1 bullet
    • 331.82
    • No coding +/- behavioral disturbance
frontotemporal ncd
Frontotemporal NCD

Behavioral Variant

Language Variant

Prominent decline in one:

Form of speech production

Word finding

Object naming

Grammar

Word comprehension

Relative sparing of learning /memory and perceptual-motor function

  • 3 or more bullets:
    • Behavioral disinhibition
    • Apathy or inertia
    • Loss of sympathy or empathy
    • Perseverative, stereotyped or compulsive/ritualistic behavior
    • Hyperorality and dietary changes
  • Relative sparing of learning /memory and perceptual-motor function
frontotemporal ncd1
Frontotemporal NCD
  • Probable
    • Evidence of disproportionate frontal &/or temporal involvement
    • 331.19 +
    • 294.10/294.11
  • Possible
    • 331.9
      • No coding +/- behavioral disturbance
common complications of ad
Common Complications of AD
  • Anosognosia (50%)
    • e.g. unawareness of illness, not “psychological” denial
  • Apathy (25-50%)
    • inanition, poor persistence
  • Psychosis
    • delusions (20%), hallucinations(15%)
  • Mood Disorders
    • depression (20%), anxiety (15%)
  • Agitation / Aggression (50-60%)
    • wandering, restlessness, verbal and physical attacking
  • Sundowning (25%)

Textbook of Alzheimer Disease and Other Dementias, Weiner & Lipton, 2009

interventions medication
Interventions - Medication
  • Cholinesterase Inhibitors
    • tacrine, donepezil, rivastigmine, galantamine
  • Memantine
  • Vitamin E
  • Monoamine Oxidase Inhibitor
    • selegeline
  • GinkoBiloba
  • Anti-Inflamatory Agents
  • Estrogen Replacement Therapy
  • Lipid Lowering Agents
non medicinal interventions
‘Non-Medicinal’ Interventions
  • Education, support, counseling, community resources
    • for the patient AND the caregiver
  • Long-Term Planning
    • state and private resources
    • will
    • durable power of attorney
    • advance directive
non medicinal interventions1
‘Non-Medicinal’ Interventions
  • Environmental / Home Safety
    • remove dangerous objects
      • Medications, clutter
    • beware:
      • water temperature, stairs, sharp furniture, glassware, windows, locks, kitchen equipment
    • assess activities of daily living
    • institutionalization
    • driving
behavioral management
Behavioral Management
  • Environmental vs. Medication
    • meds are a last resort
the 4 d approach

The “4D Approach”

adapted from

Practical Dementia Care

by Rabins, Lyketsos, and Steele

our assumptions
Our Assumptions:
  • Behavioral dyscontrol can have multiple etiologies.
  • They can be distinguished from each other.
  • Identifying the cause can directly lead to treatment strategies.
  • There is rarely “one-best” approach to address these issues.
  • Directed“trial and error” is the rule, not the exception.
the 4 d approach1
The “4D Approach”
  • Define and Describe
  • Decode
  • Devise a treatment plan
  • Determine “does it work?”
behavioral management1
Behavioral Management
  • Environmental vs. Medication
    • meds are a last resort
  • If you chose a medication… Which One?
    • antipsychotics
      • typical vs. atypical
    • benzodiazepine
    • other
      • e.g valproate
catie ad lon s schneider et al
CATIE-ADLon S. Schneider et. Al.
  • Primary outcome – time to discontinuation for any reason
    • great “real world” approach to study design
  • Atypicals were no better “tolerated”
  • Big media spin after data released:
    • Known higher mortality per FDA.
    • Now evidence of “lack of efficacy.”
    • Therefore, doctors are abusing elderly patients.
  • Actually, study shows:
    • Placebo stopped more due the lack of benefit than S.E.
    • Atypicals stopped more due to S.E. than lack of benefit.
what you and your patients should watch for
What you (and your patients) should watch for:
  • EPS
  • Dystonia
  • Akathisia
  • NMS
  • TD
  • Glucose Dyscontrol
  • Cholesterol Dyscontrol
  • Delirium
  • Torsades de pointes
  • Postural hypotension
  • Weight gain
  • Agranulocytosis
  • Increased risk of all cause death
what about anticonvulsants
What About Anticonvulsants?
  • Initial trials were promising, but…
  • Most recent studies show far less benefit if not more behavioral discontrol
  • However, can be helpful in some augmenting strategies or in catastrophic reactions.
benzodiazepine side effects
Benzodiazepine Side Effects
  • Sedation
  • Deliriogenic
  • Behavioral disinhibition
  • Emotional lability
  • Cognitive impairment – particularly amnesia
  • Ataxia
  • Respiratory depression
  • Rebound insomnia and anxiety
  • Withdrawal / Physiologic dependence
major depression
Major Depression

DSM-5 – 5 of 9

Betz – 2 of 3

Dysphoric change in mood

sadness, irritability, no ‘yeah’

Impaired self-attitude

low self-esteem, worthlessness, guilt, etc.

Neurovegitative symptom impairment

eating, sleeping, energy, conc., sex drive, etc.

  • *Depressed mood (reported or observed)
  • *Markedly diminished interest /pleasure
  • >5% weight loss or gain
  • Insomnia or hypersomnia
  • Psychomotor slowing or agitation (observable)
  • Fatigue or loss of energy
  • Worthlessness or inappropriate guilt (not of being sick)
  • Poor concentration
  • Recurrent thoughts of death
dysthymia 2 years
Dysthymia (>2 years)

DSM – 5

Betz – 2 of 3

Dysphoric change in mood

sadness, irritability, no ‘yeah’

Impaired self-attitude

low self-esteem, worthlessness, guilt, etc.

Neurovegitative symptom impairment

eating, sleeping, energy, conc., sex drive, etc.

  • Depression
  • 2 of 6
    • Poor appetite or overeating
    • Insomnia or hypersomnia
    • Low energy or fatigue
    • Low self-esteem
    • Poor concentration or difficulty making decisions
    • Feelings of hopelessness
premenstrual dysphoric disorder
Premenstrual Dysphoric Disorder
  • At least one:
    • Affective liability
    • Depressed mood, hopelessness
    • Anxiety, tension
  • At least one:
    • Apathy
    • Poor concentration
    • Anergia, lethargy
    • Sense of being overwhelmed
    • Physical symptoms (e.g. bloating, breast tenderness, joint pain etc.)
  • 5 of 9 symptoms present in week before menses
  • Improves within a few days of onset of menses
  • Absent (or minimal) the week post menses
my most worrisome issues
My Most Worrisome Issues
  • Hopelessness
  • Suicide
    • NIMH
      • 18% of total in those ≥ 65yo (only 13% of pop)
      • 6x higher risk if ≥ 80yo
    • suicidal thoughts in 7% of elderly
    • suicidal thoughts in 30% of elderly with MDD
    • 20% saw physician within 24 hours
    • 41% saw physician within 1 week
    • 75% saw physician within 1 month
acute management
Acute Management:
  • Antidepressant + psychotherapy
    • Alternate:
      • Mild – meds alone or psychotherapy alone
      • Severe – meds alone or ECT
what antidepressants
What Antidepressants?
  • SSRI
    • escitalopram, citalopram, sertraline
    • (avoid paroxetine, fluoxetine, fluvoxamine)
  • SNRI
    • venlafaxine, duloxetine
  • buproprion
  • mirtazapine
  • TCA
    • NTP, protriptyline, desipramine
    • (avoid others such as amytriptyline)
psychosocial interventions
Psychosocial Interventions
  • Psychotherapy
    • supportive, cog-behav, problem solving, interpersonal
  • Education
  • Family Counseling
  • Visiting nurse to help with meds
  • Bereavement groups
  • Senior citizen center
schizophrenia
Schizophrenia
  • 1 Month: Two or More (has to include 1 of first 3):
    • Delusions
    • Hallucinations
    • Thought Disorder
    • Catatonia
    • Negative Symptoms
      • Ambivalence, Autism, Affect, Associations
  • Functional Impairment
  • Continued disturbance for 6 months
    • may be just negative symptoms
  • No longer has subtypes (except w or w/o catatonia)
psychosocial interventions1
Psychosocial Interventions
  • Psychotherapy
    • supportive, cog-behav, problem solving, interpersonal
  • Education
  • Family Counseling
  • Visiting nurse to help with meds
  • Bereavement groups
  • Senior citizen center
lets define the atypicals
Lets Define the Atypicals
  • Atypical: “Deviating from what is usual or common or to be expected” – Websters
  • So, what are Typical Antipsychotics?
    • Drugs that had high probability of inducing Extrapyramidal Side Effects (EPS)
      • EPS ≡ Parkinsonism
        • via high D2 antagonism
  • High Potency vs. Low Potency
    • EPS generally mitigated by anticholinergic activity
    • exception is risperidone which uses 5HT2 antagonism
  • Examples:
    • high: haloperidol, fluphenazine, droperidol, pimozide
    • low: chlorpromazine, thioridazine,
lets define the atypicals not a class created of equals
Lets Define the Atypicals – not a class created of equals
  • Clozapine (Clazaril)
  • Risperidone (Risperdal)
  • Olanzapine (Zyprexa)
  • Quetiapine (Seroquel)
  • Ziprasidone (Geodon)
  • Aripiprazole (Abilify)
  • Paliperidone (Invega)
  • Asenapine (Saphris)
  • Iloperidone (Fanapt)
  • Lurasidone (Latuda)
ad