Overview of dementia depression and schizophrenia in the elderly
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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 ofTreatment Psychological LifeMental DisorderInitiatives Personal ChronicleDisruptive Life StoriesRescript

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Overview of dementia depression and schizophrenia in the elderly

Overview of Dementia, Depression and Schizophrenia in the Elderly

Peter Betz, M.D.


Hierarchical levels of human mental life

Hierarchical Levels of Human Mental Life

Components of Modes ofTreatment

Psychological LifeMental DisorderInitiatives

Personal ChronicleDisruptive Life StoriesRescript

ConstitutionalProblematic DispositionsGuide

Dimensions

Motivational RhythmsBehavior DisordersInterrupt

Cerebral FacultiesPsychiatric DiseasesRemedy

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


Fda approved treatments for complications of ad

FDA Approved Treatments for Complications of AD


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.


What not to use

What NOT To Use


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)


What not to use1

What NOT To Use


Overview of dementia depression and schizophrenia in the elderly

ECT


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)


Clinical recepterology

Clinical Recepterology


Dissociation constants

Dissociation Constants


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