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Geriatric Psychiatry: A Review & Update Medical and Neurologic Aspects. J. Wesson Ashford University of Kentucky VAMC, Lexington. Dementia Definition. Multiple Cognitive Deficits: Memory dysfunction At least one additional cognitive deficit Cognitive Disturbances:

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geriatric psychiatry a review update medical and neurologic aspects

Geriatric Psychiatry:A Review & UpdateMedical and Neurologic Aspects

J. Wesson Ashford

University of Kentucky

VAMC, Lexington

dementia definition
Dementia Definition
  • Multiple Cognitive Deficits:
    • Memory dysfunction
    • At least one additional cognitive deficit
  • Cognitive Disturbances:
    • Sufficiently severe to cause impairment of occupational or social functioning and
    • Must represent a decline from a previous level of functioning

Geriatric Psychiatry:

A Review & Update

differential diagnosis top ten
Differential Diagnosis: Top Ten

1. Alzheimer Disease (pure ~40%, + mixed~70%)

2. Vascular Disease, MID (5-20%)

3. Drugs, Depression, Delirium

4. Ethanol (5-15%)

5. Medical / Metabolic Systems

6. Endocrine (thyroid, diabetes), Ears, Eyes, Environ.

7. Neurologic (other primary degenerations, etc.)

8. Tumor, Toxin, Trauma

9. Infection, Idiopathic, Immunologic

10. Amnesia, Autoimmune, Apnea, AAMI

Geriatric Psychiatry:

A Review & Update

diagnostic criteria for dementia of the alzheimer type dsm iv apa 1994
Diagnostic Criteria For Dementia Of The Alzheimer Type(DSM-IV, APA, 1994)
  • Multiple Cognitive Deficits

1. Memory Impairment

2. Other Cognitive Impairment

B. Deficits Impair Social/Occupational

  • Course Shows Gradual Onset And Decline
  • Deficits Are Not Due to:

1. Other CNS Conditions

2. Substance Induced Conditions

E. Do Not Occur Exclusively during Delirium

F. Not Due to Another Psychiatric Disorder

Geriatric Psychiatry:

A Review & Update

vascular dementia dsm iv apa 1994
Vascular Dementia(DSM-IV - APA, 1994)
  • Multiple Cogntive Impairments
  • Deficits Impair Social/Occupational
  • Focal Neurological Signs and Symptoms or Laboratory Evidence Indicating Cerebrovascular Disease Etiologically Related to the Deficits
  • Not Due to Delirium

Geriatric Psychiatry:

A Review & Update

factors associated with multi infarct dementia
Factors Associated with Multi-infarct Dementia
  • History of stroke (especially in Nursing Home)
  • Step-wise deterioration
  • Cardiovascular disease - HTD, ASCVD, & Atrial Fib
  • Depression (left anterior strokes), personality change
  • More gait problems than in AD
  • MRI evidence of T2 changes (?? Binswanger’s disease)
  • SPECT / PET show focal areas of dysfunction
  • Neuropsychological dysfunctions are patchy

Geriatric Psychiatry:

A Review & Update

post cardiac surgery
Post-Cardiac Surgery
  • 53% post-surgical confusion at discharge (delirium)
  • 42% impaired 5 years later
  • May be related to anoxic brain injury, apnea
  • May be related to narcotic/other medication
  • May occur in those patients who would have developed dementia anyway (? genetic risk)
  • Cardio-vascular disease and stress may start Alzheimer pathology
  • Any surgery may have a similar effect related to peri-op or post-op anoxia or vascular stress

Geriatric Psychiatry:

A Review & Update

Newman et al., 2001, NEJM

drug interactions
Drug Interactions
  • Anticholinergics: amitriptyline, atropine, benztropine, scopolamine, hyoscyamine, oxybutynin, diphenhydramine, chlorpheniramine, many anti-histaminics
    • May aggravate Alzheimer pathology
  • GABA agonists: benzodiazepines, barbiturates, ethanol, anti-convulsants
  • Beta-blockers: propranolol
  • Dopaminergics: l-dopa, alpha-methyl-dopa
  • Narcotics: may contribute to dementia

Geriatric Psychiatry:

A Review & Update

depression
Depression
  • Onset: rapid
  • Precipitants: psycho-social (not organic)
  • Duration: less than 3 months to presentation
  • Mood: depressed, anxious
  • Behavior: decreased activity or agitation
  • Cognition: unimpaired or poor responses
  • Somatic symptoms: fatigue, lethargy, sleep, appetite disruption
  • Course: rapid resolution with treatment, but may precede Alzheimer’s disease

Geriatric Psychiatry:

A Review & Update

delirium definition
Delirium Definition
  • Disturbance of consciousness
    • i.e., reduced clarity of awareness of the environment with reduced ability to focus, sustain, or shift attention
  • Change in cognition (memory, orientation, language, perception)
  • Development over a short period (hours to days), tends to fluctuate
  • Evidence of medical etiology

Geriatric Psychiatry:

A Review & Update

ethanol
Ethanol
  • Possibly Neuroprotective
    • May not kill neurons directly
  • Accidents, Head Injury
  • Dietary Deficiency
    • Thiamine – Wernicke-Korsakoff syndrome
  • Hepatic Encephalopathy
  • Withdrawal Damage (seizures) Delayed Alcohol Withdrawal
    • Watch for in hospitalized patients
  • Chronic Neurodegeneration
    • Cerebellum, gray matter nuclei

Geriatric Psychiatry:

A Review & Update

medical endocrine
Medical / Endocrine
  • Thyroid dysfunction
    • Hypothyoidism – elevated TSH
      • Compensated hypothyroidism may have normal T4, FTI
    • Hyperthyroidism
      • Apathetic, with anorexia, fatigue, weight loss, increased T4
  • Diabetes
  • Hypoglycemia (loss of recent memory since episode)
  • Hyperglycemia
  • Hypercalcemia
  • Nephropathy, Uremia
  • Hepatic dysfunction (Wilson’s disease)
  • Vitamin Deficiency (B12, thiamine, niacin)
    • Pernicious anemia – B12 deficiency, ?homocysteine

Geriatric Psychiatry:

A Review & Update

eyes ears environment
Eyes, Ears, Environment
  • Must consider sensory deficits might contribute to the appearance of the patient being demented
  • Central Auditory Processing Deficits (CAPD)
  • Hearing problems are socially isolating
  • Visual problems are difficult to accommodate by a demented patient, ?To do cataract op?
  • Environmental stress factors can predispose to a variety of conditions
  • Nutritional deficiencies (tea & toast syndrome)

Geriatric Psychiatry:

A Review & Update

neurological conditions
Neurological Conditions
  • Primary Neurodegenerative Disease
    • Diffuse Lewy Body Dementia (? 7 - 50%)
    • Fronto-temporal dementia (tau gene)
  • Focal cortical atrophy
    • Primary progressive aphasia (many causes)
    • Unilateral atrophy, hypofunction on EEG, SPECT, PET
  • Normal pressure hydrocephalus
    • Dementia with gait impairment, incontinence
    • Suggested on CT, MRI; need tap, ventriculography
  • Other Neurologic Conditions

Geriatric Psychiatry:

A Review & Update

slide15
Tumor
  • Toxins
  • Trauma

Geriatric Psychiatry:

A Review & Update

infectious conditions affecting the brain
Infectious Conditions Affecting the Brain
  • HIV
  • Neurosyphilis
  • Viral encephalitis (herpes)
  • Bacterial meningitis
  • Fungal (cryptococcus)
  • Prion (Creutzfeldt-Jakob disease); (mad cow disease)

Geriatric Psychiatry:

A Review & Update

amnesic disorders
Amnesic Disorders
  • Amnesia
    • Dissociative: localized, selective, generalized
    • Organic - damage to CA1 of hippocampus
      • thiamine deficiency (WKE), hypoglycemia, hypoxia
  • Epileptic events
    • Partial complex seizures
  • Specific brain diseases
    • Transient global amnesia
    • Multiple sclerosis

Geriatric Psychiatry:

A Review & Update

age associated memory impairment vs mild cognitive impairment
Age-Associated Memory ImpairmentvsMild Cognitive Impairment
  • Memory declines with age
  • Age - related memory decline corresponds with atrophy of the hippocampus
  • Older individuals remember more complex items and relationships
  • Older individuals are slower to respond
  • Memory problems predispose to development of Alzheimer’s disease

Geriatric Psychiatry:

A Review & Update

advances in alzheimer s disease

Advances in Alzheimer’s Disease

Uncovering etiology

Understanding pathophysiology

Better screening tools

Improved diagnosis

Developing interventions

etiology
Etiology
  • Age - therefore - design and stress
  • Genetics (amyloid related)
  • Relation to vascular factors, cholesterol, BP
  • Education (? design vs protection)
  • Environment - diet, exercise, smoking

Geriatric Psychiatry:

A Review & Update

neuropathology of ad
Neuropathology of AD
  • Senile plaques
  • Neurofibrillary tangles
  • Neurotransmitter losses
  • Inflammatory responses

New Neuropath Mechanisms

  • Amyloid PreProtein (APP - ch21)
  • Tau phosphorylation (relation to dementia)

Geriatric Psychiatry:

A Review & Update

biopsychosocial systems affected by ad all related to neuroplasticity
Biopsychosocial Systems Affected by AD(all related to neuroplasticity)
  • Social Systems
    • Basic ADLs - Late
  • Psychological Systems
    • Primary Loss Of Memory
    • Later Loss Of Learned Skills
  • Neuronal Memory Systems
    • Cortical Glutamatergic Storage
    • Subcortical (acetylcholine, norepi, serotonin)
    • Cellular Plastic Processes
      • APP metabolism – early, broad cortical distribution
      • TAU hyperphosphorylation – late, focal effect, dementia related

Geriatric Psychiatry:

A Review & Update

why diagnose ad early
Why Diagnose AD Early?
  • Safety (driving, compliance, cooking, etc.)
  • Family stress and misunderstanding (blame, denial)
  • Early education of caregivers of how to handle patient (choices, getting started)
  • Advance planning while patient is competent (will, proxy, power of attorney, advance directives)
  • Patient’s and Family’s right to know
  • Specific treatments now available, may delay nursing home placement longer if started earlier

Geriatric Psychiatry:

A Review & Update

need for better screening and assessment tools
Need for Better Screening and Assessment Tools
  • Genetic vulnerability testing
  • Early recognition (10 warning signs)
  • Screening tools (6th vital sign in elderly)
  • Positive diagnostic tests
    • CSF – tau levels elevated, amyloid levels low
    • Brain scan – PET – DDNP, Congo-red derivatives
  • Dementia severity assessments
  • Tracking progression rate, prediction of change

Geriatric Psychiatry:

A Review & Update

alzheimer warning signs top ten alzheimer association
Alzheimer Warning SignsTop TenAlzheimer Association

1. Recent memory loss affecting job

2. Difficulty performing familiar tasks

3. Problems with language

4. Disorientation to time or place

5. Poor or decreased judgment

6. Problems with abstract thinking

7. Misplacing things

8. Changes in mood or behavior

9. Changes in personality

10. Loss of initiative

Geriatric Psychiatry:

A Review & Update

assessment
Assessment
  • History Of The Development Of The Dementia
  • Physical Examination
  • Neurological Examination

Geriatric Psychiatry:

A Review & Update

neurological exam
Neurological Exam
  • Cranial Nerves
  • Sensory Deficits
  • Motor
  • Deep tendon
  • Pathological

Geriatric Psychiatry:

A Review & Update

slide28
Geriatric Psychiatry:

A Review & Update

slide29

Mini-Mental State Exam items

Geriatric Psychiatry:

A Review & Update

laboratory tests
Laboratory Tests

ROUTINE

  • Routine – Blood tests & Urinalysis
  • EKG
  • Chest X-Ray
  • Anatomical Brain Scan – CT (cheapest), MRI

SPECIAL

  • Functional Brain Imaging (SPECT, PET)
  • EEG, Evoked Potentials (P300)
  • Reaction Times
  • CSF Analysis - Routine Studies
  • Heavy Metal Screen (24 hr urine)
  • Genotyping

Geriatric Psychiatry:

A Review & Update

justification for brain scan in dementia diagnosis
Justification for Brain Scan in Dementia Diagnosis
  • Differential Diagnosis: Tumor, Stroke, Subdural Hematoma, Normal Pressure Hydrocephalus, Encephalomalacia
  • Confirmation of atrophy pattern
  • Estimation of severity of brain atrophy
  • MRI shows T2 white matter changes
    • Periventricular, basal ganglia, focal vs confluent
    • These may indicate vascular pathology
  • SPECT, PET - estimation of regions of physiologic dysfunction, areas of infarction
  • Helps family to visualize problem

Geriatric Psychiatry:

A Review & Update

slide32
Geriatric Psychiatry:

A Review & Update

slide33
Geriatric Psychiatry:

A Review & Update

slide34
Geriatric Psychiatry:

A Review & Update

slide35

Ashford et al,

2000

Geriatric Psychiatry:

A Review & Update

interventions
INTERVENTIONS
  • Only successful intervention –
    • Cholinesterase Inhibition

(1st double blind study - Ashford et al., 1981)

  • Available Interventions –
    • Not yet proven or unconvincing effects
  • Promising Interventions

Geriatric Psychiatry:

A Review & Update

other medical conditions
Other Medical Conditions
  • Chronic pain syndrome
  • Medical consultation-liaison

Other Neurological Conditions

  • Parkinson’s disease
  • Guillan Barre syndrome
  • Huntington’s disease
  • Seizure disorders – partial complex seizures

Geriatric Psychiatry:

A Review & Update

parkinson s disease
Parkinson’s Disease
  • Increases steadily after 50 years of age
  • Pathophysiology
  • Concomitant conditions
  • Parkinson signs
  • Symptomatic treatment

Geriatric Psychiatry:

A Review & Update

electroencephalography
Electroencephalography
  • Seizure disorders
    • Sensitivity – 50% (90% after 3 recordings)
  • Episodic behavior problems
    • Possible partial seizure disorder
  • Generalized slowing
    • Primary neurodegeneration
    • Temporal slow waves may be “normal”
  • Focal slowing (stroke, focal cortical disease)
  • Specific neurologic syndromes
    • Creutzfeldt-Jakob disease
  • Sleep disorders
    • In sleep studies: used to define stages

Geriatric Psychiatry:

A Review & Update

behavioral problems in dementia patients
Behavioral Problems In Dementia Patients
  • Mood Disorders – depression – early in AD
  • Psychotic Disorders
    • Particularly paranoia, e.g, people stealing things
  • Agitation
  • Meal Time Behaviors
  • Sleep Disorders

Geriatric Psychiatry:

A Review & Update

neuropsychiatric treatments
Neuropsychiatric Treatments
  • First treat medical problems
  • Second environmental interventions
  • Third neuropsychiatric medications

Geriatric Psychiatry:

A Review & Update

sleep disorders
Sleep Disorders
  • Primary sleep problems
    • Breathing-related sleep disorders
    • Narcolepsy / primary hypersomnia
    • Circadian rhythm disorders
    • Parasomnias
  • Secondary sleep problems
    • Due to a psychiatric condition: depression, psychosis
    • Due to a medical condition: arthritis, parkinson’s
    • Substance induced disorders
    • Fragmented circadian rhythms, sleep in AD

Geriatric Psychiatry:

A Review & Update

insomnia
Insomnia

15% of patients in sleep labs have sleep disturbance not associated with extrinsic factors or other conditions

  • Periodic limb movement, restless leg syndrome
    • Sinemet or anti-convulsants
  • PTSD, nightmares (trazodone, prazosin)
  • Jet lag (? melatonin)
  • Drugs: caffeine, nicotine,
    • Sleeping pill rebound

Geriatric Psychiatry:

A Review & Update