Delirium Worsens prognosis- significant mortality rate Lengthens stay in hospital- longer in bed,...

Delirium

• Worsens prognosis- significant mortality rate

• Lengthens stay in hospital- longer in bed, falls, pneumonia

• Increased rates of institutionalisation

• Potentially treatable

• Up to 2/3 not detected

Delirium: Clinical Features

• Clouding of consciousness, attention, memory, executive function all affected

• 2 types

• Apathetic

• Active, psychotic, behavioural symptoms

• Symptoms worse at night

Delirium:Risk Factors

• Increasing age• Dementia• Sensory deficits• Previous episode• Severe comorbidity• Immobility• Sleep Disturbance• Alcohol Consumption• Operation• Dehdration• Low albumin

Delirium-Medication Risk factors

• Benzodiazepines

• Anticholinergics

• Opiates

• Digoxin

• Warfarin

Delirium Causes

• Almost anything in combination with risk factors

Delirium-Tips

• Sudden deterioration in mental state consider delirium

• The greater the number of risk factors the more delirium is likely

• Sometimes delirium can go on for weeks

Delirium:Treatment

• Identify and treat cause

• Modify risk factors

• Infections, metabolic, malignancy, cardiac, vascular

• Consider hospital admission

Delirium:TreatmentThe eight ates or Nice Coat

• Noise abate• Illuminate• Communicate• Environment manipulate• Carer participate• Orientate• Ambulate• Thermoregulate

Delirium:Medication

• If hyperactive and psychotic

• Antipsychotic-haloperidol

• Olanzapine, quetiapine

• Lorazepam

The Dementias

• Normal Ageing

• Mild Cognitive Impairment (MCI)

• Dementia

The Dementias: Clinical Features

• Progressive• Impairment of cognition, personality and intellect• Orientation,• Memory,• Language(dysphasia)• Ability to carry out tasks(praxias)• Recognition (agnosia)

The Dementias-Executive Function Impairment

• Planning

• Organising

• Abstract thinking

• Multi tasking

The Dementias: Behavioural and Psychological Symptoms in

Dementia- BPSD• Why are they important?

• Predict carer distress and breakdown of supportive network

• Predict institutionalisation

• Nearly 90% of admissions to Larch


Dementia- BPSD• Mood

• Anxiety as a presentation

• Anxiety as a concomitant

• Depression

• Elation- often pre existing bipolar disorder


Dementia- BPSD• Psychosis

• Delusions

• Phantom lodger

• Misidentifications e.g.Capgras

• Persecutory

The Dementias: Behavioural and Psychological Symptoms in Dementia- BPSD-Psychosis

• Hallucinations

• Auditory- music, voices

• Visual-people, animals


Dementia- BPSD• Wandering

• Agitation

• Day night reversal

• Verbal Aggression

• Physical Aggression

• Disinhibition

• Apathy

The Dementias: Causes

• Subdural• Brain tumour• Normal pressure hydrocephalus• Hypothyroidism• Low B12/folate• Syphilis• Diabetes• Chronic infection• Uraemia

The Dementias: Causes

• Alzheimer’s Disease(AD) 50%

• Vascular Dementia(VaD) 10%

• Mixed Dementia-Alzheimer’s with cerebrovascular disease AD/VaD 25%

• Dementia with Lewy Bodies(DLB) 10%

• Fronto Temporal Dementia (FTD) 2%

Alzheimer’s disease

• Plaques, tangles

• Insidious onset

• Gradual decline

• Memory orientation difficulties early on

• Executive function impairment

• Later on dyshasia, dyspraxia, agnosia

Vascular Dementia

• Pure form not that common

• Single large infarct

• Multi infarct dementia

• Subcortical dementia

RISK FACTORS

• Male

• Stroke/TIA

Alzheimer’s with Cerebrovascular disease

Gradual deterioration• RISK FACTORS1. Family history dementia2. Increasing age3. Atrial fibrillation4. Hypertension5. Hypercholesterolaemia6. Diabetes7. Homocysteine8. ?Lack of Exercise

Modifying Risk

• NB long latency(10+ years) between modifying risk factor and seeing effect on disease

• ANTIOXIDANTS• Vitamins C & E in combination• ?Vitamin E delaying institutionalisation• ANTIANFLAMMATORIES• Non steroidal antiinflammatory agents ?Some

benefit if taken over many years

Modifying Risk

• Tobacco- risk not reduced-stimulation of nicotinic receptors offset by other deleterious effects

• Alcohol- mild drinking up to 3 units of wine per day benefit

• Statins- beneficial in TIAs, stroke, hypercholesterolaemia, dementia-mixed results. May increase alpha secretase

• B12 & folate long term to reduce homocysteine?• Oestrogen?• Increased exercise?• Mental stimulation?

Modifying Risk

• Fish 3x/week

• Curry-turmeric

• Smart drugs?

• Bandolier’s 10 Tips

Dementia and Parkinson’s Disease(PD)

• PD and subcortical dementia

• PD and AD

• PD and hallucinations from treatment

• Dementia with Lewy Bodies(DLB)

Dementia with Lewy Bodies

• Fluctuating course

• Visual hallucinations

• Spontaneous features of Parkinsonism

Dementia with Lewy Bodies

• Falls

• Syncope

• Systemised delusions

• Hallucinations in other modalities

• Neuroleptic sensitivity

Fronto Temporal Dementia

• 30% of younger onset dementia(45-65yrs)• Duration 8yrs1. Overactive-disinhibted, lack of

concern(orbitomedial frontal, anterior temporal)2. Apathetic-perseveration, rigid thinking, lack of

volition(pan frontal)3. Stereotyped ritualistic behaviour(striatum)4. Semantic dementia-unable to understand

meaning of words, objects, sensations5. Progressive non fluent dyshasia

Fronto Temporal Dementia

• Liking for sweet things

• Emotional blunting

• Striking loss of insight

• Ability may be enhanced-artistic or musical

• Tip-frontal lobe symptoms often precede memory problems

Other Dementias

• Subdural haematoma-history of fall

• Creutzfeld-Jacob Disease-Classical-rapid decline, myoclonus, abnormal EEG, death in < 1 yr

• Normal pressure hydrocephalus- cognitive change, gait abnormality, urinary incontinence

The Dementias: Identify and Diagnose

• History

• Cognitive testing

• Primary Care 6CIT MMSE

• Physical examination

The Dementias: Dementia Screen

• FBC ESR• U&Es• LFT’s, Calcium, protein• Blood Sugar• Lipids• B12&folate• TFTs• Serological Tests for syphilis• ECG

Referral to Old Age Psychiatry

• Early for diagnosis, comprehensive assesment

Treatment With A Cholinesterase Inhibitor (CHEI)

• Mild to moderate AD, Mixed AD/VaD, DLB

• Secondary Care

• Shared Care Protocol

Dementias:Treatment

• Memory clinic

• History

• Examination

• Investigation

• Diagnosis

• Treatment

Memory Clinic

• Patient and carer(s)• Detailed assessment and review• Mini Mental State Examination• Clock Drawing Test• Demtect• Executive Function• Bristol Activities of Daily Living• Peripatetic

NICE Guidelines(2001)

• Mild to moderate Alzheimer’s Disease• >12 MMSE• Diagnosis in specialist clinic• Treatment initiated by specialist but may be continued by

primary care under shared care protocol• Seek carers’ views• Assess 2-4/12 after maintenance dose. Continue only if

improvement in MMSE score or no deterioration and behavioural or functional improvement

• Review every 6/12- MMSE must remain >12 and worthwhile effect on global functional and behavioural condition

Goals of Treatment

• Enhance Cognition

• Increase autonomy

• Decrease behavioural symptoms

• Slow or arrest progression of the disease

• Primary prevention in the presymptomatic stage

Memory Clinic- Indications for CHEIs

• Dementia screen

• ECG

• Neuropsychological testing-if MMSE>19

• CT Brain scan with medial temporal lobe views

• One hit

Memory Clinic

• If AD, mixed dementia or DLB

• MMSE >12

• Compliance with medication

• Regular observation of patient

• No contraindications

Memory Clinic

• Prescribe CHEI

• Patient and carer information

• Support or care at home

• Monitoring and treatment of BPSD

• Review 3/12 after stabilisation

Memory Clinic

• Review

• Usually every 6/12

• MMSE, CDT, EF, BADL?

• Continue if evidence of benefit- not so easy to decide!

Memory Clinic

• Stopping CHEIs

• MMSE <12

• Marked deterioration

• Withdraw over 2/52

• Often severe relapse- need to restart within 4/52

The Dementias:CHEIs

• Side effects-cholinergic-nausea, headache,sweating, bradycardia dizziness

• Cautions-asthma, sick sinus syndrome• Outcome-actual improvement in behaviour

cognition, function, psychosis• Slowing of deterioration• Up to 18/12• Stopping

The Dementias: Treatment Memantine

• Licensed for moderate to severe dementia

• Not supported by Priorities Committee in W Berks

• Modest evidence of benefit in cognition, ADL, behaviour

Other Treatments

• NSAIDs-Low rates of AD in patients with RA. Insufficient evidence

• HRT- no effect in established disease, possibly preventative

Other Treatments: Antioxidants

• Vitamin E ? Delays institutionalisation. Dose 1000 IU/day

Gingko Biloba- some benefit reported from German studies

• May interact with anticoagulants

Possible FutureTreatments

• Prevent plaque formation

• Vaccination –Beta amyloid

• Nerve growth factor

• Stem cells

The Dementias: Other Pharmacological Treatments

• Agitation, irritability, anxiety and verbal aggression

• Trazodone 50mgs/day up to 250mgs day• Sedation, anticholinergic • Citalopram 10-20mgs/day up to 40mgs/day• palpitations., postural hypotension,

confusion• Depression- antidepressant


• Acute severe anxiety or agitation

• Lorazepam 0.5 mgs up to tds

• Respiratory depression, sedation, paradoxical agitation

• Chronic agitation and restlessness-clomethiazole


• Agitation, aggression-mood stabilisers• Sodium valproate 200mgs up to 1200mgs• Liver impairment, GI side effects, drowsiness or

aggression• Carbamazapine 50mgs bd up to 1g/day• AV conduction defects,blurred vision. Dizziness,

unstaediness GI side effects, confusion, agitation,, rash(Stevens Johnson), blood dyscrasia


• Agitation & psychosis

• CHEIs

The Dementias: Antipsychotics

• Psychotic symptoms, agitation, sexual disinhibition

• Typicals; haloperidol 0.5mgs up to tds

• Sedation, EPS,

• Benperidol: sexual disinhibition

The Dementias: Antipsychotics Atypicals

• Quetiapine 25mgs/day up to 400mgs/day• sedation• Amisulpride 25mgs/day up to 300mgs/day• hypotension, sedation• Olanzapine 2.5mgs/day up to 20mgs/day• sedation weight gain, cves, mortality • Risperidone 0.5mg/day up to 2mgs/day• EPS,sedation, agitation, cves• Aripiprazole?-dopamine stabiliser

The Dementias: Non Pharmacological treatments

• Behaviour therapy- antecedents, behaviour, consequences

• Individuals preferences

• Context of behaviour

• Reinforcement strategies to reduce the behaviour

• Limited application

The Dementias: Non Pharmacological Treatments -

Reality orientation

• Signposts

• Notices

• Memory aids

• effective

The Dementias: Validation therapy

• Retreat into inner world to avoid stress, boredom & loneliness

• Validation-empathy with feelings and hidden meanings behind the confusion

• ?Effective

The Dementias:Reminiscence

• May help social interaction, motivation, self care and reduce behavioural symptoms

• At all severities of dementia

The Dementias: Art Therapy

• Self expression through painting not relying on language

• Stimulation, communication, social interaction

The Dementias:Music Therapy

• Active participation or listening

• Social interaction

• Can help those with abnormal vocalisations

• Reductions in agitation for music tailored to individual

The Dementias: Activity Therapy

• Dance, drama. Sport

• Physical activity, reduces falls, improves sleep, mood and confidence

• Day time activity-reductions in agitaion and restlessness at night

The Dementias:Complementary Therapies

• Massage,

• Reflexology,

• Herbal medicine

• Efficacy not known

The Dementias: Aromatherapy

• Lavandula augustifolia melissa officianalis

• Inhalation, bathing or topical

• Reductions in agitation

• Well tolerated

The Dementias: Light and Multisensory

• BrightLight Therapy

• Beneficial in sleep disturbance

• MultiSensory Approaches

• Fibreoptics, cushions& vibrating pads, liquid wheels

• ?improvements in agitation

The Dementias: Cognitive Behaviour Therapy

• Early dementia

• Misinterpretations, biases, distortions, erroneous problem solving strategies, communication problems

• Benefit reported

The Dementias: Interpersonal Therapy

• Individual distress within their own context

• Person Centred Approach

• Disputes, personality difficulties, bereavements, life evenst/changes

• Little used in dementia

The Dementias: Vascular risk factors

• Diabetes

• Hypertension

• Hypercholesterolaemia

Prevention

• Treat vascular risk factors energetically in Middle Age

• Exercise

• Diet

• Early life educational achievement

• Use it or lose it

• Reduce chronic stress?

Single Assessment Process (SAP)

• Contact

• Overview

• Specialist

• Comprehensive

Old Age Psychiatry Services

• Acute treatment

• Rehabilitation

• Prevention


• Consultant and other psychiatrists

• CPNs, Occupational therapy, psycchology, speech and languauge therapy, physiotherapy, dietetcis, support workers

• Home treatment Team

• Memory Clinic

• Day Hospital


• Inpatients

• OutPatients

• Domiciliary and Home visits

• Carer Support and training

• Individual and Group therapies

• Liaison Service

Old Age Psychiatry Services-Model

• Early intervention

• Treatment in the community

• Prevent admission where possible

• Work closely with primary care

• Joint working with Social services

• Resource Centre of Knowledge and expertise

Supporting the Carers

• Listening

• Informing

• Involving

• Training-problem solving

• Cognitive analytical therapy- dichotomies, ethical & moral considerations

Changing the Environment

• Housing for cognitively impaired

• Safety issues

• Aids and adaptations

• Smart technology

• Levels of sheltered accomodation

Social Care

• Social services

• Voluntary Sector

• Private Sector

Social Care

• Support for personal care

• Help with shopping, housework

• Financial support- Enduring power of attorney Court of Protection

• Allowances

• Clubs, day care

Care

• Respite Care-at home or away

• Long term care

• Care homes DE

• Nursing Homes DE

Depressive Disorder: Risk Factors

• Disability• Handicap• Stroke• Parkinson’s disease• VaD• Heart Disease• COPD

Depressive Disorder- causative Physical Disorders

• Endocrine/Metabolic

• Thyroid disorder

• Cushings syndrome

• Hypercalcaemia

• Pernicious anaemia

• Folate deficiency

Depressive Disorder- causative Physical Disorders

• Organic Brain disease• Cerebrovascular disease• CNS tumours• PD• AD• SLE• Occult Carcinoma• Pancreas• Lung• Chronic Infections• Neurosyphilis• Brucellosis• Herpes Zoster

Depressive Disorder-Medication causing Depression

• Antihypertensives:Beta blockers, methyl dopa, calcium channel blockers

• Prednisolone• Analgesics: Codeine, opioids, COX2 inhibitors• AntiParkinsonian: L Dopa, amantadine,

tetrabenazine• Psychotropics: antipsychotocs, benzodiazepines

Depressive Disorder-Detection

• History

• Anorexia, weight loss and anergia difficult to interpret

• Examination

• GDS

Depressive Disorders- Treatment

• Remission of all residual symptoms

• Provide appropriate Rx- NICE guidelines

• antidepressants, psychological ECT

• Provide info & support for patient/carers


• Optimise Function-

• Rx physical conditions,

• Attend to sensory deficits

• Review medication

• Enable Practical support

• Sign posting to appropriate agencies


• Prevention of Relapse and Recurrence

• Continue medication during recovery

• Stay on medication for at least 1 yr after recovery

• Maintenance treatment


• Antidepressants- NNT of 4• SSRI-under 80yrs, avoid if patient taking aspirin

NSAIDs, history of peptic ulcer• Over 80s-mirtazapine( sedation), venlafaxine

(hypo or hypertension, cardiac disease), lofepramine

• Moclobamide=MAOI B reversible• Phenelzine• All –low sodium-inappropriate ADH secretion• Discontinuation reactions- possible after 8 weeks


• Efficacy

• TCA=venlafaxine> SSRIs

• Often difficult to obtain a therapeutic dose of TCA

Depressive Disorders- Psychological Treatment

• Work in older people• CBT• Interpersonal therapy-relapse prevention• Problem solving• Psychoeducational techniques• Family therapy• In major depression-antidepressant +

psychological Rx


• ECT

• Severe depression80% recover

• Well tolerated

• Broader spectrum of use

• Not within 3/12 of stroke or heart attack

• Memory imapirment


• Rapid transcranial magnetic stimulation- ? Less effective in older patients

• Exercise in prevention

• Enhanced or stepped care- case mangement, antidepressants+ problem solving+ close links between primary & 2o care

Depressive Disorders- Treatment Resistant Depression

• Medical cause for depression• Patient tolerates med• Compliance with medication• Proper dose• For long enough up to 8-12 weeks However

recovery unlikely if no response within 4 weeks

Depressive Disorders- Treatment Resistance

• Substitute with another antidepressant (fewer interactions, easier to attribute success or failure or side effects)

• Augmentation-( do not need to withdraw, possible synergy)

• TCA with SSRI• SSRI+Mirtazapine• Antidepressant + Lithium• Up to 300mgs of venlafaxine

Depressive Disorders- MaintainanceTreatment

• Single episode major depression-1 yr after recovery

• > 3episodes continue indefinitely at therapeutic dose

• TCA, citalopram

• Antidepressant+ psychological Rx

Depressive Disorders- Prognosis

• Thirds- 1/3 got better, 1.3 had relapses, 1/3 continuing sympotms

• Better than this with active intervention-OAP-2/3 got better

• Psychotic depression lethal- excess mortality from physical conditions

• Increased risk of heart attacks and stroke• Vascular depression poor prognosis

Communication

• ROAPI

• Emails

• Template e referral

• Web site: www.roapi.net

Final Thoughts

• Prepare for old age

• Have good relationships with others

• Eat well

• Plenty of mental stimulation

• Physical exercise

• Earn enough money

• When you Retire Don’t stop

• Si jeunesse savait; si vieillesse pouvait.

• [If only youth knew; if only age could.]

• H. Estienne, Les Prémices

• Picture

Delirium Worsens prognosis- significant mortality rate Lengthens stay in hospital- longer in bed,...

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