Everything You Need to Know About Geriatric Psychiatry in 75 Minutes

Everything You Need to Know About Geriatric

Psychiatry in 75 Minutes

Andrea Stewart, MD, FRCPCWriter of LMCC, 2002

Aged ≥80 years in 1994Aged ≥80 years in 2020

Pro

port

ion o

f popula

tion a

ged ≥

80

years

(%

)

AGE DEPENDENCY

RATIO

Co-morbid medical illness / cognitive disorders

Sensory loss

Financial worries

Retirement

Dependency

Dying and death

Bereavement

Challenges of Late Life

OVERVIEW

Dementia - BPSD

Late Onset Psychosis

Depression in late life

Anxiety in late life

Delirium

Other types of dementia (Lewy Body, FTD)

Case 2

Approach to Memory Loss

Speaking to the person (safety first)

Speaking to the family (safety first)

History, physical examination

Create a differential and then direct investigations (bloodwork, urinalysis, ECG, imaging) to firm up the diagnosis

Investigations

Follow-up Plan

Differential Diagnosis

Delirium

Cognitive Impairment but not dementia/ Mild Cognitive Impairment/ Age Associated Memory Decline

Dementia - subtypes

Depression or other psychiatric illness

Other CNS disease (cancer, demyelination, etc.) or a dementia secondary to GMC

Alzheimer’s DementiaMemory Impairment

One or more other cognitive impairment:

Aphasia, apraxia, agnosia, executive functioning deficit

Gradual onset and continual decline

Impairments cause significant social or occupational functional decline compared to previous level of functioning

Impairments are not delirium, substance-induced, or caused by another GMC or psychiatric illness

Defining the Diagnostic Threshold

MCI/ CIND

Normal Cognition

Dementia

Screening Tools

MMSE score <24/30

MOCA score <26/30

Mini-Cog (3 word registration & recall, CDT)

Work-up1

CBC, Cr, urea, electrolytes, TSH, vitamin B12

Neuroimaging if the onset is recent (<1 year), early (<65), or the presentation is atypical or suggestive of another neurological disease

Other tests prn (VDRL, HIV, carotid U/S, EEG, chest Xray, urinalysis, LP)

ECG prior to medication management1Burns A, BMJ

Act

ivit

ies

of

Daily

Liv

ing

MMSE 25 20 15 10 5 0

KEEP APPOINTMENTS

TELEPHONE

OBTAIN MEAL/SNACK

TRAVEL ALONE

USE HOME APPLIANCES

FIND BELONGINGS

SELECT CLOTHES

DRESS

GROOM

MAINTAIN HOBBY

DISPOSE LITTER

CLEAR TABLE

WALK

EAT

30

Adapted from Galasko. Eur J Neurol. 1998;5(suppl 4):S9-S17; Galasko et al. Alzheimer Dis Assoc Disord. 1997;11(suppl 2):S33-S39.

Mild AD Moderate AD Severe AD

Bars show 25th to 75th %ile Bars show 25th to 75th %ile of patients losing of patients losing

independent performance.independent performance.

May improve:

ADLs- activities of daily living, time to institutionalization

Behaviour/Mood- decreased concomitant psychotropics

Cognitive enhancement

Types

Acetylcholine-esterase inhibitors (boost ACh)

NMDA antagonists (Block glutamate)

Cognitive Enhancers

Other Medications/ CAMNimodipine (Ca channel blocker) at 90 to 180 mg/day

General BP lowering

Vitamin B12

Extract of Ginkgo biloba 761

Vitamin E no longer used due to bleeding risk

DHEA may be harmful to memory

Cognitive training, reminiscence therapy

Case 2

Behavioural and Psychological Symptoms

of Dementia

ABC Approach

AAntecedents

BBehaviours

CConsequences

www.piecescanada.com

Physical: delirium, diseases, drugs, discomfort, disability

Intellectual: dementia – cognitive abilities/losses

Emotional: depression, psychosis

Capabilities: environment not too demanding yet stimulating enough, balancing demands and capabilities

Environment: noise, relocation, schedules…

Social, cultural, spiritual: life story, relationships family dynamics, personality traits...

http://www.piecescanada.com/

http://www.piecescanada.com/

Atypical antipsychotics1

RSP & OZP reduce aggression, RSP reduces psychosis

Higher risk CVEs, EPS, death

Antidepressants2,3

db trials show CIT = RSP with fewer SEs

Trazodone has trend of effectiveness in FTD

Benzodiazepines

Pharmacological Management of BPSD

1Cochrane, 2008; 2Pollock, BG Am J Ger Psych; 3Cochrane, 2008

a) Insidious, gradual and progressive decline

b)Motor symptoms are absent until later in the disease

c) A dramatic presentation is not the same as an abrupt onset

d)Behavioural symptoms are often the most distressing symptom for families and caregivers

e)The ‘head turning sign’ refers to sexual disinhibition

f) Vascular events may co-occur and cause cognitive dysfunction

The following is NOT true of Alzheimer’s:

Case 6

Psychosis in the Elderly1

4% in the community

15% presenting to a geriatric medicine clinic

10-38% of people in LTC (21% of new admissions to LTC)

1Holyrood S, Int J Ger Psych 1999

Approach

Speaking to the family (safety first)

Speaking to the person (safety first)

History, physical examination

Create a differential and then direct investigations (bloodwork, urinalysis, ECG, imaging) to firm up the diagnosis

Investigations

Follow-up Plan

Differential DiagnosisPsychosis in People <45

MDE or Mania

SZP/SZA/ delusional D/O

2 GMC/subs

Delirium

Personality disorder

Psychosis in People >45

Cognitive Disorders (delirium, dementia)

2 GMC/ Subs

Psychotic Disorder (SZP, SZA, Del D/O) or paraphrenia

MDE, Mania

Differentiating the Dx

Dementia MDE Delirium Mania LO SZP

Memory loss,

impaired function, insidious onset & progress

Prominent mood

and anxiety sx, past hx MDD, somatic/

guilt/ nihilistic delusions

Acute, fluctuates, clouded sensorium sleep

reversal, delusions from env., vulnerabl

ehost

Mixed states more

common, less

grandiosity

confusion &

irritability

Delusions may be bizarre, no dis-

orientationbaseline paranoid

or schizoid PD traits

Outcomes and Associated Factors

Elderly with psychosis are more likely to have a history of psychosis, live in LTC, and have lower MMSE scores1

1Holyrood S, Int J Ger Psych 1999

Case 6

a)Most paranoid disorders of old age are due to schizophrenia

b)More women develop late onset schizophrenia

c) With ageing, schizophrenia tends to give less severe positive symptoms

d)Patients with schizophrenia live 10-30 years less on average

Which of the following is not true in LLP?

Case 7

Approach to Mood Complaint

History (with collateral) and physical examination

Make the diagnosis considering the differential, assess severity (psychosis) and suicidality

Thorough medication review

Investigate causes (bloodwork, urinalysis, ECG, imaging) and remove promoting factors

Review past episodes and treatments


Depressive Disorder (dysthymia, MDE, BP with MDE, personality disorder)

Bereavement

Dementia

Delirium

Substance (drug of abuse, medication) or GMC

Epidemiology1

Lifetime risk 11%

Incidence in the general population: 4%/ year

Incidence in people > 65: 1-3%/ year

Incidence in hospitalized people: 11%

Incidence in people in LTC: 12-22%

1Narrow WE, NIMH ECA prospective data

Predisposers Precipitators Perpetuators

Female gender, widowed or

divorced, PHx MDD, CeVD, Personality type, major physical or disabling

illness, some meds, alcohol abuse, social disadvantage,

Caregiver stress

Recent bereavement, moving to an institution, adverse life

events (separation,

loss, financial crisis),

declining health,

relationship problems

Persistent sleep

problems, chronic stress,

social isolation, stigma, adverse

effects of medication therapies

Diagnostic Criteria

Sleep change

Interests lost

Guilty or worthless feelings

Energy lost

Mood depressed/irritable or anhedonia for > 2 weeks and 4/8:

Concentration impaired

Appetite changed/ wt change

Psychomotor symptoms

Suicidal or death-related thinking

DSM-IV-TR

Late Life DepressionLess More

Complaints of sadness

Somatic symptoms,

Anxiety, Cognitive

symptoms, Medical

comorbidity

CCSMH, Assessment and Treatment of Depression 2006

Subtypes

With or without psychosis, graded severity, recurrent or first episode, bipolar depression

Secondary to something else

Dysthymia

Co-morbid with dementia or substance abuse

MDE vs GriefMDE

+/- onset after trigger

Symptoms worsen with time

SI/ preoccupation with death

Intense guilt & worthlessness

Persistent mood state

Functional impairment

Psychosis

Grief

Onset after death of loved one

Symptoms improve with time

Passive wishes to have died 1st or with person

Self esteem preserved

Sadness comes in waves

Functional impairment <2 mo.

APA, 2000

Management

Mild: bibliotherapy, exercise, close follow-up or supportive therapy

Moderate: antidepressants +/- psychotherapy, or psychotherapy alone

Severe: refer to psychiatry, +/- hospitalization for safety, ECT, antipsychotics with antidepressants, psychotherapy alone only effective for specific patients if done by experts - otherwise in combination

Suicide Risk

Fixed RFs Modifiable RFsV. High Risk Behaviours

Old ageMale genderWidowed or

divorcedPrevious attemptLosses (health,

status, role, independence,

relations)

Social isolation, Presence of chronic pain (OR moderate

pain 1.9, severe pain 7.5)

Presence and severity of MDEHopelessness,

Suicidal ideationAccess to means,

especially firearms

AgitationGiving away possessions

Reviewing one’s willIncrease use alcohol

Non-compliance with treatment

Taking unnecessary risks

Preoccupation with death

CCSMH, Assessment of Suicide Risk and Prevention of Suicide, 2006

Language of Treatment

AntidepressantsMeta-analysis of trials of 2nd generation antidepressants in people >60 with non-psychotic depression and no dementia

1American Journal of Geriatric Psychiatry, 2008

Medication Placebo

Response 44% 35%

Remission 33% 27%

Discontinuation 24% 20%

Antidepressant

Works

Maintenance Go to 8 wks

Reassess diagnosis, increase dose, switch to escitalopram, sertraline, mirtazapine,

effexor

>20% betterNo change after 4wks

>20% better after above: Li, antipsychotic, psychotherapy

Clinical Use of Antidepressants

If anything protective for suicide in elderly

Elderly more likely to die of overdose if taken

Electrolytes pre and post (1 week to 1 month)

Risk of GI bleed, especially with concurrent NSAID or ASA use - monitor, add gastroprotective agent

Follow q2 weeks for the first 1-3 months, keep on medication >1 yr post remission

Psychotherapy

Cognitive Behavioural Therapy

Problem Solving Therapy

Interpersonal Therapy

a) it is a treatable condition that with antidepressants has a remision rate of 30-40% and response rates of 67-90%

b) the neurotransmitters serotonin and noradrenaline are involved

c) Psychotherapy is effective in severe depression

d) an association between early life trauma, hippocampal atrophy and depression can be seen

e) it often presents with multi-system physical complaints

f) it is associated with coronary artery disease, stroke, diabetes, cancer, Parkinson’s, and MS.

g) ECT should be considered only when all other treatments have failed

The following is true regarding depression:

a) it is a treatable condition that with antidepressants has a remission rate of 70-80% and response rates of 67-95%

b) the neurotransmitters serotonin and noradrenaline are involved

c) Psychotherapy is effective in severe depression

d) an association between early life trauma, hippocampal atrophy and depression can be seen

e) it often presents with multi-system physical complaints

f) it is associated with coronary artery disease, stroke, diabetes, cancer, Parkinson’s, and MS.

g) ECT should be considered only when all other treatments have failed

The following is true regarding depression:

a) Is more prevalent in women than men

b)Prevalence rates rise sharply with age

c) Is accompanied by a much lower suicide risk than in younger adults

d) Is unresponsive to treatment in half of cases.

e) Is often precipitated by a loss

f) Both b) and d)

Which of the following are true of depression in old

age:

a) Is more frequent in elderly.

b) Remits with antidepressants in 50% of cases

c) Remits with antidepressants + antipsychotics in 75% of cases

d) Responds and remits best with ECT

e) Should prompt thorough search for symptoms of bipolar illness in pt and family members.

f) All of the above except b)

g) All of the above except b) and c)

Which of the below options are true for psychotic

depression:

a) Is more frequent in elderly.

b) Remits with antidepressants in 20% of cases

c) Remits with antidepressants + antipsychotics in 45% of cases

d) Responds and remits best with ECT

e) Should prompt thorough search for symptoms of bipolar illness in pt and family members.

f) All of the above except b)

g) All of the above except b) and c)

Which of the below options are true for psychotic

depression:

a)“Nerves”

b)Excessive fatigue

c) Hypersomnia (sleeping too much)

d)Digestive problems

e)Fear of Alzheimer’s disease

f) All of the above except C

Which of the following are frequent “reasons for consultation” by elderly who have an episode of depression:

a)Active suicidal ideation

b)Prominent psychotic symptoms

c) Crying spells when she thinks of her deceased husband.

d)Being less active socially

e)Being unable to attend to her usual daily activities 3 months after the death of her husband

Which of the following would go against a diagnosis of normal grief:

Case #3

81 year old widow, lives alone in her home, presents with 2 year history of insidious increase in worrying, indecisiveness, isolation, insomnia, and feeling tense. Her husband recently died in a NH after having dementia for 8 years. Her kids say she is increasingly dependent on them for running errands, and she has stopped doing her own taxes and driving.

She appears nervous, with a smile that doesn’t match her words.

Mood Disorder AnxietyDisorder

APA 1994; Keller MB 1995; Clayton PJ et al 1991; Coplan JD, Gorman JM 1990

■ Depressed /

irritable mood

■ Anhedonia

■ Euphoria

■ Weight

gain/loss

■ Loss of

interest

■ Fear■ Apprehension■ Panic attacks■ Chronic pain■ GI complaints

■ Excessive worry■ Agitation■ Difficulty

concentrating■ Sleep

disturbances

■ Hypervigilance

■ Agoraphobia

■ Compulsive rituals

As many as 90% of depressed patients suffer from anxiety symptoms1-3

More severe illness at baseline

More psychosocial impairment

Greater likelihood of chronic illness

Poorer, slower response to treatment

Greater likelihood of committing suicide

1. Richou H. et al. Human Psychopharmacol 1995; 10:263-712. Coplan JD et al. J Clin Psych 190; 51(Suppl 10):9-13

3. Kasper S. et al. Primary Care Psych 1997; 3:7-16

Secondary anxiety disorders more common in elderly

Primary anxiety disorders generally do not have an onset in the elderly (same for personality disorders)

High co-morbidity with depression

Overall less common in the elderly.

Phobias and GAD are the most common. Panic disorder is relatively rare, less than the 1-3% described in younger populations (Flint AJP 1994).

Caution with anxiolytics

can cause paradoxical disinhibition

Diphenylhydramine (Benadryl), Dimenhydrinate (Gravol), Chlorpromazine, Amitriptyline, chloral hydrate and barbiturates are not good anxiolytics due to their side effects

Elderly are more sensitive to benzodiazepines. Associated with an increased risk for falls and MVAs

Anxiety Disorders in the Elderly

Cognition Amnesia (esp. alcoholics with benzos)

Memory and visuospatial impairment

Psychomotor Accentuate postural sway and incoordination

Increase risk for MVAs and falls

Paradoxical dysinhibition

Respiratory Depression avoid benzos in sleep apnea

Sleep Decreased sleep latency but also decreased stage 3 and 4 sleep with

Benzos

Anxiolytic Side Effects

Which of the following is NOT true of anxiety Which of the following is NOT true of anxiety disorders in old agedisorders in old age

a) It is more often secondary to another axis 1 condition like depression or medical condition

b) Anxiolytics can worsen not only anxiety but can cause sleep disruption, falls, and MVAs.

c) Benzodiazepines are safe in the elderly

d) Benadryl, Gravol, Chlorpromazine, Amitriptyline and other anticholinergic medications can be dangerous in the elderly because of delirium and associated other receptor effects (orthostatic hypotension)

e) Primary anxiety disorders and personality disorders, including dependent personality disorder, do not begin in old age

a) Prevalence rates increase with ageing.

b) Phobias are the most common anxiety disorder

c) Overall prevalence rates for all anxiety disorders in old age is around 10%

d) Panic disorder affects approx. 5% of elderly.

MCQ#9

Case 8


Generalized Anxiety Disorder

Dysthymia

MDE

Anxiety secondary to GMC, substance

Bereavement

Anxiety in Late Life

Less common, 5-10% in the community

F>M, peak onset adolescence

Agoraphobia alone as having a second peak

Late life onset usually heralds another condition:

MDD, dementia, medication toxicity, withdrawal, GMC (cardio and cerebrovascular disease)

Presentations of Anxiety Disorders in

Late Life1

Autonomic hyper-arousal pronounced:

palpitations, dry mouth, dizziness, hot flashes, GI distress

Low prevalence of panic disorder and OCD

Onset after therapy with DA agonists, steroids, sympathomimetics, Beta-adrenergic agonists (salbutamol), theophylline, digoxin, thyroxine

Flint AJ, Comprehensive Textbook of Geriatric Psychiatry: Anxiety Disorders, 2004

Agoraphobia

Most prevalent anxiety disorder in the community1

Onset not uncommon after 601

Late onset related to abrupt onset physical illness or trauma (fall, being mugged)2

Associated with early parental loss3

1,3Lindesay J, Br J Psych, 1991; 2Burvill PW, Br J Psych, 1995

APA 1994; Keller MB, 1995; Clayton PJ, 1991; Coplan JD,1990

■ Depressed /

irritable mood

■ Anhedonia

■ Euphoria

■ Weight

gain/loss

■ Loss of

interest

■ Fear■ Apprehension■ Panic attacks■ Chronic pain■ GI complaints

■ Excessive worry■ Agitation■ Difficulty

concentrating■ Sleep

disturbances

■ Hypervigilance

■ Agoraphobia

■ Compulsive rituals

Depressive Disorder

Anxiety Disorder

Management

Diagnose, initiate treatment or refer

Investigate +/- treat co-morbid illness

Psychotherapy: CBT

Pharmacotherapy: SSRI (sertraline)

More severe illness at baseline

More psychosocial impairment

Poorer, slower response to treatment

Greater likelihood of committing suicide

Greater likelihood of morbidity (cardiovascular, respiratory, GI diseases) and mortality (cardiovascular, COPD, neoplastic causes)

Outcome

Flint AJ, Comprehensive Textbook of Geriatric Psychiatry: Anxiety Disorders, 2004

a) It is more often secondary to another axis 1 condition like depression or medical condition

b) Anxiolytics can worsen not only anxiety but can cause sleep disruption, falls, and MVAs.

c) Benzodiazepines are safe in the elderly

d) Benadryl, Gravol, Chlorpromazine, Amitriptyline and other anticholinergic medications can be dangerous in the elderly because of delirium and associated other receptor effects (orthostatic hypotension)

e) Primary anxiety disorders and personality disorders, including dependent personality disorder, do not begin in old age

Which of the following is NOT true of anxiety disorders in old

age:

a)Prevalence rates increase with age

b)Phobias are the most common anxiety disorder

c) Overall prevalence rates for all anxiety disorders in old age is around 20%

d)Panic disorder affects around 5% of elderly.

Which of the following is true regarding anxiety disorders in old

age:

Case 1

Approach

History (with collateral) and physical examination

Make the diagnosis considering the differential

Thorough medication review

Investigate causes (bloodwork, urinalysis, ECG, imaging) and remove promoting factors

Consult prn (OT, PT, RD, SW, other MD)


Delirium

Dementia

Depression, Mania, Psychotic disorder

Other CNS disease (cancer, demyelination, etc.)

Delirium20% of hospitalized patients >651

10-30% of people >65 it is the presenting symptom of a life-threatening illness1

LOS approximately doubled to 8 days2

Mortality doubled, morbidity increased3

Unrecognized in ~ 70%4

1Centers for Medicare and Medicaid Services, 2004 CMS Statistics; 2Agostini JV, Principles of Geriatric Medicine and Gerontology; 3McCusker J, Arch Intern Med; 4Gillis AJ, Can Nurse

Delirium

C - Consciousness fluctuates

C - Course has an acute onset

C - Cognition disturbed

C - Cause is a GMC

Subtypes of Delirium

Meagher (1996), BJP

Predisposers Precipitators Perpetuators

Old ageVisual loss

Hearing lossHx deliriumDementiaFunctional

dependenceMedical

morbiditiesPolypharmacyEtOH/ drugs

Med change Trauma (IV, restraints, foley, fall)

UTI, pneumonia

MI, CVALow BP or O2

AbN lytesGI or GU disease

Periop. factors

Poor nutritionEnvironmental

changesPain

IV/FoleyDehydration

Sensory deprivation/

overstimulation

Poor sleepHypothermia

Causes of DeliriumCauses of Delirium

I - Infections

W - Withdrawal

A - Acute metabolic Encephalopathy

T - Trauma

C - CNS pathology

H - Hypoxia

D - Deficiencies

E - Endocrine Disorders

A - Acute Vascular Insufficiency

T - Toxins and drugs

H - Heavy metals

Case 1

QuickTime™ and aGIF decompressor

are needed to see this picture.

Treatment of Delirium1,2,3

Psychological/ Social/ Environmental

Ensure pt wears glasses, hearing aid, dentures, encourage independence & regular activity, allow adequate sleep

Support family, enlist their help in decreasing distress and providing frequent reorientation

Place person near NS station in single room with adequate lighting, reorientation cues, and LIMIT RESTRAINTS

Biological

Treatment related to cause of delirium

Manage sx (low dose neuroleptics)

Ensure adequate hydration, stop unneeded lines

1Cole MG, J Geriatr Psychiatr Neurol; 2Simon I, Geriatr Nurs; 3Meagher DJ, Br J Psychiatry

Antipsychotics in Delirium1

Evidence suggests modest benefits in decreasing duration and severity of delirium with use of antipsychotic

Low dose haldol (0.25-1.5 mg/24h) is equivalent to low dose risperidone (0.25 -1/24h) or olanzapine (1.25-5 mg/24h) in efficacy, but may cause more akathisia, definitely costs less

Cochrane Collaboration, 2009

Delirium Outcomes

Delirium in the elderly patient is associated with increased mortality, longer hospital stays, and increased risk of institutional placement

It is a reversible syndrome, that improves or resolves with treatment of the precipitating illness and addressing precipitating and perpetuating factors

a) It is characterized by problems and fluctuations with attention and consciousness

b) In the elderly, it is most often completely reversible

c) Hypoactive subtypes are more often missed

d) Environmental interventions do not help

e) It is a significant independent risk factor for death

f) It can be superimposed on dementia or depression

g) It is rare in the elderly

h) It is better to use benzodiazepines than neuroleptics for psychotic and behavioural symptoms

MCQ: The following is true for delirium:

a) It is characterized by problems and fluctuations with attention and consciousness

b) In the elderly, it is most often completely reversible

c) Hypoactive subtypes are more often missed

d) Environmental interventions do not help

e) It is a significant independent risk factor for death

f) It can be superimposed on dementia or depression

g) It is rare in the elderly

h) It is better to use benzodiazepines than neuroleptics for psychotic and behavioural symptoms

The following is true for delirium:

Everything You Need to Know About Geriatric Psychiatry in 75 Minutes

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