Geriatric Psychiatry: A Review & Update Medical and Neurologic Aspects J. Wesson Ashford University...

Geriatric Geriatric Psychiatry:Psychiatry:

A Review & UpdateA Review & Update

Medical and Medical and Neurologic AspectsNeurologic Aspects

J. Wesson AshfordJ. Wesson AshfordUniversity of KentuckyUniversity of Kentucky

VAMC, LexingtonVAMC, Lexington

Geriatric Psychiatry: A Review & Update

Dementia DefinitionDementia Definition

Multiple Cognitive Deficits:Multiple Cognitive Deficits: Memory dysfunction Memory dysfunction At least one additional cognitive deficitAt least one additional cognitive deficit

Cognitive Disturbances:Cognitive Disturbances: Sufficiently severe to cause impairment Sufficiently severe to cause impairment

of occupational or social functioning of occupational or social functioning and and

Must represent a decline from a Must represent a decline from a previous level of functioningprevious level of functioning


Differential Diagnosis: Differential Diagnosis: Top Ten Top Ten

1.1. AAlzheimer Disease (pure ~40%, + lzheimer Disease (pure ~40%, + mixed~70%)mixed~70%)

2.2. VVascular Disease, MID (5-20%)ascular Disease, MID (5-20%)3.3. DDrugs, rugs, DDepression, epression, DDeliriumelirium

4.4. EEthanolthanol (5-15%) (5-15%)5.5. MMedical / edical / MMetabolic Systemsetabolic Systems6.6. EEndocrine (thyroid, diabetes), ndocrine (thyroid, diabetes), EEars, ars, EEyes, yes,

EEnviron.nviron.7.7. NNeurologic (other primary degenerations, etc.)eurologic (other primary degenerations, etc.)8.8. TTumor, umor, TToxin, oxin, TTraumarauma9.9. IInfection, nfection, IIdiopathic, diopathic, IImmunologicmmunologic10. 10. AAmnesia, mnesia, AAutoimmune, utoimmune, AApnea, pnea, AAAMIAMI


Diagnostic Criteria For Dementia Diagnostic Criteria For Dementia Of The Alzheimer TypeOf The Alzheimer Type (DSM-IV, APA, (DSM-IV, APA,

1994)1994)

A.A. Multiple Cognitive DeficitsMultiple Cognitive Deficits1. Memory Impairment 1. Memory Impairment 2. Other Cognitive Impairment2. Other Cognitive Impairment

B. Deficits Impair Social/Occupational B. Deficits Impair Social/Occupational C.C. Course Shows Gradual Onset And DeclineCourse Shows Gradual Onset And DeclineD.D. Deficits Are Not Due to:Deficits Are Not Due to:

1. Other CNS Conditions1. Other CNS Conditions2. Substance Induced Conditions2. Substance Induced Conditions

E. Do Not Occur Exclusively during DeliriumE. Do Not Occur Exclusively during DeliriumF. Not Due to Another Psychiatric DisorderF. Not Due to Another Psychiatric Disorder


Vascular DementiaVascular Dementia(DSM-IV - APA, 1994)(DSM-IV - APA, 1994)

A.A. Multiple Cogntive ImpairmentsMultiple Cogntive Impairments

B.B. Deficits Impair Social/OccupationalDeficits Impair Social/Occupational

C.C. Focal Neurological Signs and Focal Neurological Signs and Symptoms or Laboratory Evidence Symptoms or Laboratory Evidence Indicating Cerebrovascular Disease Indicating Cerebrovascular Disease Etiologically Related to the DeficitsEtiologically Related to the Deficits

D.D. Not Due to DeliriumNot Due to Delirium


Factors Associated with Multi-infarct Factors Associated with Multi-infarct DementiaDementia

History of stroke (especially in Nursing History of stroke (especially in Nursing Home)Home)

Step-wise deteriorationStep-wise deterioration Cardiovascular disease - HTD, ASCVD, & Cardiovascular disease - HTD, ASCVD, &

Atrial FibAtrial Fib Depression (left anterior strokes), Depression (left anterior strokes),

personality changepersonality change More gait problems than in ADMore gait problems than in AD MRI evidence of T2 changes (?? MRI evidence of T2 changes (??

Binswanger’s disease)Binswanger’s disease) SPECT / PET show focal areas of dysfunctionSPECT / PET show focal areas of dysfunction Neuropsychological dysfunctions are patchyNeuropsychological dysfunctions are patchy


Post-Cardiac SurgeryPost-Cardiac Surgery 53% post-surgical confusion at discharge 53% post-surgical confusion at discharge

(delirium)(delirium) 42% impaired 5 years later42% impaired 5 years later May be related to anoxic brain injury, apneaMay be related to anoxic brain injury, apnea May be related to narcotic/other medicationMay be related to narcotic/other medication May occur in those patients who would have May occur in those patients who would have

developed dementia anyway (? genetic risk)developed dementia anyway (? genetic risk) Cardio-vascular disease and stress may start Cardio-vascular disease and stress may start

Alzheimer pathologyAlzheimer pathology Any surgery may have a similar effect related to Any surgery may have a similar effect related to

peri-op or post-op anoxia or vascular stressperi-op or post-op anoxia or vascular stress

Newman et al., 2001, NEJMNewman et al., 2001, NEJM


Drug InteractionsDrug Interactions Anticholinergics: amitriptyline, atropine, Anticholinergics: amitriptyline, atropine,

benztropine, scopolamine, hyoscyamine, benztropine, scopolamine, hyoscyamine, oxybutynin, diphenhydramine, oxybutynin, diphenhydramine, chlorpheniramine, many anti-histaminicschlorpheniramine, many anti-histaminics May aggravate Alzheimer pathologyMay aggravate Alzheimer pathology

GABA agonists: benzodiazepines, GABA agonists: benzodiazepines, barbiturates, ethanol, anti-convulsantsbarbiturates, ethanol, anti-convulsants

Beta-blockers: propranololBeta-blockers: propranolol Dopaminergics: l-dopa, alpha-methyl-Dopaminergics: l-dopa, alpha-methyl-

dopadopa Narcotics: may contribute to dementiaNarcotics: may contribute to dementia


DepressionDepression Onset: rapidOnset: rapid Precipitants: psycho-social (not organic)Precipitants: psycho-social (not organic) Duration: less than 3 months to Duration: less than 3 months to

presentationpresentation Mood: depressed, anxiousMood: depressed, anxious Behavior: decreased activity or agitationBehavior: decreased activity or agitation Cognition: unimpaired or poor responsesCognition: unimpaired or poor responses Somatic symptoms: fatigue, lethargy, Somatic symptoms: fatigue, lethargy,

sleep, appetite disruptionsleep, appetite disruption Course: rapid resolution with treatment,Course: rapid resolution with treatment,

but may precede Alzheimer’s but may precede Alzheimer’s diseasedisease


Delirium DefinitionDelirium Definition

Disturbance of consciousnessDisturbance of consciousness i.e., reduced clarity of awareness of i.e., reduced clarity of awareness of

the environment with reduced ability the environment with reduced ability to focus, sustain, or shift attentionto focus, sustain, or shift attention

Change in cognition (memory, Change in cognition (memory, orientation, language, perception)orientation, language, perception)

Development over a short period Development over a short period (hours to days), tends to fluctuate(hours to days), tends to fluctuate

Evidence of medical etiologyEvidence of medical etiology


EthanolEthanol Possibly NeuroprotectivePossibly Neuroprotective

May not kill neurons directlyMay not kill neurons directly Accidents, Head InjuryAccidents, Head Injury Dietary DeficiencyDietary Deficiency

Thiamine – Wernicke-Korsakoff Thiamine – Wernicke-Korsakoff syndromesyndrome

Hepatic EncephalopathyHepatic Encephalopathy Withdrawal Damage (seizures) Withdrawal Damage (seizures)

Delayed Alcohol WithdrawalDelayed Alcohol Withdrawal Watch for in hospitalized patientsWatch for in hospitalized patients

Chronic NeurodegenerationChronic Neurodegeneration Cerebellum, gray matter nucleiCerebellum, gray matter nuclei


Medical / EndocrineMedical / Endocrine Thyroid dysfunctionThyroid dysfunction

Hypothyoidism – elevated TSHHypothyoidism – elevated TSH Compensated hypothyroidism may have normal T4, Compensated hypothyroidism may have normal T4,

FTIFTI HyperthyroidismHyperthyroidism

Apathetic, with anorexia, fatigue, weight loss, Apathetic, with anorexia, fatigue, weight loss, increased T4increased T4

DiabetesDiabetes Hypoglycemia Hypoglycemia (loss of recent memory since episode)(loss of recent memory since episode) HyperglycemiaHyperglycemia HypercalcemiaHypercalcemia Nephropathy, UremiaNephropathy, Uremia Hepatic dysfunction (Wilson’s disease)Hepatic dysfunction (Wilson’s disease) Vitamin Deficiency (B12, thiamine, niacin)Vitamin Deficiency (B12, thiamine, niacin)

Pernicious anemia – B12 deficiency, ?Pernicious anemia – B12 deficiency, ?homocysteinehomocysteine


Eyes, Ears, Eyes, Ears, EnvironmentEnvironment

Must consider sensory deficits might Must consider sensory deficits might contribute to the appearance of the patient contribute to the appearance of the patient being dementedbeing demented

Central Auditory Processing Deficits (CAPD)Central Auditory Processing Deficits (CAPD) Hearing problems are socially isolatingHearing problems are socially isolating Visual problems are difficult to accommodate Visual problems are difficult to accommodate

by a demented patient, ?To do cataract op?by a demented patient, ?To do cataract op? Environmental stress factors can predispose Environmental stress factors can predispose

to a variety of conditionsto a variety of conditions Nutritional deficiencies (tea & toast Nutritional deficiencies (tea & toast

syndrome)syndrome)


Neurological Neurological ConditionsConditions

Primary Neurodegenerative DiseasePrimary Neurodegenerative Disease Diffuse Lewy Body Dementia (? 7 - 50%)Diffuse Lewy Body Dementia (? 7 - 50%) Fronto-temporal dementia (tau gene)Fronto-temporal dementia (tau gene)

Focal cortical atrophyFocal cortical atrophy Primary progressive aphasia (many causes)Primary progressive aphasia (many causes) Unilateral atrophy, hypofunction on EEG, Unilateral atrophy, hypofunction on EEG,

SPECT, PETSPECT, PET Normal pressure hydrocephalusNormal pressure hydrocephalus

Dementia with gait impairment, incontinence Dementia with gait impairment, incontinence Suggested on CT, MRI; need tap, Suggested on CT, MRI; need tap,

ventriculographyventriculography Other Neurologic ConditionsOther Neurologic Conditions


Tumor Tumor ToxinsToxins TraumaTrauma


Infectious Conditions Infectious Conditions Affecting the BrainAffecting the Brain

HIVHIV NeurosyphilisNeurosyphilis Viral encephalitis (herpes)Viral encephalitis (herpes) Bacterial meningitisBacterial meningitis Fungal (cryptococcus)Fungal (cryptococcus) Prion (Creutzfeldt-Jakob disease); (mad Prion (Creutzfeldt-Jakob disease); (mad

cow disease)cow disease)


Amnesic DisordersAmnesic Disorders

AmnesiaAmnesia Dissociative: localized, selective, Dissociative: localized, selective,

generalizedgeneralized Organic - damage to CA1 of hippocampus Organic - damage to CA1 of hippocampus

thiamine deficiency (WKE), hypoglycemia, hypoxiathiamine deficiency (WKE), hypoglycemia, hypoxia

Epileptic eventsEpileptic events Partial complex seizuresPartial complex seizures

Specific brain diseasesSpecific brain diseases Transient global amnesiaTransient global amnesia Multiple sclerosisMultiple sclerosis


Age-Associated Memory Age-Associated Memory ImpairmentImpairment

vsvsMild Cognitive ImpairmentMild Cognitive Impairment

Memory declines with ageMemory declines with age Age - related memory decline corresponds Age - related memory decline corresponds

with atrophy of the hippocampuswith atrophy of the hippocampus Older individuals remember more complex Older individuals remember more complex

items and relationshipsitems and relationships Older individuals are slower to respondOlder individuals are slower to respond Memory problems predispose to Memory problems predispose to

development of Alzheimer’s diseasedevelopment of Alzheimer’s disease

Advances in Advances in Alzheimer’s DiseaseAlzheimer’s Disease Uncovering etiologyUncovering etiology Understanding Understanding pathophysiologypathophysiology Better screening toolsBetter screening tools Improved diagnosisImproved diagnosis Developing interventions Developing interventions


EtiologyEtiology

Age - therefore - design and stressAge - therefore - design and stress Genetics (amyloid related)Genetics (amyloid related) Relation to vascular factors, Relation to vascular factors,

cholesterol, BPcholesterol, BP Education (? design vs protection)Education (? design vs protection) Environment - Environment - diet, exercise, diet, exercise,

smokingsmoking


Neuropathology of ADNeuropathology of AD Senile plaquesSenile plaques Neurofibrillary tanglesNeurofibrillary tangles Neurotransmitter lossesNeurotransmitter losses Inflammatory responsesInflammatory responses

New Neuropath New Neuropath MechanismsMechanisms

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

dementia)dementia)


Biopsychosocial Systems Biopsychosocial Systems Affected by ADAffected by AD(all related to neuroplasticity)(all related to neuroplasticity)

Social SystemsSocial Systems Basic ADLs - LateBasic ADLs - Late

Psychological SystemsPsychological Systems Primary Loss Of Memory Primary Loss Of Memory Later Loss Of Learned SkillsLater Loss Of Learned Skills

Neuronal Memory Systems Neuronal Memory Systems Cortical Glutamatergic StorageCortical Glutamatergic Storage Subcortical (acetylcholine, norepi, serotonin)Subcortical (acetylcholine, norepi, serotonin) Cellular Plastic Processes Cellular Plastic Processes

APP metabolism – early, broad cortical distributionAPP metabolism – early, broad cortical distribution TAU hyperphosphorylation – late, focal effect, TAU hyperphosphorylation – late, focal effect,

dementia relateddementia related


Why Diagnose AD Why Diagnose AD Early?Early?

Safety (driving, compliance, cooking, etc.)Safety (driving, compliance, cooking, etc.) Family stress and misunderstanding (blame, Family stress and misunderstanding (blame,

denial) denial) Early education of caregivers of how to handle Early education of caregivers of how to handle

patient (choices, getting started)patient (choices, getting started) Advance planning while patient is competent Advance planning while patient is competent

(will, proxy, power of attorney, advance (will, proxy, power of attorney, advance directives)directives)

Patient’s and Family’s right to knowPatient’s and Family’s right to know Specific treatments now available, may delay Specific treatments now available, may delay

nursing home placement longer if started earliernursing home placement longer if started earlier


Need for Better Need for Better ScreeningScreening

and Assessment Tools and Assessment Tools Genetic vulnerability testingGenetic vulnerability testing Early recognition (10 warning signs)Early recognition (10 warning signs) Screening tools (6th vital sign in elderly)Screening tools (6th vital sign in elderly) Positive diagnostic testsPositive diagnostic tests

CSF – tau levels elevated, amyloid levels lowCSF – tau levels elevated, amyloid levels low Brain scan – PET – DDNP, Congo-red derivativesBrain scan – PET – DDNP, Congo-red derivatives

Dementia severity assessmentsDementia severity assessments Tracking progression rate, prediction of Tracking progression rate, prediction of

changechange


Alzheimer Warning SignsAlzheimer Warning SignsTop TenTop Ten

Alzheimer AssociationAlzheimer Association

1. Recent memory loss affecting job1. Recent memory loss affecting job2. Difficulty performing familiar tasks2. Difficulty performing familiar tasks3. Problems with language3. Problems with language4. Disorientation to time or place4. Disorientation to time or place5. Poor or decreased judgment5. Poor or decreased judgment6. Problems with abstract thinking6. Problems with abstract thinking7. Misplacing things7. Misplacing things8. Changes in mood or behavior8. Changes in mood or behavior9. Changes in personality 9. Changes in personality 10. Loss of initiative10. Loss of initiative


AssessmentAssessment

History Of The Development Of History Of The Development Of The DementiaThe Dementia

Physical ExaminationPhysical Examination Neurological ExaminationNeurological Examination


Neurological ExamNeurological Exam Cranial NervesCranial Nerves Sensory DeficitsSensory Deficits Motor Motor Deep tendonDeep tendon PathologicalPathological


ALZHEIMER DETERIORATION ON THE MINI-MENTAL STATE EXAM

OVER TIME

05

1015202530

-5 0 5 10AVERAGE TIME OF ILLNESS (years)

SC

OR

E


AD all (easiest to hardest at p=.5)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

-4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10

DISABILITY ("time-index" year units)

PR

OB

AB

ILIT

Y C

OR

RE

CT

PENCILAPPL-REPWATCLOCATIONPENY-REPTABL-REPCLOS-ISRIT-HANDCITYFOLD-HLFSENTENCECOUNTYNO-IFSFLOORSEASONYEARPUT-LAPMONTHADDRESSDRAW-PNTDAYSPEL_ALLDATEAPPL-MEMPENY-MEMTABL-MEM

Mini-Mental State Exam items


Laboratory TestsLaboratory TestsROUTINEROUTINE

Routine – Blood tests & UrinalysisRoutine – Blood tests & Urinalysis EKGEKG Chest X-RayChest X-Ray Anatomical Brain Scan – CT (cheapest), MRIAnatomical Brain Scan – CT (cheapest), MRI

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


Justification for Brain Justification for Brain Scan in Dementia Scan in Dementia

DiagnosisDiagnosis Differential Diagnosis: Tumor, Stroke, Differential Diagnosis: Tumor, Stroke,

Subdural Hematoma, Normal Pressure Subdural Hematoma, Normal Pressure Hydrocephalus, EncephalomalaciaHydrocephalus, Encephalomalacia

Confirmation of atrophy patternConfirmation of atrophy pattern Estimation of severity of brain atrophyEstimation of severity of brain atrophy MRI shows T2 white matter changesMRI shows T2 white matter changes

Periventricular, basal ganglia, focal vs Periventricular, basal ganglia, focal vs confluentconfluent

These may indicate vascular pathologyThese may indicate vascular pathology SPECT, PET - estimation of regions of SPECT, PET - estimation of regions of

physiologic dysfunction, areas of infarctionphysiologic dysfunction, areas of infarction Helps family to visualize problemHelps family to visualize problem


Ashford et al, 2000


INTERVENTIONSINTERVENTIONS Only successful intervention – Only successful intervention –

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

Available Interventions – Available Interventions – Not yet proven or unconvincing effectsNot yet proven or unconvincing effects

Promising InterventionsPromising Interventions


Other Medical Other Medical ConditionsConditions

Chronic pain syndromeChronic pain syndrome Medical consultation-liaisonMedical consultation-liaison

Other Neurological Other Neurological ConditionsConditions

Parkinson’s diseaseParkinson’s disease Guillan Barre syndromeGuillan Barre syndrome Huntington’s diseaseHuntington’s disease Seizure disorders – partial complex Seizure disorders – partial complex

seizuresseizures


Parkinson’s DiseaseParkinson’s Disease

Increases steadily after 50 years of Increases steadily after 50 years of ageage

PathophysiologyPathophysiology Concomitant conditionsConcomitant conditions Parkinson signsParkinson signs Symptomatic treatmentSymptomatic treatment


ElectroencephalographyElectroencephalography Seizure disordersSeizure disorders

Sensitivity – 50% (90% after 3 recordings)Sensitivity – 50% (90% after 3 recordings) Episodic behavior problemsEpisodic behavior problems

Possible partial seizure disorderPossible partial seizure disorder Generalized slowing Generalized slowing

Primary neurodegenerationPrimary neurodegeneration Temporal slow waves may be “normal”Temporal slow waves may be “normal”

Focal slowing (stroke, focal cortical Focal slowing (stroke, focal cortical disease)disease)

Specific neurologic syndromesSpecific neurologic syndromes Creutzfeldt-Jakob diseaseCreutzfeldt-Jakob disease

Sleep disordersSleep disorders In sleep studies: used to define stagesIn sleep studies: used to define stages


Behavioral Problems In Behavioral Problems In Dementia PatientsDementia Patients

Mood Disorders – depression – early Mood Disorders – depression – early in ADin AD

Psychotic DisordersPsychotic Disorders Particularly paranoia, e.g, people Particularly paranoia, e.g, people

stealing thingsstealing things AgitationAgitation Meal Time BehaviorsMeal Time Behaviors Sleep DisordersSleep Disorders


Neuropsychiatric Neuropsychiatric TreatmentsTreatments

First treat medical problemsFirst treat medical problems Second environmental Second environmental

interventionsinterventions Third neuropsychiatric Third neuropsychiatric

medicationsmedications


Sleep DisordersSleep Disorders Primary sleep problemsPrimary sleep problems

Breathing-related sleep disordersBreathing-related sleep disorders Narcolepsy / primary hypersomniaNarcolepsy / primary hypersomnia Circadian rhythm disordersCircadian rhythm disorders ParasomniasParasomnias

Secondary sleep problemsSecondary sleep problems Due to a psychiatric condition: depression, Due to a psychiatric condition: depression,

psychosispsychosis Due to a medical condition: arthritis, Due to a medical condition: arthritis,

parkinson’sparkinson’s Substance induced disordersSubstance induced disorders Fragmented circadian rhythms, sleep in ADFragmented circadian rhythms, sleep in AD


InsomniaInsomnia

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

Periodic limb movement, restless leg syndromePeriodic limb movement, restless leg syndrome Sinemet or anti-convulsantsSinemet or anti-convulsants

PTSD, nightmares (trazodone, prazosin)PTSD, nightmares (trazodone, prazosin) Jet lag (? melatonin)Jet lag (? melatonin) Drugs: caffeine, nicotine, Drugs: caffeine, nicotine,

Sleeping pill reboundSleeping pill rebound

Geriatric Psychiatry: A Review & Update Medical and Neurologic Aspects J. Wesson Ashford University...

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