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
The Dementias: Behavioural and Psychological Symptoms in
Dementia- BPSD• Mood
• Anxiety as a presentation
• Anxiety as a concomitant
• Depression
• Elation- often pre existing bipolar disorder
The Dementias: Behavioural and Psychological Symptoms in
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
The Dementias: Behavioural and Psychological Symptoms in
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
The Dementias: Other Pharmacological Treatments
• Acute severe anxiety or agitation
• Lorazepam 0.5 mgs up to tds
• Respiratory depression, sedation, paradoxical agitation
• Chronic agitation and restlessness-clomethiazole
The Dementias: Other Pharmacological Treatments
• 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
The Dementias: Other Pharmacological Treatments
• 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
Old Age Psychiatry Services
• Consultant and other psychiatrists
• CPNs, Occupational therapy, psycchology, speech and languauge therapy, physiotherapy, dietetcis, support workers
• Home treatment Team
• Memory Clinic
• Day Hospital
Old Age Psychiatry Services
• 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
Depressive Disorders- Treatment
• Optimise Function-
• Rx physical conditions,
• Attend to sensory deficits
• Review medication
• Enable Practical support
• Sign posting to appropriate agencies
Depressive Disorders- Treatment
• Prevention of Relapse and Recurrence
• Continue medication during recovery
• Stay on medication for at least 1 yr after recovery
• Maintenance treatment
Depressive Disorders- 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
Depressive Disorders- Treatment
• 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
Depressive Disorders- Treatment
• ECT
• Severe depression80% recover
• Well tolerated
• Broader spectrum of use
• Not within 3/12 of stroke or heart attack
• Memory imapirment
Depressive Disorders- Treatment
• 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
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