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:

Sufficiently severe to cause impairment of occupational or social functioning and Must represent a decline from a Geriatric Psychiatry: A Review & Update

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.) Geriatric Psychiatry: A 8.Review &umor, Toxin, Trauma T Update

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

1994)

A. Multiple Cognitive Deficits 1. Memory Impairment 2. Other Cognitive Impairment B. Deficits Impair Social/Occupational C. Course Shows Gradual Onset And Decline D. 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)

A. Multiple Cogntive Impairments B. Deficits Impair Social/Occupational C. Focal Neurological Signs and Symptoms or Laboratory Evidence Indicating Cerebrovascular Disease Etiologically Related to the Deficits A. Not Due to Delirium
Geriatric Psychiatry: A Review & Update

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 (?? Binswangers disease) SPECT / PET show focal areas of Geriatric Psychiatry: A Review & Update dysfunction

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 Geriatric Psychiatry: Newman et or related to peri-op or post-op anoxia al., 2001, NEJM A Review & Update

Drug Interactions

Anticholinergics: amitriptyline, atropine, benztropine, scopolamine, hyoscyamine, oxybutynin, diphenhydramine, chlorpheniramine, many anti-histaminics

May aggravate Alzheimer pathology

Geriatric Psychiatry: A Review & Update

GABA agonists: benzodiazepines, barbiturates, ethanol, anti-convulsants Beta-blockers: propranolol Dopaminergics: l-dopa, alpha-methyldopa Narcotics: may contribute to dementia

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 Geriatric Psychiatry: Course: rapid resolution with A Review & Update

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

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 Cerebellum, gray matter nuclei

Chronic Neurodegeneration

Geriatric Psychiatry: A Review & Update

Medical / Endocrine

Thyroid dysfunction

Hypothyoidism elevated TSH Hyperthyroidism

Compensated hypothyroidism may have normal T4, FTI Apathetic, with anorexia, fatigue, weight loss, increased T4

Diabetes Hypoglycemia (loss of recent memory since episode) Hyperglycemia Hypercalcemia Nephropathy, Uremia Hepatic dysfunction (Wilsons disease) Vitamin Deficiency (B12, thiamine, niacin)
Pernicious anemia B12 deficiency, ? homocysteine

Geriatric Psychiatry: A Review & Update

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 Geriatric Psychiatry: A Review & Update predispose to a variety of conditions

Neurological Conditions

Primary Neurodegenerative Disease

Diffuse Lewy Body Dementia (? 7 - 50%) Fronto-temporal dementia (tau gene) Primary progressive aphasia (many causes) Unilateral atrophy, hypofunction on EEG, SPECT, PET Dementia with gait impairment, incontinence Suggested on CT, MRI; need tap, ventriculography

Focal cortical atrophy

Normal pressure hydrocephalus

Other Neurologic Conditions

Geriatric Psychiatry: A Review & Update

Tumor Toxins Trauma

Geriatric Psychiatry: A Review & Update

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

Amnesia

Dissociative: localized, selective, generalized Organic - damage to CA1 of hippocampus

thiamine deficiency (WKE), hypoglycemia, hypoxia

Epileptic events

Partial complex seizures Transient global amnesia Multiple sclerosis

Specific brain diseases

Geriatric Psychiatry: A Review & Update

Age-Associated Memory Impairment vs Mild 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 Alzheimers disease

Geriatric Psychiatry: A Review & Update

Advances in Alzheimers Disease

Uncovering etiology Understanding pathophysiology Better screening tools Improved diagnosis Developing interventions

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

Senile plaques Neurofibrillary tangles Neurotransmitter losses Inflammatory responses

New Neuropath Mechanisms

Geriatric Psychiatry: A Review & Update

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

Biopsychosocial Systems Affected by AD

(all related to neuroplasticity)

Social Systems

Basic ADLs - Late Primary Loss Of Memory Later Loss Of Learned Skills Cortical Glutamatergic Storage Subcortical (acetylcholine, norepi, serotonin) Cellular Plastic Processes

Psychological Systems

Neuronal Memory Systems

APP metabolism early, broad cortical distribution TAU hyperphosphorylation late, focal effect, dementia related

Geriatric Psychiatry: A Review & Update

Why Diagnose AD Early?

Geriatric Psychiatry: A Review & Update

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) Patients and Familys right to know Specific treatments now available, may

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

Need for Better Screening and Assessment Tools

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

Dementia severity assessments Tracking progression rate, prediction of Geriatricchange Psychiatry: A Review & Update

Alzheimer Warning Signs Top Ten

Alzheimer 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

History Of The Development Of The Dementia Physical Examination Neurological Examination

Geriatric Psychiatry: A Review & Update

Neurological Exam

Cranial Nerves Sensory Deficits Motor Deep tendon Pathological

Geriatric Psychiatry: A Review & Update

ALZHEIM ER DETERIORATION ON THE M INI-M ENTAL STATE EXAM OVER TIM E 30 25 20 15 10 5 0 -5 0 5 10 AVERAGE TIM E OF ILLNESS (years)

SCORE

Geriatric Psychiatry: A Review & Update

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

1 0.9 PROBABILITY CORRECT 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 -4 -3 -2 -1 0
Geriatric Psychiatry: A Review & Update

Mini-Mental State Exam items

PENCIL A PPL-REP WA TC LOCA TION PENY -REP TA BL-REP CLOS-IS RIT-HA ND CITY FOLD-HLF SENTENCE COUNTY NO-IFS FLOOR SEA SON Y EA R PUT-LA P MONTH A DDRESS DRA W-PNT DA Y SPEL_A LL DA TE A PPL-MEM PENY -MEM TA BL-MEM

9 10

DISABILIT Y ("time-index" year units)

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

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

Geriatric Psychiatry: A Review & Update

Geriatric Psychiatry: A Review & Update

Geriatric Psychiatry: A Review & Update

Geriatric Psychiatry: A Review & Update

Ashford et al, 2000

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

Chronic pain syndrome Medical consultation-liaison

Other Neurological Conditions

Parkinsons disease Guillan Barre syndrome Huntingtons disease Seizure disorders partial complex seizures Geriatric Psychiatry:

A Review & Update

Parkinsons Disease

Increases steadily after 50 years of age Pathophysiology Concomitant conditions Parkinson signs Symptomatic treatment

Geriatric Psychiatry: A Review & Update

Electroencephalography

Seizure disorders

Sensitivity 50% (90% after 3 recordings) Possible partial seizure disorder Primary neurodegeneration Temporal slow waves may be normal

Episodic behavior problems

Generalized slowing

Focal slowing (stroke, focal cortical disease) Specific neurologic syndromes

Creutzfeldt-Jakob disease In sleep studies: used to define stages

Sleep disorders

Geriatric Psychiatry: A Review & Update

Behavioral Problems In Dementia Patients

Mood Disorders depression early in AD Psychotic Disorders

Particularly paranoia, e.g, people stealing things

Geriatric Psychiatry: A Review & Update

Agitation Meal Time Behaviors Sleep Disorders

Neuropsychiatric Treatments

First treat medical problems Second environmental interventions Third neuropsychiatric medications

Geriatric Psychiatry: A Review & Update

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, parkinsons Substance induced disorders Geriatric Psychiatry: A Review & Update Fragmented circadian rhythms, sleep in

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, Geriatric Psychiatry:

A Review & Update

Sleeping pill rebound