Geriatric Psychiatry

1. Geriatric Psychiatry Vicki Kijewski, M.D. vicki-kijewski@uiowa.edu June 8, 2016

2. Objectives • Compare and Contrast the 3 D’s • Delirium, dementia, depression • Identify 4 other common geriatric psychiatric syndromes • Describe diagnosis and management strategies

3. Geriatric Psychiatry Syndromes • Acute Confusion (Delirium) • Memory Loss (Dementia) • Depression • Insomnia • Anxiety • Suspiciousness and Agitation • Hypochondriasis

4. Acute Confusion (Delirium) • De “Away from” • Lira “Furrow in a field” • Ium Singular • “A going off the ploughed track, a madness”

5. Delirium • Acute onset • Decreased ability to maintain attention • Difficulty shifting attention • Disorganized thinking and speech • Memory disturbance • Altered level of consciousness • Disturbance in sleep-wake cycle • Anxiety, fear, irritability and anger • May appear apathetic and withdrawn

6. Why worry about delirium? • Common • Leads to prolonged hospitalizations • Leads to functional decline • Leads to institutionalization • Mortality at 2 year f/u nearly 50% • Although generally reversible, often the harbinger of future problems

7. Types of Delirium • Hyperactive • Hypoactive • Mixed

8. Epidemiology • Found wherever there are sick patients • ICU 70% • ERs 10% • Hospice units 42% • Post acute care settings 16% • Duration • 20% last one day • 50% lasts three days • 67% is over in four days • 20% lasts 5-10 days • 15% lasts 10 days to one month

9. Precipitating Factors • Medications and/or Polypharmacy • Infection • Dehydration • Immobility • Malnutrition • Bladder catheters

10. Tools to assist with the identification of delirium • Confusion Assessment Method • Bedside Tests for Attention • Recognition/Suspicion • Folstein Mini-Mental • Confusion Assessment Method-ICU • Clock Drawing • Verbal Trails

11. History and Physical Examination • Obtain collateral information • Review medication lists • Over the counter medications • New medications or recently discontinued medications • Physical examination • Neurological examination

12. WHHHHIMP • Wernicke’s or withdrawal • Hypoxemia • Hypertensive encephalopathy • Hypoglycemia • Hypoperfusion • Intracranial bleeding or infection • Meningitis or Encephalitis • Poisons or medications

13. Prevention and Treatment • Identify those at risk for delirium • Prevent dehydration, immobility, physical restraints, sleep deprivation, indwelling bladder catheters • Avoid factors known to cause or aggravate delirium • Identify and treat underlying acute illness • Provide supportive care to prevent further cognitive and physical decline • Control dangerous/disruptive behaviors

14. Prevention strategies • Adequate CNS oxygen delivery • Pain management but titrate to lowest dose • Elimination of unnecessary medications • Regulation of bowel/bladder function • Nutrition • Early mobilization • Monitoring for complications • Assuring appropriate environmental stimuli • ? Use of medications to prevent delirium

15. Symptomatic Treatment • No medications are FDA approved for the treatment of delirium • Use of Anti-psychotics is controversial • No clinical practice guidelines • UK-NIHCE recommends short term, lowest dose • Distressed individuals with harmful behaviors not responsive to other environmental strategies • Benzodiazepines • Indicated only for alcohol or sedative-hypnotic withdrawal

16. Delirium • Multifactorial • Remains poorly understood • Prevention and early recognition are key • Identify and treat underlying medical conditions • Nonpharmacologic interventions should be attempted

17. Memory Loss • Major Neurocognitive Disorders • Mild Neurocognitive Disorders • More common in those > 75 • At least 10% of persons > 65 in community • Relatively indolent • Progressive

18. Memory Loss (Dementia) • Alzheimer’s dementia 60% • Vascular dementia • Dementia with Lewy bodies • Mixed type • Mild cognitive impairment

19. Clinical Characteristics • Memory impairment • Language disturbance • Difficulty carrying out motor activities • Failure to recognize objects • Difficulty with calculations • Focal neurological signs (VaD) • Disturbances in executive function

20. Screening/Diagnosis • Folstein MMSE • Montreal Cognitive Assessment • www.mocatest.org • Neuropsychological Assessment • TSH, B12, Metabolic Profile • Hearing, vision, alcohol use, drug use • HIV, syphilis • Imaging

21. Memory Loss • Prevention? • Using a computer • Moderate physical exercise • Not helpful • Gingko biloba • Fish oil • Antioxidants • Vitamins • NSAIDS

22. Treatments • Increasing patient safety • Increasing functionality • Improving quality of life • Reduce patient harm • Reduce caregiver stress • Educate patient and caregiver • www.alz.org or 1-800-272-3900

23. Treatments • Initiation of environmental safety measures • Formal driving evaluation • Home safety evaluation • Regular exercise • Social supports • Consistent environment • Problem solving therapy

24. Capacity EvaluationsEnd of Life Planning • Capacity assessment • Specific ability to make a decision at a given point in time • Conversation • Communicate • Understanding of intervention • Risks/benefits/alternatives • Express a choice • Rationale for decision

25. Medications • FDA approved medications for moderate dementia • Donepezil (cholinesterase inhibitor) • Rivastigmine (cholinesterase inhibitor) • Galantamine (cholinesterase inhibitor) • Memantine (NMDA receptor antagonist) • When should they be stopped?

26. Medications • Consider an SSRI if mood disorder • In general avoid benzodiazepines • What about antipsychotics? • Controversial • 10% of hospitalizations in the setting of dementia are related to behavioral issues

27. Dementia associated behaviors • Physical aggression • Verbal aggression • Wandering • Hoarding • Disinhibition • Calling out

28. Treatment of behaviors • Non-pharmacologic interventions • Determine cause of behavior • Hunger, boredom, pain, toileting needs, isolation, infection, …. • Familiar surroundings/caregivers • Transitional object • Simple task

29. Use of Antipsychotics in Dementia • Controversial • 2005 Black Box Warning • Consider if history of psychosis, mania, hallucinations or overt psychosis • Most studies ≤ 35% reduction in behavior • Efficacy similar for typical and atypical Aps • Obesity, DM, falls, TD, AMI, EPS, death

30. Consequences of Dementia • Failure to Thrive • Anorexia, weight loss • Frailty • Unintentional weight loss • Slow movement • Fatigue • Weakness • Low physical activity

31. Depression • Frequent • Often do not complain of depressed mood spontaneously • Weight loss • Insomnia • Anhedonia • Complain of difficulties with concentration and memory loss

32. Depression • > 10% of older adults seen by PCP suffer from depressive disorders • Rates increase in both sexes after 65 • Vague, nonspecific symptoms • Somatic complaints • Pain, change in weight, constipation, irritability, agitation, fatigue, headache, insomnia, hypersomnia, weakness

33. Diagnosis of Depression • Geriatric Depression Scale • PHQ-9 • Cornell Scale for Depression in Dementia • Up to 50% of caregivers of older adults may have depressive symptoms as well

34. Treatment of Depression • Medication • SSRIs, SNRIs, other agents • Start low, go slow but GO • Therapy • CBT, IPT, Psychodynamic • Electroconvulsive Therapy • 30% of older adults are undertreated

35. Suicide Risk • 5-10% of older adults suicidal ideation • 30% of those with MDD • ↑ Lower SES, ↑ Cerebral microbleeds • Most likely to be reported to PCP • Ask directly • 40% of older adults who completed suicide had communicated wish to die to provider in last 12 months

36. Insomnia • 28% report difficulty falling asleep • 46% report difficulty staying asleep • Normal changes with aging • ↓ total sleep time • ↓ sleep efficiency • ↓ slow wave and REM • ↑ incidence of napping/falling asleep during day • Less tolerance for jet lag/shift work

37. Sleep disturbances leading to insomnia • Primary insomnia • Sleep-disorder breathing (OSA) • Periodic leg movements or noc myoclonus • Anxiety and mood disorders • Dementia • Medications • Physical Illness (CHF, COPD, Nocturia, …)

38. Treatment of Insomnia • Nonpharmacologic Interventions • Sleep education • Sleep hygiene • Cognitive behavioral therapy • Bright light therapy

39. Pharmacotherapy of Insomnia • Melatonin/Ramelteon • May be helpful • OTC sleep aids (diphenhydramine) • Drug interactions, confusion, falls • Habit forming • Do not normalize sleep cycle • Sedative/Hypnotics • Increased risk of falls, confusion

40. Anxiety • 5% of older adults • Medical causes • Hyperthyroidism • Cardiac arrhythmia • Pulmonary emboli • Hypoglycemia • Medications such as caffeine, OTC sympathomimetic drugs, anticholinergic

41. Causes of Anxiety • Confusion • Depression • Fear of falling, getting lost, being attacked • Dementing disorders

42. Treatment • Nonpharmacologic interventions • Medications

43. Suspiciousness and Agitation • More common in those with cognitive impairment • Persecutory delusions • Somatic delusions

44. Treatment • Ensure a safe environment • Initiate a therapeutic alliance • Consider pharmacologic treatment • Anticipate acute behavioral crises.

45. Illness Anxiety Disorder (Hypochondriasis) • Belief of suffering from one or more serious illnesses • Exaggerated interpretation of physical signs • Abdominal/GU symptoms • Concerns not alleviated by reassurance from physician or medical evaluation • Side effects from medications

46. Contributing Factors • Shift anxiety from psychological conflicts to concrete problems with body functioning • Social factors • Isolation

47. Diagnostic Evaluation • History • Routine physical examination • Routine laboratory evaluation if indicated

48. Treatment • Best managed by PCP • Relatively brief but regularly scheduled visits

49. Managing Illness Anxiety Disorder (Hypochondriasis) • Control excessive use of healthcare services. Prescribe meds with caution. • Decrease concern and anxiety in patient • Provide assurance of professional commitment to management • Decrease family stress • Decrease anxiety, anger and frustration of health care professional

50. Conclusions • Acute confusion in hospitalized elders is common. Careful screening is indicated. • Important to work with family of patient with memory loss. • Good sleep hygiene is more important than pharmacological treatment • Anxiety is often comorbid with other conditions