Everything You Need to Know About Geriatric Psychiatry in 75 Minutes

1. Everything You Need to Know About Geriatric Psychiatry in 75 Minutes Andrea Stewart, MD, FRCPC Writer of LMCC, 2002

2. Aged ≥80 years in 1994Aged ≥80 years in 2020 AGE DEPENDENCY RATIO Proportion of population aged ≥80 years (%)

4. Challenges of Late Life • Co-morbid medical illness / cognitive disorders • Sensory loss • Financial worries • Retirement • Dependency • Dying and death • Bereavement

5. OVERVIEW • Dementia - BPSD • Late Onset Psychosis • Depression in late life • Anxiety in late life • Delirium • Other types of dementia (Lewy Body, FTD)

6. Case 2

7. 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

8. 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

9. Alzheimer’s Dementia • Memory 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

10. Defining the Diagnostic Threshold Normal Cognition MCI/ CIND Dementia

11. Screening Tools • MMSE score <24/30 • MOCA score <26/30 • Mini-Cog (3 word registration & recall, CDT)

12. 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 management 1Burns A, BMJ

13. OBTAIN MEAL/SNACK KEEP APPOINTMENTS USE HOME APPLIANCES TELEPHONE FIND BELONGINGS MAINTAIN HOBBY DISPOSE LITTER CLEAR TABLE SELECT CLOTHES WALK EAT TRAVEL ALONE GROOM DRESS Bars show 25th to 75th %ile of patients losing independent performance. Activities of Daily Living 30 25 20 15 10 5 0 MMSE Mild AD Moderate AD Severe AD 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.

14. Cognitive Enhancers • 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)

17. Other Medications/ CAM • Nimodipine (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

18. Case 2

19. Behavioural and Psychological Symptoms of Dementia

20. ABC Approach A Antecedents B Behaviours C Consequences

21. 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... www.piecescanada.com

22. Pharmacological Management of BPSD • 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 1Cochrane, 2008; 2Pollock, BG Am J Ger Psych; 3Cochrane, 2008

23. The following is NOT true of Alzheimer’s: • Insidious, gradual and progressive decline • Motor symptoms are absent until later in the disease • A dramatic presentation is not the same as an abrupt onset • Behavioural symptoms are often the most distressing symptom for families and caregivers • The ‘head turning sign’ refers to sexual disinhibition • Vascular events may co-occur and cause cognitive dysfunction

25. Case 6

26. 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

27. 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

28. Differential Diagnosis • Psychosis 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

29. Differentiating the Dx

31. 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

32. Case 6

33. Which of the following is not true in LLP? • Most paranoid disorders of old age are due to schizophrenia • More women develop late onset schizophrenia • With ageing, schizophrenia tends to give less severe positive symptoms • Patients with schizophrenia live 10-30 years less on average

34. Case 7 What is in your differential diagnosis? What kind of investigations would you order? Assuming you believe her to be depressed what would be your plan of treatment? Is there a reason for suggesting one antidepressant over another? Assuming she does not have any response to treatment after 3 weeks what would you do?

35. 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

36. Differential Diagnosis • Depressive Disorder (dysthymia, MDE, BP with MDE, personality disorder) • Bereavement • Dementia • Delirium • Substance (drug of abuse, medication) or GMC

37. 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

39. Diagnostic Criteria Mood depressed/irritable or anhedonia for > 2 weeks and 4/8: • Sleep change • Interests lost • Guilty or worthless feelings • Energy lost • Concentration impaired • Appetite changed/ wt change • Psychomotor symptoms • Suicidal or death-related thinking DSM-IV-TR

40. Late Life Depression CCSMH, Assessment and Treatment of Depression 2006

41. 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

42. MDE vs Grief • 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. MDE • +/- onset after trigger • Symptoms worsen with time • SI/ preoccupation with death • Intense guilt & worthlessness • Persistent mood state • Functional impairment • Psychosis APA, 2000

43. 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

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

45. Language of Treatment

46. Antidepressants • Meta-analysis of trials of 2nd generation antidepressants in people >60 with non-psychotic depression and no dementia 1American Journal of Geriatric Psychiatry, 2008

48. Antidepressant No change after 4wks Works >20% better Maintenance Go to 8 wks Reassess diagnosis, increase dose, switch to escitalopram, sertraline, mirtazapine, effexor >20% better after above: Li, antipsychotic, psychotherapy

49. 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

50. Psychotherapy • Cognitive Behavioural Therapy • Problem Solving Therapy • Interpersonal Therapy