OLD AGE PSYCHIATRY FOR PRIMARY CARE VOCATIONAL TRAINEES

1. OLD AGE PSYCHIATRY FOR PRIMARY CARE VOCATIONAL TRAINEES Dr Nick Pearson Consultant in the Psychiatry of Old Age Reading 040308

2. Plan For This Afternoon Introduction Overview of older person�s mental disorders in primary care Clinical Vignettes-Group Work Specialist Service and Primary care

3. GETTING OLDER What does it mean to you?

4. GETTING OLDER Direct Experience of Caring

5. Abilities that endure with ageing Language comprehension and expression Tip of the tongue states- word not immediately recalled but strong sense of knowing what that word is Skills Knowledge Emotional states Memory-cued recall better than free recall New learning Once learned remains

6. What improves with ageing? Improved problem solving Use of more flexible strategies Better able to keep calm in a crisis

7. Abilities that diminish with ageing Speed of thinking slows Working memory reduced (remembering several things at any one time) Episodic memory may be reduced (knowing exactly when, where, what and with whom)

8. Which brain areas are related to which tasks? Left inferior-lateral prefrontal-meaning of memory Middle temporal lobe- binds episodic memory together L insula-tip of the tongue states Multiple areas including frontal, temporal & parietal-working memory White matter connects different areas of brain together- ?executive function Amygdala-emotion

9. Other ageing related effects Reorganisation into other brain areas within same hemisphere or opposite Functions that were lateralised become bilateral Less specialisation of function Reduced dopamine related signalling

10. Cognitive functions may be able to adapt Adaptation does not mean less effective-just different Adaptation may preserve function

11. Cerebrovascular Events Single large stroke or multiple strokes disrupt the reorganisation process ? Effect of small vessel disease-disruption to cognitive processes

12. Assisting Cognition in Normal Ageing Allow time Presenting information singly Spoken word-Improve comprehension by making meaning clear, avoid jargon Written word-avoid ambiguity and more complex words as they require more processing Older people respond better to positive stimuli

13. Stereotyping older people Up to � of older people >65yrs believe they have a memory problem The more you accept this view the more you seem to succumb to it On memory testing if show older person negative word e.g. senile- perform badly If positive word e.g. wisdom- perform well Positive cultural view of ageing e.g. China people perform better on memory tests

14. Older Person�s Mental Disorders in Primary Care The terrific trio Depression Dementia Delirium

15. Older Persons� Depressive Disorders in Primary Care Depression in older age is not an inevitable consequence it is a pathological state 10-15% over 65yrs GP list of 1700 20% > 65 yrs (340) Depressed patients= 42 Treatment Resistant= 14

16. Older Person�s Depression in Primary Care 15-30% seek help Prevalence Care homes 30-40% Nursing homes 70% General hospitals 15-20%

17. Older Persons� Dementia in Primary Care Prevalence >65 yrs= 5% Patients with dementia average GP caseload=17 >75yrs=10% >85 yrs= 20% >90yrs= 30% Younger person with dementia-1

18. Older Persons� Dementia in Primary Care Significant Behavioural and Psychological Symptoms in Dementia BPSD (30%)= 5 Mild to moderate (2/3) = 11 May benefit from treatment (3/4)= 8

19. Older Person�s Mental Disorders in Primary Care Younger onset dementia 1in 1000 < 65yrs

20. Older Persons� Delirium in Primary Care Prevalence in primary care unknown 40% of>65yrs in hospital

21. Older Persons� Psychotic Disorders in Primary Care Prevalence in community >65yrs of 1% Schizophrenia Persistent delusional disorders Mania Psychotic depression

22. Older Persons� Psychotic Disorders in Primary Care for 65-86 yr olds over a 6 yr period mortality men 30% women 20% Psychotic depression mortality men 75 % women 40%

23. Older Persons� Neurosis in Primary Care Prevalence anxiety disorders>65yrs= 4% Phobias= 10%

24. Older Persons� Psychoactive Substance Use in Primary Care 4% of older males had drunk> 8 units of alcohol on at least 1 day in the previous week. 16-24yr olds? Alcohol more commonly a complicating factor

25. Older Persons� Mental Disorders in Primary Care: Factors Physical disorders Medication Social Context Environmental Context Individual�s meaning

26. CLINICAL CASE CaseStem1 CaseStem2 CaseStem3

27. Reading Old Age Psychiatry ServiceWhat are we aiming to do? Provide a specialist service for older people with mental health problems Be Responsive Be Flexible in our approach-needs led Provide evidence based holistic care Use latest technology where appropriate Communicate effectively Know what we do and how we can improve Provide a service which is community focussed

28. Reading Old Age Psychiatry ServiceWhat do we do? Urgent treatment Non urgent treatment Recurrence/relapse prevention Carer support and treatment Specialist opinion e.g. complex Court of Protection issues Service innovation e.g. www.roapi.net Planning and audit Research

29. Reading Old Age Psychiatry ServiceWhat do we do? Work with others- clinical, educational primary care, elderly medicine, social services, voluntary sector, independent sector GP forum 50+ forum

30. What do we not do? Provide social care Keep people on case load indefinitely without good reason Try not to foster dependency & production of psychiatric disorder

31. Reading Old Age Psychiatry ServiceHow do we do it? Home treatment team CPN service Day Hospital Memory clinic (Outpatients) Inpatients Liaison with acute trust, general psychiatry Through a range of therapeutic options

32. Who is involved? Consultant, staff grade, GPSI psychiatrists CPNs, Occupational therapist, Psychologist, Speech and language therapy Community support workers Secretarial support

33. Which Patients? Older (using other older people�s services) Frail Complex medical/psychiatric Older people with suspected dementia or cognitive impairment Younger people with dementia-confirmed or highly probable

34. Patients Not to Refer Acute physical illness Delirium

35. Supporting the Carers Listening Informing Involving CBT for carers Cognitive analytical therapy- dichotomies, ethical & moral considerations

36. Changing the Environment Housing for cognitively impaired Safety issues Aids and adaptations Smart technology Levels of sheltered accomodation

37. Social Care Social services Voluntary Sector Private Sector

38. Social Care Support for personal care Help with shopping, housework Mental Capacity Act Lasting Power of attorney- welfare, health Court of Protection Allowances Clubs, day care

39. Care Respite Care-at home or away Long term care Care homes DE Nursing Homes DE

40. 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

41. Delirium: Clinical Features Clouding of consciousness, attention, memory, executive function all affected 2 types Apathetic Active, psychotic, behavioural symptoms Symptoms worse at night

42. Delirium:Risk Factors Increasing age Dementia Sensory deficits Previous episode Severe comorbidity Immobility Sleep Disturbance Alcohol Consumption Operation Dehdration Low albumin

43. Delirium-Medication Risk factors Benzodiazepines Anticholinergics Opiates Digoxin Warfarin

44. Delirium Causes Almost anything in combination with risk factors

45. 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

46. Delirium:Treatment Identify and treat cause Modify risk factors Treat Infections, metabolic, malignancy, cardiac, vascular Consider hospital admission

47. Delirium:TreatmentThe eight ates or Nice Coat Noise abate Illuminate Communicate Environment manipulate Carer participate Orientate Ambulate Thermoregulate

48. Delirium:Medication If hyperactive and psychotic Antipsychotic-haloperidol Olanzapine, quetiapine Lorazepam

49. Mild Cognitive Impairment (MCI) Disputed entity 25% 0f community populations Subjective and objective changes of cognitive impairment Amnestic type Vascular type

50. The Dementias: Clinical Features Progressive Impairment of cognition, personality and intellect Orientation, Memory, Language(dysphasia) Ability to carry out tasks(praxias) Recognition (agnosia) Mood-prodromal depression

51. The Dementias-Executive Function Impairment Planning Organising Abstract thinking Multi tasking

52. 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 dementia ward

53. The Dementias: Behavioural and Psychological Symptoms in Dementia- BPSD Mood Anxiety as a presentation Anxiety as a concomitant Depression as a precursor Elation- often pre existing bipolar disorder

54. The Dementias: Behavioural and Psychological Symptoms in Dementia- BPSD Psychosis-delusions Phantom lodger Misidentifications e.g.Capgras Persecutory

55. The Dementias: Behavioural and Psychological Symptoms in Dementia- BPSD-Psychosis Hallucinations Auditory- music, voices Visual-people, animals

56. The Dementias: Behavioural and Psychological Symptoms in Dementia- BPSD Wandering Agitation Day night reversal Verbal Aggression Physical Aggression Disinhibition Apathy

57. The Dementias: Causes Subdural Brain tumour Normal pressure hydrocephalus Hypothyroidism Low B12/folate Syphilis Diabetes Chronic infection Uraemia

58. The Dementias: Causes Alzheimer�s Disease(AD) 25% Vascular Dementia(VaD) 10% Mixed Dementia-Alzheimer�s with cerebrovascular disease AD/VaD 40% Dementia with Lewy Bodies(DLB) 15% Fronto Temporal Dementia (FTD) 5% Others

59. Alzheimer�s disease Plaques (beta amyloid) Tangles (hyperphosphorylated tau) Insidious onset Gradual decline Memory (immediate & delayed recall), orientation difficulties early on Later on dysphasia, dyspraxia, agnosia

60. Alzheimer�s with cerebro vascular disease Alzheimer�s + Impairment of executive function early Brings forward onset

61. Vascular Dementia Single large infarct Multi infarct dementia Subcortical dementia Executive function impaired early Some recall on delay Visual & verbal memory differentially affected Abrupt onset, step wise deterioration

62. Prevention and treatment of cognitive impairment and dementia Prevention:Reduce dementia incidence by ? 50% Treatment: Improve cognition (and other function) once impaired- by how much?

63. Prevention and treatment of cognitive impairment and dementia Neuro protection Neuronal reserve Vascular risk factors

64. Prevention and treatment of cognitive impairment and dementia Which is your target population? Prevention- general population Healthy Middle aged people Healthy Older people Prevention- those at risk-vascular risk factors Treatment- Older people with MCI Treatment- Older people with dementia

65. Prevention and treatment of cognitive impairment and dementia Genetics Chromosome 21-APOE4 Chromosome14 Pre senelin 1 Chromosome 1 Presenelin 2 Single Mutations in the above account for 10% of familial cases in early onset Most older onset not accounted for by single genetic mutations

66. Prevention and treatment of cognitive impairment and dementia Alter Gene Expression in the Brain lifelong Physical activity Learning Social Improve neural connectivity

67. Neuroprotection Oxidative stress?free radicals?inflammation?vascular damage Antioxidants. Vitamins C & E, alcohol. Fruit & veg >5 portions per day Fish 3x/week Turmeric Red wine Older Males< 10units/week, Older females,< 7 units/week

68. Neuroprotection Antiinflammatory Alzheimer�s as an inflammatory disease Non steroidal anti inflammatories? Statins Hyperhomocysteinaemia-vascular damage Low levels of B12 & folate Oestrogen?

69. Increase neuronal reserve Keep Active Mental Physical Social Leisure

70. aLive Mind Cognitive stimulation Multi sensory stimulation Lead in Theme for the afternoon �Eating Well� �Looking Good� Patients and carers Collaboration with voluntary sector

71. Vascular Risk Factors-Cerebro and cardiovascular Hypertension- what BP? Hypotension-what BP? TIAs- aspirin? Diabetes-what control? Ischaemic heart disease Cardiac arrhythmias Carotid atherosclerosis Coronary artery bi pass grafting Angioplasty Metabolic syndrome

72. Vascular Risk Factors-Cerebro and cardiovascular Cholesterol increases beta amyloid Hypercholesterolaemia-what cholesterol level? Statins-reduce cholesterol, ? cerebral blood flow, ? �amyloid, antiinflammatory Smoking-vascular dementia Obesity

73. Lewy Body-Parkinson�s disease spectrum disorder PD- Lewy Bodies in subcortex Dementia with Lewy Bodies-cortex Which comes first? Alzheimer�s disease PD and hallucinations from treatment DAT scan

76. Dementia with Lewy Bodies Fluctuating course Visual hallucinations Spontaneous features of Parkinsonism

77. Dementia with Lewy Bodies Falls Syncope Systemised delusions Hallucinations in other modalities Neuroleptic sensitivity

78. Fronto Temporal Dementia 30% of younger onset dementia(45-65yrs) Duration 8yrs Overactive-disinhibted, lack of concern(orbitomedial frontal, anterior temporal) Apathetic-perseveration, rigid thinking, lack of volition(pan frontal) Stereotyped ritualistic behaviour(striatum) Semantic dementia-unable to understand meaning of words, objects, sensations Progressive non fluent dysphasia

79. 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

80. 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

81. The Dementias: Identify and Diagnose History Cognitive testing Primary Care 6CIT MMSE Physical examination

82. The Dementias: Dementia Screen FBC ESR U&Es LFT�s, Calcium, protein Blood Sugar Lipids B12&folate TFTs Serological Tests for syphilis ECG?

83. Referral to Old Age Psychiatry Early for diagnosis, comprehensive assesment

84. Dementias:Treatment Memory clinic History Examination Investigation Diagnosis Treatment

85. 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

86. Goals of Treatment Enhance Cognition Increase autonomy Decrease behavioural symptoms Slow or arrest progression of the disease Primary prevention in the presymptomatic stage

87. Memory Clinic- Work up for CHEIs Dementia screen ECG-if pulse< 60/min Neuropsychological testing-if MMSE>19 CT Brain scan

88. Treatment With A Cholinesterase Inhibitor (CHEI) Mild to moderate AD, AD with CVD, DLB Carers opinion on progress Good compliance No contraindications

89. Treatment With A Cholinesterase Inhibitor (CHEI) Secondary Care Prescription Donepezil Rivastigmine Galantamine

90. Memory Clinic Prescribe CHEI Patient and carer information www.roapi.net Support or care at home Monitoring and treatment of BPSD Review 3/12 after stabilisation

91. Memory Clinic Review Usually every 6/12 MMSE, CDT, EF, BADL, CGIC Continue if evidence of benefit

92. Memory Clinic Stopping CHEIs MMSE <12 Marked deterioration No evidence of benefit Taper over 2-4 weeks Occasionally severe relapse- need to restart within 4/52

93. 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

94. 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

95. 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

96. 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

97. 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

98. The Dementias: Other Pharmacological Treatments Cholinergic deficit syndrome Anxiety Agitation Hallucinations CHEIs

99. The Dementias: Antipsychotics Psychotic symptoms, agitation, sexual disinhibition Typicals: Haloperidol 0.5mgs up to tds Sedation, EPS Benperidol: sexual disinhibition

100. 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-DA partial agonist

101. The Dementias: Non Pharmacological Treatments -Reality orientation Signposts Notices Memory aids effective

102. The Dementias: Validation therapy Retreat into inner world to avoid stress, boredom & loneliness Validation-empathy with feelings and hidden meanings behind the confusion ?Effective

103. The Dementias: Reminiscence May help social interaction, motivation, self care and reduce behavioural symptoms At all severities of dementia

104. The Dementias: Art Therapy Self expression through painting not relying on language Stimulation, communication, social interaction

105. The Dementias: Music Therapy Active participation or listening Social interaction Can help those with abnormal vocalisations Reductions in agitation for music tailored to individual

106. The Dementias: Activity Therapy Dance, drama. Sport Physical activity, reduces falls, improves sleep, mood and confidence Day time activity-reductions in agitation and restlessness at night

107. The Dementias:Complementary Therapies Massage, Reflexology, Herbal medicine Efficacy not known

108. The Dementias: Aromatherapy Lavandula augustifolia melissa officianalis Inhalation, bathing or topical Reductions in agitation Well tolerated

109. The Dementias: Light and Multisensory Bright Light Therapy Beneficial in sleep disturbance Multi Sensory Approaches Fibreoptics, cushions& vibrating pads, liquid wheels ?improvements in agitation

110. The Dementias: Cognitive Behaviour Therapy Early dementia Misinterpretations, biases, distortions, erroneous problem solving strategies, communication problems Benefit reported CBT for carers

111. The Dementias: Interpersonal Therapy Individual distress within their own context Person Centred Approach Disputes, personality difficulties, bereavements, life evenst/changes Little used in dementia

112. Depressive Disorder: Risk Factors Disability Handicap Stroke Parkinson�s disease VaD Heart Disease COPD

113. Depressive Disorder- causative Physical Disorders Endocrine/Metabolic Thyroid disorder Cushings syndrome Hypercalcaemia Pernicious anaemia Folate deficiency

114. 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

115. 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

116. Depressive Disorder-Detection History Anorexia, weight loss and anergia difficult to interpret Examination Depression screen- FBC ESR, renal, liver, calcium, thyroid GDS

117. Depressive Disorders- Treatment Remission of all residual symptoms Provide appropriate Rx- NICE guidelines antidepressants, psychological ECT Provide info & support for patient/carers

118. Depressive Disorders- Treatment Optimise Function- Rx physical conditions, Attend to sensory deficits Review medication Enable Practical support Sign posting to appropriate agencies

119. Depressive Disorders- Treatment Prevention of Relapse and Recurrence Continue medication during recovery Stay on medication for at least 1 yr after recovery Maintenance treatment Bipolar disorders-treatment for life

120. 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

121. Depressive Disorders- Treatment Efficacy TCA=venlafaxine> SSRIs Often difficult to obtain a therapeutic dose of TCA

122. 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

123. Depressive Disorders- Treatment ECT Severe depression 80% recover Well tolerated Broader spectrum of use Not within 3/12 of stroke or heart attack Memory impairment

124. Depressive Disorders- Treatment Rapid transcranial magnetic stimulation- research only Exercise in prevention Enhanced or stepped care- case mangement, antidepressants+ problem solving+ close links between primary & 2o care

125. 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

126. 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

127. Depressive Disorders- MaintainanceTreatment Single episode major depression-1 yr after recovery > 3episodes continue indefinitely at therapeutic dose TCA, citalopram Antidepressant+ psychological Rx

128. 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

129. Communication ROAPI- computerised patient care record including tabulated summary Emails-quick, easy & written Template for e referral on Balmore Pk EMIS Bespoke Reading Old Age Psychiatry Web site: www.roapi.net