Review Of Geriatric Psychiatry

1. T. Lau, MD, FRCPC [psych], MSc., Director Undergraduate Education, Faculty of Medicine, UNIVERSITY OF OTTAWA Royal Ottawa Mental Health Centre Geriatrics Review Of Geriatric Psychiatry

2. Why is it important to know something about the elderly

3. Geriatrics Overview • 3 D’s • Depression • Dementia • Delirium (check the pee, poop etc) • 2 Extra D’s • Drugs • Delusional sx (Psychosis in the Elderly) • Overview and cases of • DEPRESSION • MANIA • ANXIETY • PSYCHOSIS • DELIRIUM • DEMENTIA “I want to die in my sleep like my grandfather, not like the people kicking and screaming in the backseat of his car.” Sue McKay Geriatric Psychiatrist

4. Case 1 • 73 year old woman who presents with 2 month history of tearfulness, loss of energy, apathy, inability to get out of bed in the morning, and insomnia with early morning awakenings. • She describes increasing anxiety, an inability to cope, forgetfulness, problems reading or even watching TV, a 30 lb weight loss and feels very constipated. • She expresses a concern that something is wrong with her stomach. Her lower back has also been bothering her more.

5. Case 1 • She lost her husband 8 months ago and one of her children a little over 1 year ago. • She has a remote history of resected breast cancer and a more recent history of thyroid cancer which was resected 3 years ago. She also has a history of atrial fibrillation. • She has no past psychiatric history and has always been able to cope with difficulties until recently. • She is on coumadin and a beta blocker.

6. Case 1 Questions • 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?

7. Case 1 Questions • Assuming she does not have any response to treatment after 3 weeks what would you do? • How effective are antidepressants? • Does duration of sx or number of previous episodes effect remission rates? • Are they less effective in the elderly? • What is different about the depressed elderly compared to younger adults?

8. MDD Tx: Summary BIO: • SIMILAR EFFICACY • Choose antidepressants based on expected side effects • Consider serotonergic agents for anxious, sleep depressed • Consider noradrenergic agents for psychomotor retarded, excessive sleepiness • ADEQUATE TRIALS • Adequate trial 4-6 weeks (look for some response @ 2 weeks as a predictor of success). Switching amongst the same class may also work. Effective (Response: 70% w 1st, 70% w 2nd, 90% overall). BUT 50% discontinue in first 3/12, <30% complete full course of tx. Watch for adherence.

9. MDD Tx: Summary BIO: • SPECIAL POPULATIONS • Recurrent & FHx of BAD consider Li. • Psychotic features: ECT vs add AAP to antidepressant. • ECT (particularly psychotic depression 95% RR). • Consider especially if situation is urgent, not eating.drinking, taking medication, suicidal, medication intolerance • MEDICALLY UNWELL • Comorbid medical conditions, consider stimulants, which are relatively safe and work faster. Methylphenidate, dextroamphetamine, and modafinil

10. MDD Tx Resistance: Summary • AUGMENTATION • Lithium, T3, Ritalin, Tryptophan, Dopamine agonists • Atypical antipsychotics [Risperidone, Olanzapine, Aripiprazole] • COMBINATIONS • SSRI/SNRI + Wellbutrin • SSRI/SNRI + Remeron • QUETIAPINE MONOTHERAPY

11. Depression in the Elderly: Tx • More likely to have somatic complaints, anxious, melancholic and psychotic features. Therefore ECT often used and is effective. • Similar response rates (although may take longer to tx), high relapse rates. Only 10-20% are tx resistant. With aging, more frequent episodes and longer untreated episodes (duration to spontaneous remission is longer) or may change to chronic course. • May have comorbid cognitive impairments. Non-compliance and physical disability often lead to chronicity. • More often confronted by death, grief may be a complicating feature

12. Depression in the Elderly • Controversy exists still about whether depression in late life is assoc with poorer outcome • Post Hoc analysis of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D). • Early onset age<55. Late onset age 55-75. (n=574) with non psychotic MDD with baseline HAMD>14. Citalopramx14 weeks. Outcome: 16 item Quick Inventory of Depressive Sx-self rated score. • Time to remission, remission rates did not differ between the groups. Am J Geriatr Psychiatry 2008 • (Next slide for details….)

14. Grief vs. depression • Depression • Persistent mood state • Poor self esteem (from Mourning and Melancholia, Freud: introjected lost object w negative assoc feelings experienced as part of self) • Fxnal impairment beyond 2/12 • Suicidal thoughts with desire to die • Grief • Dysphoria, sadness comes in waves with marked fluctuation, often w triggers • No fxnal impairment > 2/12 • No psychomotor retardation, active suicidality, psychosis (although transient phen may occur)

15. Grief vs. depression • Kubler Ross • 1) Shock/denial, 2) anger, 3) bargaining, 4) depression, 5) acceptance • Grief in Children • Protest, Despair, Detachment

16. MCQ # 1 The following is true regarding depression • With the first antidepressant patients feel completely well 1/3 of the time and feel better 2/3 of the time • the neurotransmitters acetylcholine and adrenalin are involved c) Psychotherapy is effective in severe depression d) it rarely presents with multi-system physical complaints • ECT should be considered only when all other treatments have failed a

17. MCQ #2 Depression in old age: • Does not respond as well to antidepressants • Is accompanied by a much lower suicide risk than in younger adults • Are more likely to have anxious, somatic and psychotic features • Is a normal part of aging • Is not associated with the death of a loved one C

18. Which of the following are infrequent “reasons for consultation” by elderly who have their first depressive episode: MCQ # 3 a) “Nerves” b) Excessive fatigue c) Hypersomnia (sleeping too much) d) Digestive problems • Fear of Alzheimer’s disease C

19. Which of the following would be more consistent with normal grief? MCQ# 4 a) Active suicidal ideation b) Prominent psychotic symptoms c) Crying spells when she thinks of her deceased husband. d) Profound feelings of guilt e) Being unable to attend to her usual daily activities 3 months after the death of her husband C

20. Anxiety disorders and the Elderly • Secondary anxiety disorders more common in elderly • Primary anxiety disorders, like personality disorders, generally do not have an onset in the elderly • High comorbidity with depression • Overally less common in the elderly. • Phobias and GAD are the most common. Panic disorder is relatively rare, less than the 1-3% described in younger populations (Flint AJP 1994). • Caution with anxiolytics • can cause paradoxical disinhibition • Diphenylhydramine (Benadryl), Dimenhydrinate (Gravol), Chlorpromazine, Amitriptyline, chloral hydrate and barbiturates are not good anxiolytics for older patients due to their side effects • Elderly are more sensitive to benzodiazepines. Associated with an increased risk for falls and MVAs

21. Potential Anxiolytic Side Effects and the Elderly • Cognition • Amnesia specially in alcoholics with benzos • Memory and visuospatial impairment • Psychomotor • Accentuate postural sway and coordination • Increase risk for MVAs and falls • Paradoxical dysinhibition • Respiratory Depression • avoid benzos in sleep apnea • Sleep • Decreased sleep latency but also decreased stage 3 and 4 sleep with Benzos

22. Case 2 • 85 year old woman who lives alone, never married and has no children. She is hard of hearing and visually impaired. • She has become increasingly seclusive and withdrawn. Her hydro and water stopped being paid and was cut off. • A nephew who was concerned called the CCAC to ask if someone could check in on her and help her at home. She refused to allow anyone in and talked about a how people were trying to break into her house and kill her. She was convinced the mail man was delivering messages from the devil.

23. Case 2 Questions • What is your DDx? • How is late life psychosis different than the younger population? • What is the natural history of schizophrenia?

24. Differential Diagnosis In the Elderly • PRIMARY PSYCHOTIC DISORDERS • Schizophrenia • Late onset 25% • Early onset grown old 75% • Delusional Disorder • 0.03% but 1-2% of hospital admissions • Paraphrenia • MOOD DISORDERS • Depression • (33% of severe subtype cf 15% mild to moderate) • Mania • COGNITIVE DISORDERS • Dementia • (~50% have psychotic symptoms) • Delirium • Substance-GMC In younger patients • Psychosis • Substance - GMC • Mood D/O (MDD or BAD) • SCZ, SCZ-A • BPE • Dissociative D/O • Delusional disorder • Delirium • Personality disorders

26. Biphasic in the women

27. MCQ#5 Regarding psychosis in late life, which is the best answer? • Paranoia is most often due to schizophrenia. • More men develop late onset schizophrenia. • Psychosis is often associated with mood and cognitive disorders • Psychosis is often caused by illicit drugs of abuse • Patients with schizophrenia live 5-10 years less on average c

28. Case 3 • 68 year old woman who you, as her family physician have followed over many years, presents with increasing confusion, gait instability, falls, and incontinence. The change appears abrupt. She is now sleeping much of the day and is up at night. • She is on several medications including beta blockers, diuretics and Mobicox for arthritis. She continues to have some brandy after supper. When she last came to the clinic you were away and a locum prescribed some clonazepam to help her sleep better and relieve some of her anxiety. • She is admitted to the hospital under your care. • What is in your differential diagnosis? • What tests would you order?

29. Case 3 • A urine C&S and CT head were normal. • Routine blood work was also normal. • She is now extremely agitated at night. Falling frequently and is distressed with the belief that people are trying to kill her and she has to escape out of this prison. The nurses on the floor are requesting sedation or restraints for safety. • What are your next steps and why?

30. Delirium • Disturbance of 4Cs • C Consciousness (focus, sustain or shift attention) • C Cognition (memory, disorientation, language) or perceptual disturbance • C Course • C Consequence of GMC • Why is it important? • Delirium in the elderly patient is associated with increased mortality, longer hospital stays, and increased risk of institutional placement.

31. Delirium • DSM IV Subcategories: • due to GMC, substance intoxication/withdrawal, multiple etiologies • Prevalence: 10-15% of those hospitalized. • Under recognized. in those >65 higher (10-40%). • Independent risk factor for mortality 40% @ one yr. • Lab features: EEG generalized slowing

33. Delirium Meagher (1996), BJP • Hypo: • dec Ach in nucleus basilis & RAS, associated with CVA, metabolic disorders, late sepsis, aspiration, pulmonary embolism, decubitus ulcers and other complications related to immobility. Characterized by: Unawareness, inattention, decreased alertness, sparse or slow speech, lethargy, decreased motor activity, staring, apathy. Liptzin (1992) BJP • Hyper: • mediated by LC-NA. • withdrawal states, acute infection, • Etiology: Hyper and hypactive delirium • Ach in RAS (dorsal tegmental pathway). • Risk factors • Medical illness, sensory impairment, hx of delirium, ETOH, pre-existing brain damage (eg. Dementia), malnutrition

36. INDEPENDENT PRECIPITATING FACTORS (n=196) • Precipitating factor Adjusted Relative Risk • Use of physical restraints 4.4 (2.5-7.9) • Malnutrition 4.0 (2.2-7.4) • >3 medications added 2.9 (1.6-5.4) • Use of bladder catheter 2.4 (1.2-4.7)

37. Delirium: Treatment • Biological • Determine cause if possible and treat (eg. infection, med ASE’s, metabolic d/o, pain, renal/hepatic failure, drug intoxication/withdrawal, SOL, CVA, NPH, etc). • Manage sx (low dose neuroleptics), watch for AC ASE of meds (Breitbart AJP 1996). • Psychological • Establish calm and safe environment. Develop trust and provide reassurance • Place near NS station with adequate lighting, reorientation, familiar faces, voices. • Social • Support family, may be helpful in decreasing distress and reorientation

38. Delirium • Environmental interventions • Noise reduction • Diurnal variation in noise and lighting • Frequent reorientation • Day/date in room, big clock in room • Keep familiar items in room e.g., family pictures • Early mobilization, physical therapy • Limit use of restraints • Early recognition and treatment of dehydration

39. MCQ #6 The following is true of delirium • In the elderly, it is rare and most often completely reversible • Hyperactive subtypes are more often missed • It is a significant independent risk factor for death • It can be superimposed on dementia or depression • It is better to use benzodiazepines than neuroleptics for psychotic and behavioural symptoms C

40. Case 4 • A 78-year-old widow who lives alone and whom you have seen infrequently is brought to your office by her daughter. • Although the patient has no complaints, her daughter indicates that for the past 2 years she has become more forgetful. Her behaviour is repetitive, and she sometimes calls her daughter several times a day to ask the same question. • The quality of her housework is beginning to decline (her house is untidy, food is left to spoil in the refrigerator, she is limiting food preparation to simple, familiar items, and she has to check recipes even for easy dishes). • Her personal hygiene is also declining, and some bills are not being paid on time.

41. Case 4 • What is in your differential diagnosis? • What tests would you order? • What are your next steps? • You see her several years later in a nursing home. She is more confused and no longer recognizes you. She is frequently exit seeking and is resistive with care at times. She has injured staff and co residents during periods of anger and agitation. • What would you do?

42. Defining the Diagnostic Threshold

43. Dementia • What is Dementia? • Memory problems with difficulties in another cognitive area (aphasia, apraxia, agnosia, executive dysfunction) together with a loss of function

44. Projected number of dementia, AD, and VaD cases in Canada from 1991-2031 x 3 x 2 Canadian Study of Heath and Aging Working Group. CMAJ 1994;150:899-913.

45. What are the Different Types: Frequencies… • Alzheimer’s • Vascular • Dementia with Lewy Bodies • Frontotemporal Dementia • Others • Parkinson’s with dementia • PSP • Prion • Huntington’s

46. Progression of AD AD Progression • Mild cognitive impairment • Memory impairment • Absence of ADL • deficits • Apathy, anxiety, • irritability Nursing home placement, death from pneumonia and/or other comorbidities Mild - MMSE >20 • Forgetfulness • Problems with shopping, driving and hobbies • Depression Moderate - MMSE 10-20 • Marked memory loss • Require help with ADLs • Wandering • Insomnia • Delusions Severe - MMSE <10 • Very limited language • Loss of basic ADLs • Incontinence • Agitation Adapted from Galasko D. Eur J Neurol. 1998;5:S9-S17.

47. Symptomatic Treatment Cholinergic replacement Therapy Glutamate Modulation Mood and Behaviour Management Secondary Prevention (“Mild cognitive Impairment”) Antioxydants Anti-inflammatories Neurotrophic factors Estrogens Primary Prevention Vaccine Estrogen NSAID Ginkgo Vascular Prevention THERAPEUTIC STRATEGIES Detection Latency .Traumatisms . Vascular risk factors Symptoms Induction .Genetic/hereditary Pathogenesis Disease

48. Original Case ReportB-Behaviours • 51 y-old ♀ with cognitive impairment and: delusions of sexual infidelity, paranoid delusions, hallucinations, hiding objects inappropriately, screaming and agitation, physical aggression Alois Alzheimer 1906

49. PIECES • 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……

50. Pharmacologic Management of BPSD • Herrmann and Lanctot Canadian Journal of Psychiatry Oct 2007 • Atypicals • Remain the best studied and most effective but side effects limit their use • Antidepressants • Some evidence for Trazadone and Celexa but effect size may limit use in urgent situations • Anticonvulsants • Tegretol can be effective but poorly tolerated. Negative studies with Epival. Not as thoroughly studied as atypicals • Benzodiazepines • Short term use only