Geriatric Psychiatry

Geriatric Psychiatry Anita S. Kablinger MD Associate Professor Psychiatry and Pharmacology

Objectives: • Differentiate between the various cognitive disorders • Know aspects of normal aging • Gain knowledge of the best treatment options for geriatric psychiatric illnesses

Why is it a subspecialty? • Mental disorders may have different manifestations, pathogenesis, and pathophysiology from younger adults • Coexisting chronic medical illness • More medicines • Cognitive impairments • Increased risk for social stressors, including retirement and widowhood

Geriatric population increasing • 2000, estimated that 1 in 5 Americans were over 55 years of age, and 13% over 65 years of age • By 2050, estimates are that 22% will be over the age of 65, and 5% over age 85.

Aging and the Life Cycle (Erickson) • Young adulthood--intimacy versus isolation • Middle-aged--generativity versus self-absorption • Elderly--Integrity versus despair (Acceptance of mortality, satisfaction with one’s meaning in the world) • Fear of death is usually a mid-life issue

Other tasks of elderly • Reminiscence is normative • Loss • On-time normative incidents do not usually result in crisis • Fears are usually pain, disability, abandonment, and dependency

Cognition and aging • Cognition includes learning, memory, & intelligence • Learning is the ability to gain new skills and information. It may be slower in elderly, especially verbal learning.

Cognition and aging (continued) • Memory is divided into immediate, short- and long- term memory. Immediate memory remains intact. • Short-term memory is also intact, however, it is affected by concentration which may be less in older adults. • Long-term memory is most affected by aging. Retrieval is less efficient; the elderly need more cues

Intelligence • Ability to use information in an adaptive way or to apply knowledge to specific circumstances • Crystallized intelligence includes vocabulary, verbal skills, and general information can continue to increase throughout life. • Fluid intelligence consists of recognizing new patterns and creative problem solving. This peaks in adolescence.

Benign senescent forgetfulness • Age associated mild memory problems. May also have cognitive problems due to anxiety. • Examples are forgetting names, misplacing items, and experiencing difficulty with complex problem-solving. • (aging-associated cognitive decline)

Psychiatric Evaluation • See patient alone to assess for suicidal/homicidal ideation even if cognitively impaired • May need info from caretaker • May take extended time due to slower response time

Other important aspects of history • Family history--Alzheimer’s disease is transmitted as an autosomal dominant trait in 10-30% of the offspring of parents with Alzheimer’s disease • Review of all meds, over the counter, prescribed, herbal • Alcohol and substance abuse history

MSE • General description • mood, feelings, affect • witzelsucht is caused by frontal lobe dysfunction and is the tendency to make puns and jokes and laugh aloud at them

MSE (continued) • perceptual disturbances • may be transitory resulting from decreased sensory acuity • types of agnosia (the inability to recognize and interpret the significance of sensory impressions: the denial of illness (anosognosia), the denial of a body part (atopognosia); or the inability to recognize objects (visual agnosia) or faces (prosopagnosia)

MSE (continued) • Language output • nonfluent or Broca’s aphasia--understanding intact but can not speak, speech may be telegraphic • fluent or Wernicke’s aphasia • global aphasia • ideomotor apraxia--can not demonstrate use of simple objects • Visuospatial functioning--some decline is normal with age

MMSE affected by educational level • median score for 9-12 yrs of school is 26, high school diploma 28 • less sensitive in those with high intelligence, and less specific with those below average intelligence

Neuropsychological Assessment • MMSE is not used to make a formal diagnosis • WAIS-R vocabulary holds up with age. Performance part is a more sensitive indicator of brain damage than the verbal part. • Depression can impair psychomotor performance, especially visuospatial functioning and timed motor performance. The Geriatric Depression Scale is a useful screening instrument that excludes somatic complaints from its list of items.

Mental Disorders of old age • Most common: depressive disorders, cognitive disorders, phobias, and alcohol use. • High risk of suicide • Risk factors include loss of social roles, loss of autonomy, deaths, declining health, increased isolation, financial constraints, and decreased cognitive functioning.

Cognitive Disorders • Include: • Delirium • Dementia • Amnestic Disorders • Psychiatric disorders due to a Medical Condition • Postconcussion Syndrome • Replaces the term “organic disorders”

Note that major psychiatric illnesses may also have changes in cognition, but they are not called cognitive disorders

Delirium • Usually acute and fluctuating • Altered state of consciousness (reduced awareness of and ability to respond to the environment) • Cognitive deficits in attention, concentration, thinking, memory, and goal-directed behavior are almost always present

Features of delirium • May be accompanied by hallucinations, illusions, emotional lability, alterations in the sleep-wake cycle, psychomotor slowing or hyperactivity • Usually abrupt

Causes of Delirium—I WATCH DEATH • Infectious Deficiencies • Withdrawal Endocrinopathies • Acute metabolic Acute vascular • Trauma Toxins/drugs • CNS Pathology Heavy Metals • Hypoxia • Note that prescribed medicines may cause delirium

Treatment of delirium • Look for underlying cause “always be suspicious” • Close supervision, especially by family • Reorient frequently • Adequate lighting

Treatment of delirium (continued) • Use consistent personnel • Try not to use restraints, as it can worsen confusion. • Medication only if behavioral attempts fail • Avoid polypharmacy • Low dose neuroleptic is treatment of choice, unless the delirium is due to withdrawal. If due to withdrawal, use a short-acting benzodiazepine.

ICU Syndrome • May be multifactorial • Postcardiotomy delirium occurs 3 or 4 days after surgery

Changes in dementia • Cognition, memory, language • Personality change, abstract thinking, aphasias • Visuospatial functioning • However, level of awareness and alertness usually intact in early stages (differentiates dementia from delirium) • Chronic, versus acute

Amnestic Disorders • Differs from delirium and dementia because major problem is short-term memory only. • Impairment may be due to hemorrhage in mamillary bodies, or degenerative changes in the dorsal medial nucleus of the thalamus • Most common cause is alcoholism

Transient global amnesia • Transient inability to learn new info • Variable retrograde amnesia that “shrinks” following recovery • Level of conscousness and personal identity intact • Due to transient vascular insufficiency of the mesial temporal lobe, or medicines, tumors, arrhythmias, cerebral embolism • Also have risk problems for stroke

Postconcussion syndrome • Follows a history of head trauma resulting in cerebral concussion • LOC, posttraumatic amnesia, less commonly, post-traumatic seizures • Impairment in attention, concentration, performing simultaneous cognitive tasks, and in learning new information, or recalling information shortly after the injury • Not a form of dementia

Dementing Disorders • Only arthritis more common in geriatric population • 5% have severe dementia, and 15% mild dementia in those over 65 • Over 80, 20% have severe dementia • Most common causes: Alzheimer’s disease, vascular dementia, alcoholism, and a combination of these 3 • Risk factors are age, family history, and female sex

Noncognitive symptoms accompanying dementia • Mood disorders--dementia and depressive symptoms can coexist and the depression responds to treatment • Pathological laughter and crying occurs • Irritability and explosiveness

Other noncognitive symptoms in dementia • Excessive emotional outbursts that occur after task failure are “catastrophic reactions” and can be avoided by educating family members to avoid confrontation • Delusions or hallucinations occur during the course of dementias in nearly 75%

Behavior problems in dementia • Agitation, restlessness, wandering, violence, shouting • Social and sexual disinhibition, impulsiveness • Sleep disturbances

Dementia and treatable conditions • 10-15% from: • heart disease, renal disease, and congestive heart failure • endocrine disorder, vitamin deficiency, • medication misuse • primary mental disorders

Subcortical dementia • Subcortical dementias are associated with movement disorders, gait apraxia, psychomotor retardation, apathy, akinetic mutism. • Alert, but slowly responsive and inactive • Not fluent in language, but comprehends • Often dysarthric, difficulty with forming complex sentences • Difficulty with executive function

Subcortical dementia • Causes: • Huntington’s disease, Parkinson’s disease, NPH, multi-infarct dementia, Wilson’s disease

Cortical dementias-- • Ex: Alzheimer’s, CJD, and Pick’s disease • Involve aphasia, agnosia, apraxia • Fluent, moderately attentive, normally responsive to questions, and normally active in his environment

Human prion disease • result from dicing mutations of the prion protein gene and may be inherited, acquired, or sporadic. • They include familial CJD, Gerstmann-Straussler-Scheinder syndrome, and fatal familial insomnia. • Autosomal dominant

Sporadic CJD • Accounts for 85% of human prion diseases • Occurs world-wide with a uniform distribution and incidence of around 1 in 1 million per annum • A mean age of onset of 65 • Rare in those less than 30

Dementia of the Alzheimer’s Type (DAT) • 50-60% of patients with dementia • 5% of those who reach 65 have DAT • 15-25% of those 85 or older • More common in women • Occupy 50% of all NH beds

DAT • General sequence is memory, language, then visuospatial functions • Death occurs in about 7 yrs • On autopsy: neurofibrillary tangles and neuritic plaques with an amyloid core and deposition of amyloid in blood vessels • Involves cholinergic system arising in basal forebrain, nucleus basalis of Meynert--reductions in brain acetylcholine, and the adrenergic system

DAT (Genetics) • Chromosome 21 • Most severe form associated with chromosome 14 • Genetically heterogeneous disease caused by 2 or more genes located on 2 or more chromosomes (14, 19, 21) • Slow virus? • Deposition of aluminum

PET Scans of DAT • Decreased metabolic rate of glucose in temporoparietal area, and in frontal regions in more severe cases

Pick’s Disease • Slowly progressive • Focal cortical lesions, primarily frontal that produce aphasia, apraxia, and agnosia. • Lasts 2-10 yrs., average duration 5 yrs

CJD • Usual course one year • Not associated with aging • Incidence decreases after age 60 • Terminal stage: severe dementia, generalized hypertonicity, and profound speech disturbance • Typical burst pattern on EEG

Vascular Dementia • Second most common type • Can reduce known risk factors: hypertension, diabetes, cigarette smoking, and arrhythmias

Huntington’s • Basal ganglia and cerebral cortex • Progressive dementia, muscular hypertonicity, and bizarre choreiform movements • Death in 15-20 yrs • On the G8 fragment of chromosome 4 • Screening test available

NPH • Dementia • Ataxia • Incontinence

Dementia due to Parkinson’s Disease • Motor dysfunction, frontal lobe symptoms, and memory deficit • Nearly 1/2 are depressed, and depression is most common mental disturbance in Parkinson’s • Increased risk for anxiety • Levodopa, amantadine, and bromocriptine can cause psychosis and delirium

Geriatric Psychiatry