The Neuropsychiatry of Aging

1. The Neuropsychiatry of Aging Clifford Singer, MD Medical Director of Geriatric Mental Health and Neuropsychiatry The Acadia Hospital and Eastern Maine Medical Center Bangor, Maine

2. Overview • Introduction • Dementia/Depression/Delirium • Clinical Assessment • Treatment • Summary

3. Introduction • Normal neurological and psychological aging: • Challenging to define • Increased variability in old age • Effect of “preclinical” disease hard to detect • Of neuropsychiatric variables, memory, mood and motor functions are the most sensitive to aging and pathology: “The 3 D’s”

4. Clinical Syndromes in Old Age: The Four D’s • Dementia: Cognitive disorder • Depression: Mood disorder • Delirium: Attention/arousal disorder • Delusions: Disorder of perception and beliefs • All share a “Fifth D”: disability • And a “sixth D”: dyskinesia

5. The Overlapping Syndromes Cognition Depression Attention Mood Delirium Delusions Dementia Perception Motor

6. Dementia • Decline in cognitive function from a previous adult level • Recent memory impairment • Impaired executive function is the real disability • Many underlying causes; detection of dementia should prompt effort to diagnosis underlying cause

7. Mood in Dementia • Changes in mood and behavior can be seen before changes in cognition are noticeable • Apathy (loss of: initiative, motivation, drive, emotional responsiveness, engagement) is disabling • Depression, irritability and anxiety are very common in dementia • Affect dysregulation can be severe in later stages leading to “catastrophic reactions”

8. Major Depressive Disorder • Disorder of mood with cognitive and motor features • MDD increases with disability in old age • Mood is affected by other common conditions: 3 I’s: isolation, immobility, impairment • Brain diseases of aging increase prevalence rates: especially vascular and parkinsonian diseases

9. Depression and Dementia • Complex relationship of cause and affect • Old concept of “pseudodementia” no longer valid • Depression “accelerates” brain aging: cortisol, decreased neurotrophic factors • MDD and AD co-existing bring on dementia sooner than either alone

10. Delirium • Disorder of cortical arousal and confusion • Alert-delirious-stuporous-comatose • AKA: Transient confusional episode, encephalopathy, altered mental status • Hallmark: impaired sustained attention • Other features: disorientation, hallucinations, delusions, agitation, anxiety, fluctuating congition and awareness, sleep-wake cycle disturbances

11. Causes of Delirium • Predisposing factors: Immature brain development or brain damage or dysfunction • Precipitating factors: infection, metabolic derangements, vascular events, toxic substances (including meds), seizures, stress, surgery (multifactorial) • Good prognosis for index episode, less favorable for long term

12. Delusional Disorders • Late life psychosis may occur in context of mood disorder (MDD, Bipolar), dementia, delirium, long standing mental illness (schizophrenia) or late life onset (delusional disorder) • Psychosis without delusions: visual hallucinations (Charles Bonnet), musical hallucinations

13. Key Elements of Clinical Assessment • History • Geriatric ROS and functional status • Exam • Labs • Imaging

14. History • What has changed? • When did it change? • What did you notice first? • Gradual or progressive? • Personality change?

15. Memory • The impaired ability to learn new information is the core of dementia • Affected by normal aging, beginning in early adulthood: annoying, not disabling • Aging affects episodic and working memory not implicit memory • Severe memory impairment without dementia is known as “MCI” or mild cognitive impairment

16. Executive Functions • Reasoning, decision-making, judgment, impulse control, initiation, abstraction, planning, task execution • Served by the frontal cortex: not affected by normal aging • The real disability of dementia • Impaired by depression

17. Attention • Essential for survival • Must be selectively focused or organism becomes overwhelmed • Brain stem, reticular activating system and frontal cortex all necessary • Diffuse processes affect system at all levels and produce delirium

18. Motor Functions • Diseases that affect central motor functions usually cause cognitive and mood changes • Stroke, Parkinsonian diseases, ALS, Huntington’s • Dementia, depression and delirium also associated with motor changes

19. Geriatric Review of Systems for Neuropsychiatry • MOMS: mobility, output, memory, sleep • AND: aches, neurological, depression • DADS: delusions, appetite, dermis, sensory

20. Functional Status • ADLs • IADLs (instrumental or cognitive ADLs) • Descriptive instruments • Clinical Dementia Rating Scale • Morris JC, 1993, Neurology 43:2412-4 • Rate five domains (memory, orientation, problem solving, community affairs, home and hobbies, self-care) on 0-3 scale to score no dementia, questionable, mild, moderate, severe

21. Cognitive Exam • Select instrument or assessment based on your objective: • Screening (high sensitivity, fast, easy) • Differential diagnosis (high selectivity) • Detecting change over time (high test-retest reliability)

22. Executive Function • Key concept in assessment: the true disability of dementia • Refers to frontal lobe cognition: abstraction, reasoning, decision-making, impulse control, initiation, cognitive flexibility, attention and concentration, planning and sequencing in task execution, verbal skills

23. Looking for AD • Abnormal tests of memory and orientation, verbal fluency, copy of geometric design, praxis in context of normal gait, balance, mood and affect • Screening: Mini-Cog, Mini-Cog + verbal fluency task • Global tests recommended: MMSE, MoCA (mocatest.org), SLUMS

24. Quick Screen: Mini-CogBorson S et al. 2003 JAGS 51(10):1451-1454 • 3-word recall • Clock draw test • Sensitivity and specificity rivals MMSE • Validated cross cultures • Can be augmented with other quick tests of attention and verbal fluency to create an impromptu screening tool

25. Common Global Tests • Mini-Mental State Exam • Modified MMSE (3MSE) • Montreal Cognitive Assessment • Public domain • Excellent website with instructions and validation data • Validated in numerous languages • More sensitive than MMSE • St. Louis University Mental Status

26. www.mocatest.org

28. Differential Diagnosis • Nature and severity of impairment give critical clues to diagnosis. • Sample broad spectrum of cognitive functions, but take a “deeper biopsy” where you think the lesion is based on history.

29. Alzheimer’s Disease • Medial temporal/hippocampal phase: • AD begins with a long phase of recent memory impairment • Dementia phase: • As the disease spreads to frontal and parietal cotex, it becomes disabling with task, verbal, executive and perceptual dysfunction

30. Vascular Dementia • Small vessel disease presents as a subcortical process with gradual erosion of executive function associated with parkinsonism • Large vessel disease highly variable, “step-wise” progression in cognition and neurological findings

31. Dementia with Lewy Bodies • A diffuse cortical-subcortical process characterized by a progressive, chronic delirium with parkinsonism without tremor and REM Sleep Behavior Disorder • Less memory impairment than AD • Fluctuating alertness, attention, executive function

32. Frontal Lobe Dementia • Diagnosis based on age, history of personality changes as much as cognitive changes. • Verbal fluency often impaired early on • Imaging (especially PET, SPECT) especially helpful

33. Verbal Fluency • A sensitive measure of prefrontal cortex function • Impaired in many types of dementia as well as mental illness • Number of words generated in one minute in either letter or semantic categories (FAS or animals) • >15 is good performance, <10 is impaired

34. Depression • Complex relationship to dementia as both a risk factor and cause • General memory impairment • General executive impairment • Highly variable and fluctuating • Not a “pseudo-dementia” • Depression with dementia has a poor prognosis

35. Delirium • Primarily a disorder of cortical activation with fluctuating alertness, attention and concentration • Diffuse problems with orientation, memory and executive function • Often associated with ataxia, praxis and problems with gait and balance

36. Attention and Concentration • Attention: • Digit Span (7 forward and 5 reverse) • Concentration: Sustained mental tasks • Reverse spelling • Reverse sequences (months) • Serial subtractions • Story recall

37. Assessing Mood and Behavior • Instruments: • Geriatric Depression Scale • Cornell Scale for Depression in Dementia • Neuropsychiatric Inventory

38. Lab Tests • CBC, complete metabolic profile • Thyroid function tests • UA, HIV?, RPR/FTA? • B12, folate, vitamin D • EEG? • Polysomnography?

39. Imaging • Non-contrast CT in most • MRI in vascular dementia is considered or better documentation of AD is needed (hippocampal atrophy) • SPECT or PET when FTD is considered or better documentation of AD is needed

40. Key Clinical Features

41. Summary • Changes in mood, behavior, thinking and cognition are pathological in old age and require a differential diagnosis • Assessment skills should suit the occasion • Clinicians should think about specific functions and pathology in assessment