DELIRIUM, DEMENTIA, DEPRESSION AND COMPETENCY

1. DELIRIUM, DEMENTIA, DEPRESSION AND COMPETENCY COMMON ISSUES IN GERIATRIC AND CONSULTATION PSYCHIATRY Paul B. Rosenberg, M.D. Geriatric and Consultation-Liaison Psychiatry Department of Veterans Affairs Medical Center Washington, DC

2. DELİRYUM • Bilinç ve dikkatte bozulma • Bilişsel işlevlerde (bellek, dil, yönelim) veya algıda bozulma • Hızla gelişir ve dalgalı seyreder • Tıbbi bir durum nedeniyle olur

3. Bilişsel bozulma Tıbbi hastalıktır Akut/ani başlar Yönelim bozulur Varsanılar Sanrılar Görsel-uzamsal bozulma Apraksiler Sözcük bulmada güçlük Anlama ve değerlendirmede güçlük Uykulu (hepatik, üremik, ilaç nedenli) Ajite (alkol yoksunluğu) Deliryumun Klinik Özellikleri

4. Deliryumun Eşanlamları • Akutkonfüzyoneldurum • Toksik-metabolikansefalopati • Organik beyin sendromu • ICU psychosis

5. Dahiliye servislerinde yatan hastaların %25’inde Elderly Dementia Renal failure Liver failure Immobilization Foley catheter Infected Anticholinergic medications Polypharmacy Narcotics Benzodiazepines EPIDEMIOLOGY AND RISK FACTORS

6. METABOLIC CAUSES • Hypernatremia • Hypercalcemia • Hypo-, hyper-glycemia • Hyperosmolar state • Uremia (uremic encephalopathy) • Liver failure (hepatic encephalopathy)

7. INFECTIOUS CAUSES • Urinary tract infection • Pneumonia • Sepsis • Delirium may be the first sign of infection, predating fever, leukocytosis, CXR findings

8. MEDICATIONS • Anticholinergics (Cogentin, Artane) • Psychotropic medications (Thorazine, Mellaril, TCAs, Paxil, benzodiazepines) • Lithium toxicity • Steroids • Narcotics

9. ANTICHOLINERGIC EFFECT AND DELIRIUM • Cholinergic transmission declines with age • Cerebral cortex widely innervated by cholinergic neurons in basal forebrain • Risk of delirium correlates with serum anticholinergic levels • Anticholinergic levels associated with diminished ability to perform ADLs • Anticholinergic levels normalize as delirium resolves.

10. Usual Cogentin, Artane TCAs Mellaril, Thorazine Paxil Narcotics Antihistamines OTC cold medications Surprising Furosemide Digoxin Theophylline Ranitidine Cimetidine Isordil Nifedipine ANTICHOLINERGIC EFFECTS OF MEDICATIONS

11. CNS CAUSES OF DELIRIUM • Alcohol withdrawal (delirium tremens) -- very agitated delirium • Barbiturate/benzo withdrawal (rare) • Post-ictal • Increased intracranial pressure • Head trauma • Encephalitis/meningitis • Vasculitis

12. DIAGNOSTIC STUDIES IN DELIRIUM • Metabolic studies (CBC, Chem-18, TFT’s)Urinalysis • CXR • EEG = diffuse slowing; normal EEG makes delirium less likely • CT/MRI to r/o bleed, tumor (coagulopathies, head trauma) • LP to r/o infection (febrile, leukocytosis) • ‘Fish where the fish are’

13. MANAGEMENT OF DELIRIUM • Find the cause(s) • Usually multifactorial • Look for medication toxicity • Re-orient patient • Quiet, unstimulating environment • Antipsychotic medications for agitation • Benzodiazepines often makes delirium worse • 1:1 observation/restraints only when needed

14. DEMENTIA • Pathognomic deficit is in short-term recall • Deficits in at least three cognitive areas • Insidious onset • Stable level of consciousness, not fluctuating • Major cause of institutionalization in the elderly • Current treatment is largely for psychiatric complications, not underlying dementia

15. AGING AND DEMENTIA

16. COMMON DEMENTIAS • Alzheimer’s disease • Vascular dementia • AIDS dementia • Alcoholic dementia (Korsakoff’s) • Frontotemporal dementia

17. Agitation Wandering Pacing Insomnia Hoarding Catastrophic reactions Capgras’ syndrome Psychosis Depression Anxiety Agnosia Aphasia Apraxia Deficits in abstract thinking PSYCHIATRIC ASPECTSOF DEMENTIA

18. Interviewer caregiver and patient together and separately Clinical course ADLs, IADLs Premorbid level of function B12 TSH RPR Brain imaging (CT, MRI) EEG/LP only when indicated EVALUATION OF DEMENTIA

19. Prevalence of hallucinations is about 30% Hallucinations may be selectively associated with more rapid decline in Alzheimer’s 25% of patients have misperceptions May be due to recall problems or agnosia Delusions are often fixed confabulations May be associated with more rapid neuronal loss Particularly common in Dementia with Lewy Bodies -- fluctuating cognition with recurrent VH that are detailed, contain formed elements. Dementia with Lewy Bodies -- very sensitive to parkinsonian effects of medications Psychosis is a major source of caregiver stress PSYCHOSIS IN DEMENTIA

20. Amyloid plaques (extraneuronal) Neurofibrillary tangles and tau protein (intraneuronal) Loss of cholinergic innervation (nucleus basalis of Meynert) Cerebral atrophy (nonspeciific) Decreased perfusion and metabolism in temporoparietal cortex and hippocampus Deficits may predate cognitive impairment Abnormal extraneuronal processing of b-amyloid precursor protein (b-APP) to 42- a.a. instead of 40-a.a. fragment Familial AD -- single-point mutations in b-APP Transgenic mice Presenilins (chromosome 14 and 1) may be b-APP secretases Apolipoprotein E4 -- risk factor for sporadic AD. Subtle deficits in younger life - decreased “idea density” ALZHEIMER’S -- NEUROSCIENCE

21. Cholinergic Aricept (donepizil) start 5 mg, increase to 10 mg Modest but consistent effect at all stages of AD No effect on MMSE, but ADLs, memory, attention, and neuropsychiatric symptoms often improve Suggest 3-month trial Exelon (rivastigmine) Reminyl (galantamine) Neuroprotective Antioxidants (Vitamin E, L-Deprenyl) Anti-inflammatories (steroids, NSAIDs) Inhibitors of secretases Vaccines against b-amyloid Need to find pre-morbid markers of AD ALZHEIMER’S -- TREATMENT

22. NEW IDEAS IN ALZHEIMER’S TREATMENT

23. BEHAVIORAL INTERVENTIONS IN DEMENTIA • Calm consistent environment • Cuing and reminding • Emphasize cognitive strengths • Music • Light therapy • Safe environment for wandering • Daytime exercise, minimize naps

24. TREATING AGITATION WITH MEDICATIONS

25. OTHER MEDICATIONS IN DEMENTIA • Antidepressants -- watch for agitated depression, need caregiver’s assessment • Use benzodiazepines sparingly -- watch for sedation, paradoxical agitation/stimulation • Benzos best saved for last except for restless legs/myoclonus • Trazodone is good for sleep in demented as well as non-demented patients -- 25 mg q hs • Buspirone -- a drug looking for a use

26. Risk factors of HTN, diabetes, hyperlipidemia, smoking (same as CVA) Stepwise deterioration Preserved personality Multi- or large single-infarct Lacunar state -- basal ganglia, thalamus, internal capsule Subcortical dementia -- psychomotor slowing Binswanger’s -- ischemic injury of frontal hemisphere white matter -- preserved visuospatial functions No specific treatment Quit smoking Control BP Platelet inhibition VASCULAR DEMENTIA

27. ALCOHOLIC DEMENTIA • Prevalence of 6-25% in elderly alcoholics • Often termed Korsakoff’s dementia • Overlap with AD • Associated with peripheral neuropathy • Speech functions often preserved • Confabulatory • Relatively subtle to diagnose • Case reports of improvement with cholinesterase inhibitors

28. Degeneration of frontal and temporal lobes Apathetic and disinhibited personality changes predate cognitive deficits Executive functions and naming selectively impaired Visuospatial skills preserved These patients are often initially misdiagnosed as depressed, manic, or psychopathic Subtypes include Pick’s disease, dementia of ALS. Decreased serotonin Decreased metabolism in frontal and temporal lobes Familial type with mutations in tau gene on chromosome 17 FRONTOTEMPORAL DEMENTIA

29. WHAT DO CAREGIVERS DO • Cognitive supervision • IADLs • Bathing • Dressing • Feeding • Transfer • Monitoring medical condition

30. WHAT KEEPS CAREGIVERS GOING • Love • Money • Habit • Cultural beliefs • Spirituality

31. STRESSES ON CAREGIVERS • 24-hour supervision • Lack of appreciation • Implied or overt criticism • Feeling conflicted regarding changes in roles and power relationships • Feeling uncared-for • Worry about when they need caregiving later on • Perseveration and aggression • Best laymen’s resource The 36-hour day, by Peter Rabins

32. ASSESSMENT OF AGITATION • “Incidents”, “episodes”, and other euphemisms • “Tell me the worst part” • Nature of agitation • Wandering • Disordered day-night cycle • Verbal aggression • Physical aggression • Perseveration, stimulus-seeking • Inappropriate disrobing and sexual advances

33. For many demented patients, the greatest need is to have a non-demented person present Remembering to take medications Remembering to perform time-dependent IADLs (cooking, shopping, bills, home maintenance) Caregiver supplies an intact sense of time passing and short-term recall Spouses often approach subtly and diplomatically, avoiding confrontation regarding cognitive deficits Biggest stresses is perseveration and verbal/physical aggression Adult Day Health Care supplies respite for cognitive supervision COGNITIVE SUPERVISION

34. HOW CAN WE HELP CAREGIVERS • Treat sundowning and agitation – most important pragmatic intervention • Treat depression when you can – but apathy/amotivation is more cognitive than mood and may be hard to treat • Education re dementia – insidious onset, progressive nature, limited efficacy of treatments. • Tell them what they already know (“clarification”) • Support groups • Anticipatory grief – i.e., the demented person is slowly leaving us • Empathy with anger, fear, anxiety, “wishing him dead”

35. RESPITE • Home health aides • Other family members • Adult Day Health Care (“daycare”) • Respite Care • Nursing home

36. CAREGIVER BURNOUT • Burn-out often determines the timing of nursing home placement, despite our supposedly explicit (“DelMarva”) criteria • Physical limitations – poor health of caregiver • Depression • Dementia • Financial limitations • May need permission to “give up”

37. THE RELUCTANT CAREGIVER • Loss of freedom • Financial constraints • Change of role • No respite • Cultural beliefs • Habit • Feeling forced into caregiving (and most people are)

38. COUNTERTRANSFERENCE • The feelings caregivers arouse in us • Sympathy • Depression • Hopelessness • Admiration • Frustration • Anger • Suspicion of abuse

39. DEPRESSION IN THE MEDICALLY ILL • Fewer than 1/2 of depressed patients are identified and treated in primary care clinics • Prevalence of 10-15% in medical inpatient and outpatient populations • Must be distinguished from dementia, delirium, effects of substance abuse

40. CLINICAL FEATURES OF DEPRESSION • Depressed mood • Diminished interest/pleasure (anhedonia) • Significant weight loss (or gain) • Insomnia (or hypersomnia) • Psychomotor retardation or agitation • Fatigue, loss of energy • Feelings of worthlessness, guilt • Diminished concentration, indecisveness • Suicidal ideation

41. UNDERDIAGNOSIS OF DEPRESSION • Emphasis on somatic rather than cognitive/mood complaints • Belief that depression is a natural reaction to circumstance (countertransference) • Reluctance to stigmatize patient with psychiatric diagnosis • Nonspecific symptoms, overlap with medical illness • Time limitations in primary care

42. MORBIDITY AND MORTALITY • Depression signficantly increases morbidity and mortality • Increased risk of MI, angioplasty, and death following cardiac cath • Independent risk factor for mortality post-MI • Increased mortality post-CVA • Similar results in dialysis, cancer, and general acute illness • Possible neuroendocrine mind-body connection

43. DEPRESSION AS A MEDICAL SYMPTOM/SIGN • Up to 20% of major depressive episodes turn out to be initial manifestation of medical illness • Cushing’s • Addison’s • Hypo-, hyper-thyroidism • Huntington’s • Parkinson’s • Similar overlap as in delirium

44. Anorexia -- GI illness, chronic disease, cancer, side effects of chemotherapy. Weight loss with normal appetite -- hyperthyroidism, DM, malabsorption. Insomnia -- sleep apnea (daytime somnolence), nocturnal myoclonus. Early morning awakening is more typical of depression Pain Delirium Anxiety Mania MEDICAL CONSIDERATIONS

45. PSYCHOSOCIAL FACTORS • Death and dying • Disfigurement • Disability • Pain • Loss of role • Family conflict • Lifelong issues

46. CARDIAC DISEASE • 20% of patients with CAD or post-MI are depressed • Risk factors female, prior depression, disabled • Frasure-Smith followed depressed patients post-MI. • 6-month mortality was 17% for depressed, 3% non-depressed

47. About 50% of cancer patients feel depressed Uncontrolled pain Delirium Brain metastases Death and dying Disability and independence Disfigurement Life cycle issues -- dying young, unfinished business Chemotherapy -- steroids, procarbazine, l-asparaginase, ARA-C, vinca alkaloids, interferon CANCER

48. 30-50% depressed, about half with major depression More common with left anterior lesions Not merely secondary to neurological disability Antidepressant treatment is effective High-risk period is 1st 2 years post-stroke Depression associated with higher morbidity and mortality Treatment probably improves rehabilitation STROKE

49. Parkinson’s Huntington’s Multiple sclerosis ALS Epilepsy AIDS Hypothyroidism Hyperthyroidism Hyperparathyroidism Cushing’s Chronic fatigue syndrome OTHER DISEASES ASSOCIATED WITH DEPRESSION

50. Reserpine Methyldopa Inderal (rare) High-dose (older) oral contraceptives Corticosteroids Benzodiazepines Alcohol Opioids Opiate analgesics Cocaine withdrawal MEDICATIONS CAUSING DEPRESSION