Primary types of psychiatric illness in the elderly
Dementia (DSM 5 includes Major Neurocognitive Disorder [NCD], Mild Neurocognitive Disorder, Delirium)
DSM criteria for dementia
Evidence of modest cognitive decline from a previous level of performance in 1+ cognitive domains (complex attention, executive function, learning/memory, language, perceptual motor, or social cognition) based on 2 factors: 1) Concern of the individual, a knowledgeable informant, or clinician, 2) modest impairment in cognitive performance documented by standardized neuropsychological testing or other clinical assessment
The cognitive deficits do NOT interfere with capacity for independence in everyday activities
Special considerations when treating geriatric patients
Varied diseases (more degenerative and certain types of cancer)
Unusual disease/illness presentations
Differentiating normal aging process vs. disease
Purpose of treatment - emphasis on palliative care
Medication - start low, go slow
Most common type of dementia; risk factors include female, family hx, head trauma, and Downs syndrome
Types of dementia seen in elderly include Alzheimer’s, vascular, progressive disorders, and reversible causes. What are 2 progressive disorders causing dementia in elderly pts?
Pick’s disease (frontotemporal dementia)
Lewy body dementia (neurocognitive symptoms + Parkinson-like features + visual hallucinations)
What are some reversible causes of dementia in elderly?
Normal pressure hydrocephalus
What are some symptoms of dementia in elderly?
Depression (look for weight loss, anxiety, irritability, sadness, social withdrawal): pseudodementia
Difficulty with performing tasks, organization, and coordination
Problems with disorientation (e.g., getting lost)
Inappropriate behavior (esp w/ frontotemporal dementia)
Psychotic sxs (i.e., hallucinations, delusions, paranoia)
General steps in evaluation of dementia in elderly
H and P — most important (get info regarding onset and characterization - type/manner of cognitive deficit)
Determine comorbid conditions and other signs/symptoms
Neurologic exam and mental status exam
Functional status (OT) — dressing, bathing, cooking, financial organization, etc.
What part of evaluation of dementia in elderly attempts to establish a baseline (helpful in early disease) and quantifies results of cognitive deficit?
What labs and radiology are important to order in evaluation of dementia in elderly?
Labs — endocrine panels, B12, folate, CBC, CMP, HbA1C
Radiology — CT, MRI, PET scan
The first step in treatment of dementia in elderly is to attempt to determine and treat the cause (as well as rule out other potential conditions). It is also important to consider treatment of comorbidities like diabetes, HTN, etc.
There is no perfect treatment, but you can attempt to slow the progression and increase pt functionality. One pharmacologic option is ______ which is an acetylcholinesterase inhibitor, and another is ______ which is an NMDA antagonist
What medications should be avoided in the treatment of dementia (and most other conditions) in the elderly?
Anticholinergic medications — these can impair cognitive function, esp in the elderly!!!
AVOID DIPHENHYDRAMINE AND HYDROXYZINE
Black box warning regarding treatment of psychosis in geriatric pts with dementia
Antipsychotic meds are associated with increased mortality — including olanzapine, aripiprazole, risperidone, quetiapine, and others.
Most deaths were either due to heart-related events or infections (mostly PNA)
Third most common cause of psychosis in elderly outpatients; characterized by thought disturbance with themes that tend to be from the current environment and situations, with poverty of thinking and irrationality, and with hallucinations (often visual)
Psychosis due to Delirium
What are some causes of psychosis due to delirium in the elderly?
Inappropriate drug use Withdrawal from drugs Infection Urinary retention Constipation Physiologic abnormalities CV problems Intracranial strokes Seizures Hemorrhages Sensory/sleep deprivation
Second most common diagnosis in elderly outpatients, accounting for most psychosis in this population; characterized by somatic troubles, persecution, guilt, and/or poor self-esteem
Psychosis due to MDD with Psychotic Features
Most common diagnosis accounting for psychosis in elderly pts; characterized by simple delusions that are often of a paranoid nature — i.e., pts believe that items are being stolen from them, that they are being abandoned, and/or their spouse and children are being disloyal
Psychosis due to Alzheimer’s type Dementia
Risk factors for substance use in the elderly
Marital status (single, separated, or divorced) and living alone
Absence of hobbies and socialization
Possible pharmacokinetic changes that take place in elderly may lead to increased potential for abuse of benzos or opiates
Specific consequences of substance abuse in the elderly are dependent on the drug/substance of abuse. What are some general consequences?
Depression and other mood alterations (i.e., irritability and anxiety)
Balance and vestibular problems (leads to falls/fractures)
Increase risk for developing other medical conditions
Effective way to treat benzodiazepine dependence in older persons
Initial tx for substance abuse in elderly depends on substance being abused. It is important to treat withdrawal signs/symptoms — you cannot go cold turkey with intense and chronic alcohol abuse or you risk _____ and _____
Delirium tremens; death
Primary causes of depression in elderly
Loss of independence
Loss of spouse and friends
Signs/symptoms of depression in elderly
Overall similar to all depressive disorders but with an increase in somatic symptoms and less evident symptoms in affective-mood domain
Specifically — anxiety, fatigue and hypersomnolence, somatic complaints, cognitive impairment, weight loss, insomnia, anhedonia, agitation
Major depression criteria
Anhedonia or depressed mood for 2 weeks and 4 or more of the following:
Feelings of worthlessness or guilt Decreased ability to concentrate Fatigue Psychomotor agitation Insomnia or hypersomnolence Weight/appetite changes Recurrent thoughts of suicide or death
T/F: there is a specific questionnaire called the Geriatric Depression Scale used to dx depression in elderly, but should be used with caution in pts with dementia
[score of >5 suggests depression and warrants f/u with comprehensive assessment, score of >10 almost always indicates depression]
______ and _____ onset depression in elderly with absence of social factors should raise suspicion for underlying, non-psychiatric cause, including dementia, normal bereavement, and adjustment d/o with depressed mood
How do you differentiate between dementia and depression in elderly population?
Mental status exam — focus on your pts “insight”:
Depressed pts WILL often have insight, though little effort
Dementia pts have LITTLE/NO insight
Treatment for depression in the elderly
Medication Psychotherapy CBT Exercise (walking, water aerobics) Diet Lifestyle mods (i.e., socialization)
Goals of CBT in tx of depression in elderly
Replace negative perspective/irrational thinking with rational and positive cognition
How long is a typical initial anti-depressant trial in elderly?
When treating depression in elderly pts, what medication should you use with caution in your cardiac pts?
TCAs like nortriptyline
_____ should be used with caution in elderly due to ability to cause seizures in this pt population
_____ may be used to tx depression in elderly and helps promote sleep, but should be used in low doses due to caution of orthostatic effects
______ and _____ are SNRIs utilized in tx of depression in elderly who have comorbid pain conditions
______ is used as an antidepressant in elderly and is known to increase appetite
Cautions in using SSRIs in elderly
May increase falls