Lecture 14: Geriatric Psych

Question 1

Important Considerations for Geriatric Psych (9)

Answer 1

1. aging process
2. Age related Disorders
3. Medical/Psych/neurology
4. cognitive changes
5. frailty, mobility, special senses
6. Drug effects and poly pharmacy
7. interdisciplinary and interactive specialty: elder social service
8. old-old or frail elders: special approach to medial care
9. palliative approach

Question 2

Psychosocial consideration (4)

Answer 2

1. phase of life issues
   - retirement
   - loss/grief
   - empty nest
   - grand-parenting
2. approaching mortality
3. dependency
4. functional decline

Question 3

Social Factors (4)

Answer 3

1. loss of income
2. dependence on social programs:
   - medicare
   - social security
   - medicaid
3. assisted living and nursing home care
4. isolation

Question 4

Dementia: Major and Mild neurologic disorder (5)

Answer 4

1. Dementia/Major ND: syndrome of disabling, acquired loss of memory and intellect across multiple domains
2. usually caused by a progressive loss of function
3. typically involved progression loss of function
   - ADLs
4. usually complicated by psychiatric and behavioral symptoms
5. MCI/Mild ND

Question 5

Types of Dementia (5)

Answer 5

1. Alzheimer’s Disease-most common
2. vascular dementia: stroke, white matter disease
3. Lewy Body Dementia/Parkinson’s disease
4. Fronto-temporal dementia: FTD ex, pick’s disease
5. Many others
   - neurologic
   - nutritional: B12, thiamine def.
   - endocrine: hypothyroidism
   - infectious: syphillis, HIV
   - normal pressure hydrocephalus; involving CSF (tx shunting)
6. mixed dementia: more than one illness at work
   - alcohol use, head trauma, etc.

Question 6

Alzheimer’s (8)

Answer 6

1. early and late onset types
   - early=before 65, familial
   - late=after 65
2. long prodromal period
3. often preceded by mild cognitive impairment
4. short-term memory loss
   - ability to learn and retain new information
   - episodic
   - autobiographical memory
5. gradual progression over years, 6-10 years
6. early, middle, late clinical stages
7. evolving/overlapping definitions
   - clinical symptoms vs. biomarkers (lab tests for definitive answer, not very useful, no great biomarker for alzheimer’s)
8. about 2/3 of dementias

Question 7

Alzheimer’s Diagnosis (4)

Answer 7

1. current no specific definitive tests
2. R/O other disorders
3. R/I characteristic presentation and course
4. use of rating scales
   - MMSE
   - MOCA: montreal cognitive assessment
   - clock: good for tracking progress
   - SLUMS

Question 8

Pathology Alzheimer’s (3)

Answer 8

1. plaques and tangles
2. amyloid and tau
   - amblyoid, extracellular
   - Tau intracellular
3. amyloid hypothesis
   - that amyloid is the cause, not proven

Question 9

Alzheimer’s Loss of Function and ADLs (Activities for Daily Living) (6)

Answer 9

1. instrumental ADLs lost first:
   - driving: can make car work, but judgement is impaired
   - using technology
2. basic ADL lost in 2nd and 3rd stages
   - dressing
   - bathing
   - grooming
   - toileting
3. incontinence
4. loss chewing, swallowing, interest in food
5. weight loss
6. ataxia, falling

Question 10

Early/Mild Alzheimer’s Disease-stages (3)

Answer 10

1. STM (short term memory) loss
2. anxiety
3. depression

Question 11

Middle/moderate Alzheimer’s(4)

Answer 11

1. sleep problems
2. psychosis
3. agitation
4. need for supervision

Question 12

Late/Severe Alzheimer’s (4)

Answer 12

1. 24 hour a day care
2. wandering
3. yelling
4. severe speech problems

Question 13

Vascular Dementia (4)

Answer 13

1. multi-infarct dementia
2. uneven progression, wax and wane is severity
3. vascular lesions
4. sub-cortical changes: white matter decrease

Question 14

Mild Neurocognitive Disorder (ND)

Answer 14

1. cognitive decline, but not disabled

Question 15

Major neurocognitive disorder (ND)

Answer 15

1. disabling cognitive decline

Question 16

Frontotemporal Dementia (6)

Answer 16

1. Pick’s disease-tau inclusion bodies in frontal and temporal lobes
2. “tauopathy”
   - No amyloid
3. primary progressive aphasia
4. changes in personality, executive function, judgement early in course
5. speech and language problems
6. progression to memory loss

Question 17

Lewy Body Dementia

Answer 17

1. Overlaps with PD and sometimes AD
2. fairly sudden onset
3. Early psychosis-visual hallucination
4. parkinsonian symptoms
   - not well treated with parkinson’s treatment
5. fluctuation: derlium like symptoms
6. often intolerant to antisychotics

Question 18

Lewy body

Answer 18

1. a-synunclein (protein) intracellular inclusion

- diffuse or localized

Question 19

Parkinson’s Dementia (2)

Answer 19

1. develops long agter motor symptoms
2. loss of logic and reasoning
   * falls under umbrella of lewy body dementia

Question 20

Behavioral and Psychiatric Symptoms of Dementia BPSD (9)

Answer 20

1. speech and language changes
2. circadian rhythm disturbance
   - sundowning
3. inappropriate vocalization
4. wandering
5. shadowing: following caregiver
6. agitation/aggression
7. catastrophic reaction
8. mood lability
9. delusions: paranoia, other psychotic symptoms

Question 21

Dementia Treatment (2)

Answer 21

1. cholinesterase inhibitors
   - increase brains supply of acetylcholine
   - supportive but not curative
2. Namenda: supportive, mostly mid to late disease
   - blocks NMDA receptors, glutamate receptors

Question 22

Cholinesterase inhibitors (3)

Answer 22

1. Aricept
2. Razadyne
3. Exelon
   - increase brains supply of acetylcholine

Question 23

Psychiatric Medications in Dementia

Answer 23

1. no specific psychiatric medication approved for dementia
2. off-label use
3. need for informed consent due to off-label use (from caregiver)
4. commonly used
   - antipsychotics (atypicals)
   - mood stabilizers
   - benzodiazepine
   - SSRI < SNRI
   - trasozone

Question 24

Common Off-label medications for dementia (6)

Answer 24

• antipsychotics (atypicals)
• mood stabilizers
• benzodiazepine
• SSRI < SNRI
• trasozone

Question 25

Controversial Use antipsychotics in dementia (4)

Answer 25

1. black box warning by FDA due to increased morbidity and mortality 2. limited efficacy 3. lack good alternatives, may have to use antipsychotics 4. individual patients may respond well

Question 26

Medications to BPSD (7)

Answer 26

1. target symptom approach 2. empirical, variable 3. avoid polypharmacy 4. low dose and duration 5. avoid anticholinergics 6. initially consider non=pharmacologic measures 7. consider delirium and pain

Question 27

Delirium (3)

Answer 27

1. cognitive disturbances usually related to systemic conditions - illnesses - drugs - drug withdrawal 2. altered sensorium - sensorium=senses in touch with reality 3. relatively short time course

Question 28

Rx factors for delirium (7)

Answer 28

1. elders 3. children 4. CNS disorders 5. previous episodes 6. malnourished 7. multiple organ system illness

Question 29

Delirium (5)

Answer 29

1. cognitive fluctuation, confusion, psychosis, lucid intervals 2. sleep/circadian rhythm disturbance 3. agitated and withdrawn types 4. comorbidity with dementia 5. possible sequelae

Question 30

Derlium Treatment (5)

Answer 30

1. adders underlying conditions 2. normalize environment 3. small doses antipsychotics - limit benzodiazepines 4. protection from impaired judgement 5. minimize restraints

Question 31

Goal psychiatric interview

Answer 31

1. establish rapport, relationship 2. understand their level of cognitive impairment 3. do NOT patronize 4. test memory using scale - MOCA scale - clock test 5. assess mood - ask about suicidal thinking - ask risk factors for suicide - isolation, hopelessness, depression, chronic pain, hx of drug use, recent trip to doctor's office

Question 32

Amnestic Disorder

Answer 32

1. loss of memory due to medical condition or drug - head injury - nutrient deficient

Question 33

Bereavement exclusion

Answer 33

DMS 4 would hinder treatment 6 months after a significant death -judgement call, should probably still treat patient