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Geriatric Psychiatry:A Review & UpdateMedical and Neurologic Aspects: 

Geriatric Psychiatry: A Review & Update Medical and Neurologic Aspects J. Wesson Ashford University of Kentucky VAMC, Lexington

Dementia Definition: 

Dementia Definition Multiple Cognitive Deficits: Memory dysfunction At least one additional cognitive deficit Cognitive Disturbances: Sufficiently severe to cause impairment of occupational or social functioning and Must represent a decline from a previous level of functioning

Differential Diagnosis: Top Ten : 

Differential Diagnosis: Top Ten 1. Alzheimer Disease (pure ~40%, + mixed~70%) 2. Vascular Disease, MID (5-20%) 3. Drugs, Depression, Delirium 4. Ethanol (5-15%) 5. Medical / Metabolic Systems 6. Endocrine (thyroid, diabetes), Ears, Eyes, Environ. 7. Neurologic (other primary degenerations, etc.) 8. Tumor, Toxin, Trauma 9. Infection, Idiopathic, Immunologic 10. Amnesia, Autoimmune, Apnea, AAMI

Diagnostic Criteria For Dementia Of The Alzheimer Type (DSM-IV, APA, 1994): 

Diagnostic Criteria For Dementia Of The Alzheimer Type (DSM-IV, APA, 1994) Multiple Cognitive Deficits 1. Memory Impairment 2. Other Cognitive Impairment B. Deficits Impair Social/Occupational Course Shows Gradual Onset And Decline Deficits Are Not Due to: 1. Other CNS Conditions 2. Substance Induced Conditions E. Do Not Occur Exclusively during Delirium F. Not Due to Another Psychiatric Disorder

Vascular Dementia(DSM-IV - APA, 1994): 

Vascular Dementia (DSM-IV - APA, 1994) Multiple Cogntive Impairments Deficits Impair Social/Occupational Focal Neurological Signs and Symptoms or Laboratory Evidence Indicating Cerebrovascular Disease Etiologically Related to the Deficits Not Due to Delirium

Factors Associated with Multi-infarct Dementia: 

Factors Associated with Multi-infarct Dementia History of stroke (especially in Nursing Home) Step-wise deterioration Cardiovascular disease - HTD, ASCVD, & Atrial Fib Depression (left anterior strokes), personality change More gait problems than in AD MRI evidence of T2 changes (?? Binswanger’s disease) SPECT / PET show focal areas of dysfunction Neuropsychological dysfunctions are patchy

Post-Cardiac Surgery: 

Post-Cardiac Surgery 53% post-surgical confusion at discharge (delirium) 42% impaired 5 years later May be related to anoxic brain injury, apnea May be related to narcotic/other medication May occur in those patients who would have developed dementia anyway (? genetic risk) Cardio-vascular disease and stress may start Alzheimer pathology Any surgery may have a similar effect related to peri-op or post-op anoxia or vascular stress Newman et al., 2001, NEJM

Drug Interactions: 

Drug Interactions Anticholinergics: amitriptyline, atropine, benztropine, scopolamine, hyoscyamine, oxybutynin, diphenhydramine, chlorpheniramine, many anti-histaminics May aggravate Alzheimer pathology GABA agonists: benzodiazepines, barbiturates, ethanol, anti-convulsants Beta-blockers: propranolol Dopaminergics: l-dopa, alpha-methyl-dopa Narcotics: may contribute to dementia

Depression: 

Depression Onset: rapid Precipitants: psycho-social (not organic) Duration: less than 3 months to presentation Mood: depressed, anxious Behavior: decreased activity or agitation Cognition: unimpaired or poor responses Somatic symptoms: fatigue, lethargy, sleep, appetite disruption Course: rapid resolution with treatment, but may precede Alzheimer’s disease

Delirium Definition: 

Delirium Definition Disturbance of consciousness i.e., reduced clarity of awareness of the environment with reduced ability to focus, sustain, or shift attention Change in cognition (memory, orientation, language, perception) Development over a short period (hours to days), tends to fluctuate Evidence of medical etiology

Ethanol: 

Ethanol Possibly Neuroprotective May not kill neurons directly Accidents, Head Injury Dietary Deficiency Thiamine – Wernicke-Korsakoff syndrome Hepatic Encephalopathy Withdrawal Damage (seizures) Delayed Alcohol Withdrawal Watch for in hospitalized patients Chronic Neurodegeneration Cerebellum, gray matter nuclei

Medical / Endocrine: 

Medical / Endocrine Thyroid dysfunction Hypothyoidism – elevated TSH Compensated hypothyroidism may have normal T4, FTI Hyperthyroidism Apathetic, with anorexia, fatigue, weight loss, increased T4 Diabetes Hypoglycemia (loss of recent memory since episode) Hyperglycemia Hypercalcemia Nephropathy, Uremia Hepatic dysfunction (Wilson’s disease) Vitamin Deficiency (B12, thiamine, niacin) Pernicious anemia – B12 deficiency, ?homocysteine

Eyes, Ears, Environment: 

Eyes, Ears, Environment Must consider sensory deficits might contribute to the appearance of the patient being demented Central Auditory Processing Deficits (CAPD) Hearing problems are socially isolating Visual problems are difficult to accommodate by a demented patient, ?To do cataract op? Environmental stress factors can predispose to a variety of conditions Nutritional deficiencies (tea & toast syndrome)

Neurological Conditions: 

Neurological Conditions Primary Neurodegenerative Disease Diffuse Lewy Body Dementia (? 7 - 50%) Fronto-temporal dementia (tau gene) Focal cortical atrophy Primary progressive aphasia (many causes) Unilateral atrophy, hypofunction on EEG, SPECT, PET Normal pressure hydrocephalus Dementia with gait impairment, incontinence Suggested on CT, MRI; need tap, ventriculography Other Neurologic Conditions

Slide15: 

Tumor Toxins Trauma

Infectious Conditions Affecting the Brain: 

Infectious Conditions Affecting the Brain HIV Neurosyphilis Viral encephalitis (herpes) Bacterial meningitis Fungal (cryptococcus) Prion (Creutzfeldt-Jakob disease); (mad cow disease)

Amnesic Disorders: 

Amnesic Disorders Amnesia Dissociative: localized, selective, generalized Organic - damage to CA1 of hippocampus thiamine deficiency (WKE), hypoglycemia, hypoxia Epileptic events Partial complex seizures Specific brain diseases Transient global amnesia Multiple sclerosis

Age-Associated Memory ImpairmentvsMild Cognitive Impairment: 

Age-Associated Memory Impairment vs Mild Cognitive Impairment Memory declines with age Age - related memory decline corresponds with atrophy of the hippocampus Older individuals remember more complex items and relationships Older individuals are slower to respond Memory problems predispose to development of Alzheimer’s disease

Advances in Alzheimer’s Disease: 

Advances in Alzheimer’s Disease Uncovering etiology Understanding pathophysiology Better screening tools Improved diagnosis Developing interventions

Etiology: 

Etiology Age - therefore - design and stress Genetics (amyloid related) Relation to vascular factors, cholesterol, BP Education (? design vs protection) Environment - diet, exercise, smoking

Neuropathology of AD: 

Neuropathology of AD Senile plaques Neurofibrillary tangles Neurotransmitter losses Inflammatory responses New Neuropath Mechanisms Amyloid PreProtein (APP - ch21) Tau phosphorylation (relation to dementia)

Biopsychosocial Systems Affected by AD(all related to neuroplasticity): 

Biopsychosocial Systems Affected by AD (all related to neuroplasticity) Social Systems Basic ADLs - Late Psychological Systems Primary Loss Of Memory Later Loss Of Learned Skills Neuronal Memory Systems Cortical Glutamatergic Storage Subcortical (acetylcholine, norepi, serotonin) Cellular Plastic Processes APP metabolism – early, broad cortical distribution TAU hyperphosphorylation – late, focal effect, dementia related

Why Diagnose AD Early?: 

Why Diagnose AD Early? Safety (driving, compliance, cooking, etc.) Family stress and misunderstanding (blame, denial) Early education of caregivers of how to handle patient (choices, getting started) Advance planning while patient is competent (will, proxy, power of attorney, advance directives) Patient’s and Family’s right to know Specific treatments now available, may delay nursing home placement longer if started earlier

Need for Better Screening and Assessment Tools: 

Need for Better Screening and Assessment Tools Genetic vulnerability testing Early recognition (10 warning signs) Screening tools (6th vital sign in elderly) Positive diagnostic tests CSF – tau levels elevated, amyloid levels low Brain scan – PET – DDNP, Congo-red derivatives Dementia severity assessments Tracking progression rate, prediction of change

Alzheimer Warning SignsTop TenAlzheimer Association: 

Alzheimer Warning Signs Top Ten Alzheimer Association 1. Recent memory loss affecting job 2. Difficulty performing familiar tasks 3. Problems with language 4. Disorientation to time or place 5. Poor or decreased judgment 6. Problems with abstract thinking 7. Misplacing things 8. Changes in mood or behavior 9. Changes in personality 10. Loss of initiative

Assessment: 

Assessment History Of The Development Of The Dementia Physical Examination Neurological Examination

Neurological Exam: 

Neurological Exam Cranial Nerves Sensory Deficits Motor Deep tendon Pathological

Slide29: 

Mini-Mental State Exam items

Laboratory Tests: 

Laboratory Tests ROUTINE Routine – Blood tests & Urinalysis EKG Chest X-Ray Anatomical Brain Scan – CT (cheapest), MRI SPECIAL Functional Brain Imaging (SPECT, PET) EEG, Evoked Potentials (P300) Reaction Times CSF Analysis - Routine Studies Heavy Metal Screen (24 hr urine) Genotyping

Justification for Brain Scan in Dementia Diagnosis: 

Justification for Brain Scan in Dementia Diagnosis Differential Diagnosis: Tumor, Stroke, Subdural Hematoma, Normal Pressure Hydrocephalus, Encephalomalacia Confirmation of atrophy pattern Estimation of severity of brain atrophy MRI shows T2 white matter changes Periventricular, basal ganglia, focal vs confluent These may indicate vascular pathology SPECT, PET - estimation of regions of physiologic dysfunction, areas of infarction Helps family to visualize problem

Slide35: 

Ashford et al, 2000

INTERVENTIONS: 

INTERVENTIONS Only successful intervention – Cholinesterase Inhibition (1st double blind study - Ashford et al., 1981) Available Interventions – Not yet proven or unconvincing effects Promising Interventions

Other Medical Conditions: 

Other Medical Conditions Chronic pain syndrome Medical consultation-liaison Other Neurological Conditions Parkinson’s disease Guillan Barre syndrome Huntington’s disease Seizure disorders – partial complex seizures

Parkinson’s Disease: 

Parkinson’s Disease Increases steadily after 50 years of age Pathophysiology Concomitant conditions Parkinson signs Symptomatic treatment

Electroencephalography: 

Electroencephalography Seizure disorders Sensitivity – 50% (90% after 3 recordings) Episodic behavior problems Possible partial seizure disorder Generalized slowing Primary neurodegeneration Temporal slow waves may be “normal” Focal slowing (stroke, focal cortical disease) Specific neurologic syndromes Creutzfeldt-Jakob disease Sleep disorders In sleep studies: used to define stages

Behavioral Problems In Dementia Patients: 

Behavioral Problems In Dementia Patients Mood Disorders – depression – early in AD Psychotic Disorders Particularly paranoia, e.g, people stealing things Agitation Meal Time Behaviors Sleep Disorders

Neuropsychiatric Treatments: 

Neuropsychiatric Treatments First treat medical problems Second environmental interventions Third neuropsychiatric medications

Sleep Disorders: 

Sleep Disorders Primary sleep problems Breathing-related sleep disorders Narcolepsy / primary hypersomnia Circadian rhythm disorders Parasomnias Secondary sleep problems Due to a psychiatric condition: depression, psychosis Due to a medical condition: arthritis, parkinson’s Substance induced disorders Fragmented circadian rhythms, sleep in AD

Insomnia: 

Insomnia 15% of patients in sleep labs have sleep disturbance not associated with extrinsic factors or other conditions Periodic limb movement, restless leg syndrome Sinemet or anti-convulsants PTSD, nightmares (trazodone, prazosin) Jet lag (? melatonin) Drugs: caffeine, nicotine, Sleeping pill rebound