3 D's Flashcards
at a glance differntiate
delirum
depression
dementia
Delirium
- acue onset
- waxing and waining confusional state
- reversible with short duration
Depression
- mood disorder
- underrecognized and under diagnosed in eldery
Dementia
- organic mental syndrome
- neurodegenerative
- slow progression but fatal
Depression
DSM Criteria for diagnosis
how will older pt. present
Depression
- mood disorder with the following symptoms at least 5 of the symptoms nearly everyday for a 2-week consectutive period
SIG E CAPS
S: sleep disturbances
I: interest decreased
G: guilt or feelings of worthlessness
E: Energy decreased
C: concentration issues
A: appetite/weight changes
P: psychomotor agitation
S: suicidal ideation
Older Adult Presentation
- less outward appearance of mood disorder: they present differently
- somatic complaints (fatigue, weight loss, pain, memory changes)
- social withdrawal
- refused to eat/drink or take meds
- lack of self care
how to screen geriatrics for depression
- role of co-morbidities
- screening tools
Co-Morbidities
- concurrent conditions can mask/mimic depression signs
- medications can overlap signs (fatgiue, etc.)
- impaired communication (hearing loss, speaking loss) can make recognizing the signs diffiult
- reluctant to communicate: stigma for mental health in older adults high
Screening tools
USPSTF : anyone should be screened if resources can be provided
american geri society : screen for depression during dementia work up (overlapping signs)
geriatric Depression Scale : more in depth & most widely accepted tool for elderly
PHQ-2 or 9 good for depression but geri depression scale is more questions for elderly tailored
Treatment of depression in the eldery
historically, we undertreat, dont treat or treat too short
Treatment of depression
Psychotherapy
- very effective (especially mild depression)
- equally effective as meds & even better in concurrence with meds
Pharmacothearpy
- SSRIs: first line
- start low go slow mentality
- full response in elderly may take 16 weeks
ECT: electroconvusive thearpy
- good for unresponsive pts.
- well tolerated: mild transient short term memory loss may occur
Pharmacothearpy of Depression in Elderly
med classes and key pearls
SSRI: first line medications
- escitalopram, citalopram, sertraline, fluoxitene (paroxetine last option: antichol. SE)
SNRI: Venlafaxine, Duloxetine
- good for concominant depression + neuropathic pain
Atypicals (list = concominant conditions it helps)
-Mirtazipine: insomniam agitation, anorexia (helps weight gain)
Trazadone: insomnia
Buproprion: added on as adjuct treatment
AVOID TCAS!!!!: too many side effects and arrythmic and anticholenergic risks
Delirium
what is it & what does it signal
symptoms of hyperactive & hypoactive
Delirum
- neuropsychiatric syndrome
- commonly in elderly pt. with multple medical conditions
- these pts. are sick!!! this suggests an underlying acute illness
define
- acute change in mental status that fluctuates
- a reversible condition if underlying problem can be addressed : lasting days, weeks, months
- can have complete loss of function in a specific neurologic condition
Types of Delirium + symptoms
Hyperactive
- agitataed
- incoherant speech
- disoriented
- hallucinations
- delusions
Hypoactive
- sluggish and drowsy
- less reactive
- withdrawn
can be mixed presentation
Delirium
patho
risk factors
possible underlying conditions
Patho
- not well understood
- abnormal depolarizations + inflammation
Risk factors & Underlying Conditions
D: dementia, drugs
E: eye, ears & sensory deprivation
L: low O2 state (HF, COPD, MI, PE)
I: Infection
R: retention (urine or stool)
I: ictal state
U: undernutrtion/hydrated
M: Metabolic Upst: dernged, DM, electrolytes
S: subdural, sleep deprivation
ICU: 70% of pts.
General inpt: 30%
ER: 10%
Delirium
Evaulation
Testings
Diagnosing
when in doubt: presume delirium and rule out other common things
- < 1/3 ICU physicians cannot recognize delirum without a screening toold
Testing
- no specific testing : do a workup to rule out other things
- CBC,CMP,drug levlels, US, alchol, ABG, cultures
- CRX, cerebral imaing rarely helpful (unless acute change in neurologic fndings or head trauma)
- EEG and LP rarely helpful (unless r/o seizure or meningitis)
Diagnosis of Delirum
- acute onset or fluctuation findings
- inattention
- and either…
- disorganized thinking
- or
- altered level of consciousness
- using the CAM-ICU score to determine if inattention, etc. through specific tests
- exampple: inattention = SAVEAHAART test
Delirium
prevention & treatment
prevention is the best treatment!
Treatment
- identify the underlying cause & treat
- modifity the Risk Factors
- environmentla modifications: help get more sleep
- adequate nutrtion/hydration
- early mobilization
- avoid restraints
Psychotropic Medication can be used (use caution with these)
- only as needed basis
- Haloperidol: low doses (avoid in parkinsons and LB dementia)
- Benzos: good for alcohol abuse pt.
In normal Aging…. what remains stable or minimally changed in terms of cognition
- temperman remains stable
- routine memory, skills and knowledge stable
- ability to FUNCTION: society/workplace and home remain in tact
what is cognitive impairment
any change in which an individual has trouble remembering old information, learning new things, concentrating or making life decisions which can impact their everyday life
we break cognitive impairment diagnoses into two categories
- Mild Cognitive Impairment
- Major Cognitive Impairement (in which dementia, AD< LB, etc. all fall)
Define Minor/Mild Cognitive Impairment
symptoms to diagnosis
workup
outcomes
Mild Cognitive Impairment
Symptoms & Diagnosis
Impairment in an individuals cognition in one or more of these cognitive domains
- learning and memory
- complex attention
- exeucitve function
- language
- perceptual-motor control
- social cognition
AND
- NO SIGNS OF FUNCTIONAL IMPAIRMENT: like ADLs or iADLS (may require great effort but not deficient)
Workup
- this is common; increases with age but is NOT a normal process of aging
- MMSE and MOCA can be done to assess cognition
- neurpsychiatric testing (the cornersone) of the workup
Outcomes
- 1/3 of pt. willrevert back to original baseline
- 1/3 will stay at this level
- 1/3 will progress to worsening cognition
Major Cognitive Impairment
Major Cognitive Impairment
Diagnosis and Symptoms
- cogntive decline from previous in the areas of (1+) leraning/memory, complex attention, exeuctive function, langugae, perception/motor control & social cognition
AND
- the cognitive deficts IMPACT THE ADLS and iADLS
Criteria for dx.
- this cannot be better explained by another disorder
- this cannot exclusively occur during a setting of delirium
Dementia
sub-types
Risk Factors (the road….)
Dementia
- an umbrella term for a cluster of specific diagnoses which each include some component of memory loss, impaired judgment, personality changes and teh inability to perform daily activites
Alzheimers Disease the majority
Vasacular Dementia
Frontotemporal Dementia
Lewy Body Dementia
Risk Factors
Early on…
- less education
- hearing loss
- TBI
- hypertension, obesity
- alcohol ( > 21 a week) , smoking
- DM
- air pollution
- inactiity
- etc.
- 60% is unknown
Alzheimer’s Disease
- prevelene & onset
- pathology
- assoicated features (characteristic lost first & last)
- mediations
- life expectancy
AD : most common dementia
Prevelence
- 70% of cases
- typically > 65 y/o
- gradual, slower onset
Life expectancy
- a terminal illness; 8-10 years of slow neurological regression
Pathology
- Amyloid palques & neurofibiliary tangles
Features
- first lost: memory
- verbal fluency is preserved until the very end
Medications
- acetylcholinesterase inhibitors (first)
- NMDA-antagonists (second)
Diagnositcs for AD
what types of tests, labs, etc. do you need
Diagnosis of AD
- Diagnostic Interview: clinical understanding of social, medial and medication history
- Office Assessment: comprehensive physical exam & quantified function exams (MOCA, MMSE, trails, depression screen)
- note: mini cog can be done first to assess congition , then if further testing is warreneted you can do MOCA and MMSE
- Lab work (rule out) : CBC, CMP, TSH, VitB12, RPR (+/-)
- Imaging: MRI, but not needed
- neuropsych testing helpful to figure out what type of dementia (not needed)
defintive: the histopathology of amyloid plaques done post-mortum
Treatment of AD
in depth info about the medications
Mild to Moderate Disease
- cholinesterase inhibitors
- Donepezil (preferred)
- Galantamine
- Rivastigmine
Aducanumab (reduces amyloid levels- only FDA approved one for this MOA – saftey issues)
Severe Disease
- NMDA antagonists
- Memantine
- helps to protect neurons from excessive glutamate buildup
- can be added onto a cholensterase inhibitor or solo
differentiate between Parkinsons with dementia and dementia with lewy body
Parkinsons with dementi a
- they start iwth PD
- then alter on they develop the dementia
Dementia with LB
- dementia starts first
- then the lewey bodies form and the parkinson’s like symptoms arise
Dementia with Lewy Bodies (DLB)
- prevelence
- pathology
- associated features (essentail and core clinicals)
- medications
- life expectancy
Dementia with Lewy Bodies
Prevelence
- typically 65+
- slow gradual progression
- life expectancy: 5-7 years
Pathology
- Alpha synuclein inclusions (lewy bodies)
Essential Feature
- first thing = dementia
- later…
- core features (those of parkinsons)
- fluctuating cognition
- visual hallucinations
- REM sleep behavior disorder
- parkinsonism
Meds
- same as AD
DAT scan can be done to see the lack of DA in the brain
Diagnosis of Dementia with LB
- essential: NEED dementia first
- then + 1 core feature or more….
- core features (parkinsonism, REM sleep d/o, hallucinations, fulctuating cognition or multiple core PD features of bradkinesia, cogwheel rigidity, tremor))
1 core feature + a biomarker (DAT scan or SPECT showing abnormalities) = probably Dx.
Treatment of Dementia with LB
1st line: cholinesterase inhibitors (donepezil or rivistigmine)
- can also use quetiapine for severe behavior abnormalities
for the parkinson symptoms
- initiate the meds when the symptoms are interfering with QOL
- carbadopa-levadopa: most effective
Parkinson’s Disease with Dementia
Prevelence
Associated features
cognitive changes
medications
PD is amovement disorder of decreased DA in the brain: but over time can develop dementia
cardinal features of PD
- bradykinesais
- tremor at rest
- rigidity
Prevelence
- 75% of PD pts go on to develop dementia (10 years after)
Assoicated Features
- First change = autonomic dysfunction
- neuropsycho symptoms = visual hallucinations & REM sleep disorder
- memory is relatively preserved
early on = lost of visuolspatial dysfunction
Meds
- cholinesterase inhibitors first
- then NMDA can be used
- carbadopa/levodopa for PD symptoms
Frontotemporal Dementia
prevelence
pathology
assocaited features
cognitive deficts
special tests
meds
characterized by the focal chagnes in the frontotemporal regions of the brain
Prevelence
- rare: incidious onset
- but can happen early (50-60s)
- short life span and rapid progression once it starts
Features
- 1st change = depends on the variant
- behavioral varient = first thing to go = personality and behavior issues
- prgressive apahsi varient = impaired ability to communicate
- late disease = global dementia
meds
- no FDA drugs
- SSRI still first line for psych symptoms
neuropsych testing is critcial here to figure out the varient
Vascualr Dementia
prevelence
pathology
assocaited features
medications
Prevelence
- 2nd MC form of dementia
- abrupt stepwise progression with each additional insult
Pathology
- arterioles thickened vessesl walls
- imaging: strokes, lacunar infarcts, cerebral hemorrhages, small vessel disease
- anything causes vascualr injury to the brain that overtime creates intense damange
Features
- first change = variable locations - but wherever the location of the damange = the changes/deficts youll see
- memory is often spared!!!
Medication
- treat the risk factors
- HTN, smoking
- coagulation
- atherosclerosis
- life expect = 5 years but more likely to die due to CVA or MI first
Symptom Management of dementia
symptoms = wandering, agitation, etc. in addition to the disease process itself
FIRST :NON PHARMACOLOGIC INTERVENTIONS!!!!!!
FIRST LINE IS STILL AND ALWAYS SSRIs
- they are just as effective as antipsychotics & help with co-occuring anxiety/depression
- careful with citalopram = prolonge QT
Couceling with family
- using antipsychoitc = increased BBW risk of death in elderly and those with dementia
- if you must use antipsych.
- haldol is preferred
- risperadone
- ariprazole
- olazapine
