7. Geriatric Psychiatry Flashcards
What are the primary types of psychiatric illnesses that occur in elderly?
- Dementia (DSM 5 = Major Neurocognitive Disorder)
- Psychosis
- Substance Abuse
- Depression
What criteria for diagnosis of dementia?
- Chronic, progressive ↓ in cognitive decline from previous performance in 1 or more domains that is usually irreversible:
- Complex attention
- Executive function
- Learning and memory
- Language
- Perceptual motor
- Social cognition
- Concerns patient, other or clinician
- Modest impariment in cognitive performance on by neuropsych testing or another assessment
- Patient can STILL perform day- to -day functions/be indepedent (no LOC)
- Must rule out depression as a reversible cause of dementia (pseudodementia)
All types of dementia can be designated as what?
1. Major
2. Minor
When treating geriatric patient for psych illnesses, what is important to consider?
Can have;
- Multiple diseases
- Different diseases: most often degenerative and cancer
- Present differently
- Differentiate NL aging from disease
- Often under-report bc they dont recognize/fail to report signs of aging
How is the purpose of treatment in elderly patients different from younger??
Focus more on palliative care, instead of living longer
What is the rule of prescribing medications in geriatric patients?
Start low, go slow.
What are the types of dementia, in order from most common?
- 1. Alzheimers disease
- 2. Vascular Dementia
- 3. Progressive disorders: Picks Disease (frontotemporal dementia) or Lewy body Dementia
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4. Reversible causes:
- Drug-induced
- Thyroid-induced
- Metabolic disorders
- Hematomas
- Hydrocephalus: NL pressure hydrocephalus
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What are reversible causes of dementia?
- Drug-induced
- Thyroid disease (hypothyroid)
- Metabolic Disorders
- Hematomas
- Hydrocephalus: NL pressure hydrocephalus
What progressive disorders cause dementia?
- Pick’s Disease (frontotemporal dementia)
- Lewy body disease
What is the most common cause of dementia in elderly?
Alzheimers Disease (50-60% of people with dementia)
Who has an ↑ risk of Alzheimers?
- Female
- FHx
- Head trauma
- Down- syndrome, because APP gene is located on Chr 21.
- Schizophrenia
What is the 2nd MC cause of dementia in elderly?
Vascular dementia (15-30%) = Dementia that develops after multiple small strokes due to multiple infarcts/chronic ischemia, causing a step-wise decline in cognitive ability with late-onset memory loss
Who has an ↑ risk of Vascular dementia?
- Male
- Old age
- HTN or CV disease
What is Picks Disease?
- A progressive form of dementia due to degeneration of frontal and temporal lobes, causing change in personality and behavior (frontal lobe) and aphasia (temporal lobe).
- Assciated with:
- 1. Hyperphosphorylated spherical tau proteins
- 2. Ubiquitinated TDP-43
What is Lewy Body Dementia?
Build-up of intracellular Lewy bodies (protein alpha-synuclein) in the CTX (if buildup in BG = Parkinsons), causing a triad:
- Cognitive symptoms: Visual hallucinations (haLEWYcinations) and memory loss
- Motor symptoms: Parkinson -like symptoms occur less than 1 year after cognitive
- REM sleep behavior disorder
In Lewy-Body dementia, what happens if cognitive and motor symptoms occur > 1 year apart?
Dementia due to Parkinsons
What is pseudodementia and why is it important to rule out?
- Depression in geriatric pt’s can look like dementia!
- Tx depression and sx’s will improve!
What are unique symptoms of dementia in geriatrics?
- Disorientation (getting lost)
- Personality changes: aggressive or withdraw
- Inappropriate behavior (esp in Picks) = sexually aggressive/violent
- Psychotic symptoms (hallucinations, delusions, paranoia)
- Agitation
What is most important in evaluation of dementia in the elderly?
H and P: what is the onset, character (type/manner of cognitive deficits) and progression of sx
What other things should you do when evaluating dementia?
- Ask about co-morbid disorders
- Neuro exam and mental status exam
- Functional status: can they do things for themselves
- Neuropsych testing
- Labs: endocrine panel, B12, folate, CBC/CMP, HbA1C
- Radiology: CT, MRI, PET
Why is neuropsychological testing useful in evaluation of dementia in elderly pt?
- Attempts to establish baseline (helpful early in disease)
- Quantifies how bad memory is
Goal in treatment of dementia in elderly?
-
Slow progression and increase patient function:
- Donepezil (MOA: AChE inhibitor)
- Memantine (MOA: NMDA ANT)
TEST Q: What should be avoided when treating geriatric patients with dementia?
Anticholinergics (benadryl, hydroxyzine) = can impair cognitive function and mimic dementia
What is a black-box warning for antipsychotic meds used for tx of psychosis with dementia?
Assoc. w/ an 1.6- 1.7 increased risk of mortality: most often due to heart-related events or infections
Which antipsychotic meds that treat psychosis with dementia have a BBW , saying that they can increase mortality?
- Olanzapine
- Aripiprazole
- Risperidone
- Quetiapine
Work-up for patient with dementia
Exclude treatable causes of dementia:
- CBC/CMP
- B12, folate
- MMSE
- Imaging: CT/MRI
DDx for patient with dementia
- Stroke
- Tumor
- Delirium
- Depression
- Endocrine: hypothyroidism, DB
- Dementia
What is psychosis?
-
Loss of perception from reality, causing 3 manifestations: [delusions, disorganized thought, hallucinations] that occurs due to medical and psychiatric conditions
- Delirium (medical conditions that cause delirium)
- Schizophrenia (psych)
What are the MC causes of psychosis in elderly outpatients?
- Delirium
- MDD
- Alzheimers Dementia
What is delirium?
Acute, waxing and waning ↓ cognitive decline (LOC) that is usually reversible that is a classic cause of AMS in hospital.
- (Ex. Pt has a 104 fever and becomes delirious), that is a classic cause of AMS in hospital.
What is psychosis due to delirium?
Loss of perception of reality that occurs in medical settings, manifestated by:
- Delusions
- Disorganized thought
- Visual hallucinations
What is an example of a patient with [psychosis due to delerium]?
Patient in hospital with AMS and 104 fever: has delisions ( strongly held beliefs that conflict with reality, ID’d by speech), disorganized speech and can see dead mom.
Sx of [psychosis due to MDD with psychotic features] in elderly
- MANNNNY somatic troubles
- Persecuation/guilt
- Poor self-esteem
What are the delusions most often like in elderly pt with psychosis due to alzheimer’s type dementia?
- Often of paranoid nature:
- Pt’s believe that items are being stolen from them
- That they are being abandoned
- That their spouse and children are being disloyal to them
What is the tx of choice for Major Depressive Disorder with Psychotic Features in elderly?
ECT
Why is substance abuse often UNDER-diagnosed in elderly?
- Pharmakokinetic changes that occur as we get older: increase abuse for benzos/opiates
- Unaware of high prevelance use
- Unaware of increased impact some substaces have on elderly
- Uncomfortable asking in older ppl
RF for substance abuse in elderly
- F
- Single, separated or divorced/ living alone
- No hobbies/socialization
- Health concerns
Treatment for substance abuse in older adults:
-
Treatment depends on substance being abused
- Treat withdrawal signs and symptoms
- If intense/chronic alcoholic abuse => “cold turkey” can cause delerium tremens and death.
What should you do in tx of substance abuse in older adults which will increase compliance?
INFORM YOUR PATIENTS!
What are the primary causes of depression in elderly?
- Deteriorating health
- Cognitive decline
- Loss of independence
- Loss of spouse/friends
What should raise suspcicioun for an underlying, NON-psychiatric cause of depression?
RECENT and ABRUPT onset of depression in elderly W/O social factors
TEST Q: what medications should you avoid in treating depression in elderly?
DIPHENHYDRAMINE = > can cause 5HT syndrome
How do you differentiate between dementia and depression in elderly?
- Mental Status Exam => focus on patients insight
- Depressed patients: have insight
- Dementia patients: little/no insight
