Class 8 Flashcards
Normal Cognitive Aging, decline in
processing speed, attention in complex tasks, episodic (autobiographic) memory, abstraction, concept formation, mental flexibility, inductive reasoning, verbal fluency, visual confrontation naming, visuospatial: complex tasks
Delirium, Epidemiology in the Elderly
VERY common in LTC patients (in or out of hospital)
VERY common in ICU
Increased risk if comorbid NCD
Almost always part of the active dying process
Delirium, : Predisposing Risk Factors
Age > 75, male, hx of delirium, depression, ROH, Hx of TIA/CVA, severity of medical illness, terminal cancer, fracture on admission, Rx with significant anticholinergic activity, critical care settings, Premorbid functional disability/impairments, cog impairment, vision impairment, hearing impairment, immobility, dehydration, sleep deprivation #1 risk factor: cognitive impairment #2 risk factor: severity of medical illness Etiology is ALWAYS multifactorial
Delirium, Precipitating Risk Factors
Drugs (intox vs withdrawal): Opioids, benzodiazepines, anticholinergics, steroids. ANY Rx can be a precipitating factor.
Infection: Pneumonia, UTI, cellulitis, sepsis
Metabolic disturbances: Fluids, electrolytes, nutrition
Structural insults: CNS, cardiovascular, GI, pulmonary
Retention: Urinary, constipation
Diagnostic Criteria Delirium
Disturbance attention + awareness Abrupt onset (change from baseline) + fluctuating severity over the same day Disturbance cognition (memory, orientation, perceptions…) Direct physiological consequence of another medical condition, substance intox/withdrawal, toxin, or multiple etiologies
Delirium Specifiers: Substance intoxication delirium Substance withdrawal delirium Medication-induced delirium Delirium due to another medical condition Delirium due to multiple etiologies
Acute (days) vs persistent (months)
Hyperactive vs hypoactive vs mixed
Attenuated delirium syndrome
Commonly called subsyndromal delirium
Sometimes seen in prodromal phase
Not all Dx criteria are met
Distress or impact on functioning present
Suggestive ssx (usually new-onset)
Falls, incontinence, dysphagia, dysarthria, refusal to mobilize, hypersensitivity to environmental stimuli, mild disorientation
Unspecified Delirium
Not all Dx criteria are met
Distress or impact on functioning present
Insufficient information to make more specific Dx
eg. ER assessment
Hyperactive Delirium
Common Presentations
Psychomotor agitation Hypervigilance Sundowning/sleep-wake reversal Mood lability Delusional beliefs Perceptual disturbances (V>A) Language abnormalities
Common etiologies
Hyperactive Delirium
EtOH withdrawal (delirium tremens)
Sedative withdrawal
Medication-induced
Often mistaken for anxiety, mania, schizophrenia or BPSD
Hypoactive Delirium
Common Presentations
Psychomotor retardation Hypersomnolence Decreased arousability Apathy Confusion Perceptual disturbances (V>A) Vocalizations (eg. muttering)
Hypoactive Delirium
Common etiologies
Post-orthopedic surgery status
Severe metabolic abnormalities
Dying process
Often mistaken for depression or misinterpreted as “normal” Rx side effect
Delirium with mixed level of activity
Normal psychomotor activity
Important cognitive symptomatology
Rapid fluctuation between hyper/hypoactive state
Controversial subtype
Delirium vs NCD
delirium onset acute, course fluctuating, often worse in the evening and night, level of awareness/ alertness/ wakefulness altered (alzheimers N), attention altered (alzheimers N)
Delirium Screening Scales
Confusion Assessment Method (CAM)
Delirium is often comorbid with
NCD (up to 90% depending on setting)
Severe medical illnesses (critically ill, terminally ill)
Delirium = poor Px factor
Increased risk of 1-year mortality Increased risk of cognitive decline Increased risk of functional decline Increased risk of institutionalization Prolonged lengths of hospital stay
Dementia
Epidemiology
7 % > age 65
25 % > age 85
F > M
Dx DSM 5: Major NCD
Significant decline in ≥ 1 cognitive domain
Subjective (patient or else) AND
Objective (quantified clinical assessment)
Interference with independence in everyday activities (eg assistance required with complex iADLs)
Cognitive deficits not exclusively in context of delirium
Cognitive deficits not better explained by another mental disorder
Specifiers due to Alzheimer’s disease Frontotemporal lobar degeneration Lewy body disease Vascular disease Traumatic brain injury Substance/medication use HIV infection Prion disease Parkinson’s disease Huntington’s disease Another medical condition Multiple etiologies Unspecified
Without behavioral disturbance
With behavioral disturbance
Anxiety, apathy, mood disturbances, agitation, psychotic sx, etc.
Mild Difficulties with iADLs Moderate Difficulties with iADLs + ADLs Severe Fully dependent
Dx DSM 5: Mild NCD
Modest decline in ≥ 1 cognitive domain
Subjective (patient or else) AND
Objective (quantified clinical assessment)
No interference with independence in everyday activities
BUT greater effort, compensatory strategies, or accommodation required
Cognitive deficits not exclusively in context of delirium
Cognitive deficits not better explained by another mental disorder
NCD Etiology: Biological Risk Factors
History of stroke or transient ischémie attack, family history, lifetime history of MDD, non stabilized sleep apnea, non stabilized metabolic or cardiovascular morbidity, recent episode of delirium, first major psychiatric episode at advanced age, recent head injury, parkinson’s, mild NCD
NCD Common Presentations: Warning Signs
memory changes, loss of ADLs and IADLS, problems with executive function, impaired visual recognition, language and speech disorders, impaired ability to perform a motor ability despite intact motor capabilities, personality, behaviour and mood changes
NCD Common Presentations: Main Cognitive Deficits Alz
Learning and Memory
NCD Common Presentations: Main Cognitive Deficits Vascular
Complex Attention, Executive Function
NCD Common Presentations: Main Cognitive Deficits Lewy Body Disease / Parkinson’s
Complex Attention, Perceptual Motor
NCD: Assessment
Objective Measures: Functioning, Cognition, Behavioral Sx
Physical Examination: Neuro exam( Presence of focal signs may indicate underlying neurological disorder, cerebrovascular disease, intracranial process (eg tumor, hematoma)), Cardiovascular exam (Positive findings may be suggestive of vascular etiology to NCD), Sensory input (Vision or hearing impairment may mimic NCD)
Mobility (Gait abnormalities may orient towards NPH, Parkinson’s, cerebrovascular disease)
Blood work, MRI/ CT
Medication
Review pharmacological profile: Recent Rx changes
Drug-drug interactions, Rx with deleterious cognitive side effects, Anticholinergics, Sedatives/hypnotics, AED, Assess adherence, Unstable medical condition or serum drug level may impact cognition
MHx: Failure of major organs: eg CHF, COPD, CKD, cirrhosis, Neurological disorders eg Parkinson’s disease, MS, ALS, epilepsy, Endocrine/metabolic condition
eg hypothyroidism, hypoglycemia, B12 deficiency
Systemic illness, Auto-immune or infectious disease causing encephalitis (eg neurosyphilis), Cardio/cerebrovascular disease ** eg CAD, atrial fibrillation, TIA, Cancer (mets, chemo, radiation) Brain mets (breast, lung, colon, kidney), Brain tumor
PsychHx: Depression «pseudodementia», Anxiety disorders, Severe mental illness, Associated cognitive symptoms, SUD, EtOH and risk of Wernicke-Korsakoff
Withdrawal state, Intellectual disability and ASD, Change from baseline?, Delirium, Sleep disorders, Untreated OSAH
NCD Most common comorbidities
#1: HTN 42 % #2: Depression 32 % #3: Cardiac disease 27 % #4: TIA/CVA 18 % #5: DB 13 %
NCD Most common complications
Eating problems Dehydration Malnutrition Febrile episode (Aspiration) pneumonia Seizures GI bleeding Fractures (hip) CVA MI Distressing sx Pain, SOB, bed sores, agitation
Psychiatric Complications NCD
NPS or BPSD:
Affective and emotional: dep, anxiety, apathy, irritability, emotional lability, exaltation of mood
Behavioral disorder: wandering, repetitive vocalisations, repetitive movements, agressive disinhibition, sexual disinhibition, gluttony, utilization behaviours, initiation behaviours
Neurovegetative disorder: sleep (night wandering, sundowning, sleep-wake cycle reversal), inappropriate eating behaviours and hyperorality
BPSD Possible underlying causes
Physical sx / medical condition (eg UTI) Unmet needs (eg thirst) Environmental factors (eg noise)
BPSD present in
both mild and major NCD Early stage: mostly affective sx Late stage: mostly aggression and delusions VERY common (<90 %) Often chronic
Alzheimer’s Disease: Epidemiology
Most common cause of NCD Incidence in Canada 5 % > age 65 6-8 % > age 85 F>M 7-10 years from onset to death
Alzheimer’s Non-modifiable Risk Factors
increase age, female, first degree relative with alz, down syndrome, genetic, mild cognitive impairment
Most important RF overall: age
Alzheimer’s modifiable Risk Factors
hta, cholesterol, head injury, dep, db, moderate wine consumption, no exercise, low cognitive activity, smoking, increased dietary fate intake and reduced omega 3, lower education, exposure to environmental risk
Most important modifiable RF: cardiovascular
Combined effect of modifiable RFs account for 30 % of risk of developing Alzheimer’s
Dx: Major NCD due to Alzheimer’s Disease
Criteria met for major NCD
Insidious onset + gradual progression
Criteria met for either probable or possible Alzheimer’s disease
Not better explained by cerebrovascular or neurodegenerative disease, effects of a substance, or another mental, neurological or systemic condition
Probable (1 OR 2):
1. Evidence of causative AD genetic mutation from FHx or genetic testing
2. All of the following:
Clear evidence of decline in memory and learning + 1 other cognitive domain
Steadily progressive, gradual decline in cognition (no extended plateaus)
No evidence of mixed etiology
Possible:
Criteria not met for probable Dx
Criteria not met for probable Dx
Criteria met for mild NCD
Insidious onset + gradual progression
Criteria met for either probable or possible Alzheimer’s disease
Not better explained by cerebrovascular or neurodegenerative disease, effects of a substance, or another mental, neurological or systemic condition
Probable:
Evidence of causative AD genetic mutation from FHx or genetic testing
Possible (1 AND 2):
1. Criterion not met for probable Dx
2. All of the following:
Clear evidence of decline in memory and learning
Steadily progressive, gradual decline in cognition (no extended plateaus)
No evidence of mixed etiology
Alzheimer’s Disease: Early Stage Red Flags
Short-term memory difficulties
Not paying bills or rent on time
Not showing up to appointments
Fire hazard due to inappropriate use of stove/candles
Poor Rx adherence
Disorientation
Getting lost outside of house (walking or driving)
Lack of judgment
Scams
Being inappropriately dressed for weather
Malnutrition
Not seeking medical attention despite significant health problems
Alzheimer’s Disease: Common Presentations As the disease progresses
Gradual loss of autonomy iADLs then ADLs Developmental regression Language Mobility Continence Swallowing Emotions regulation «Plongeon rétrograde» Gradual loss of timeline of events (present -> past) Death Early stage: medical comorbidities Late stage: infection (pneumonia), malnutrition, dehydration
Dx: Mild/major NCD with Lewy Bodies
Criteria met for mild/major NCD Insidious onset + gradual progression Combination of core and suggestive Dx features Not better explained by cerebrovascular or neurodegenerative disease, effects of a substance, or another mental, neurological or systemic condition 1. Core Features Fluctuation in cognition (attention and alertness) Recurrent VH (well formed + detailed) Spontaneous parkinsonism with onset subsequent to cognitive decline 2. Suggestive Features Severe neuroleptic sensitivity REM sleep behavior disorder Probable: 2 core features OR 1 core feature + ≥1 suggestive feature Possible: 1 core feature OR ≥1 suggestive feature
NCD with Lewy Bodies 5 Important Sx Clusters
Fluctuating Cognition Motor Dysfunction Sleep Dysfunction Neuropsychiatric Features (Depression: can be very severe, Hallucinations: other than visual, Delusions: often systematized and related to VH) Autonomic Dysfunction (OH, Repeated falls and syncope Transient, unexplained loss of consciouness, Cardiac autonomic denervation)
NCD with Lewy Bodies How to distinguish from Parkinson’s disease?
Lewy bodies > Parkinson’s:
Attention deficits
Sensitivity to neuroleptics
Postural instability and gait difficulties
Lewy bodies < Parkinson’s:
Earlier age of onset
Assymmetrical parkinsonism
Better response to L-dopa
Vascular NCD Cognitive features depend on
location and size of vascular brain lesions
Different types of lesions Vascular NCD
Hemorrhagic (eg subdural hematoma)
Ischemic: Large vessels (eg CVA) Small vessels (eg lacunar infarcts) -> often subcortical
Vascular NCD > x% of people age > 70 have
> 25 % of people age > 70 have silent lacunar infarcts
Associated with subtle decline in cognition
Dx: Mild/major Vascular NCD
Criteria met for mild/major NCD
Clinical features consistent with vascular etiology by either 1 OR 2
1. Onset of cognitive decline temporally related to ≥1 cerebrovascular events
2. Prominent decline in complex attention and frontal-executive function
Evidence from Hx, P/E, or neuroimaging of cerebrovascular disease sufficient to account for deficits
Not better explained by another brain disease or systemic disorder
Probable (1 OR 2 OR 3) 1. Neuroimaging supported 2. Temporally related 3. Both clinical and genetic evidence of cerebrovascular disease CADASIL and leukoencephalopathy
Possible
Neuroimaging not available
Temporal relationship not established
Vascular NCD: Common Presentations
Abrupt Cognitive Decline («plateau»):
Abrupt change in cognition and behavior usually related to acute cerebrovascular event
If cortical lesion : Aphasia, agnosia, apraxia, amnesia (location-dependent), Motor and sensory deficits
Gradual Cognitive Decline:
Insidious onset and progressive course associated with «silent» infarcts and microvascular ischemic changes
Usually «subcortical» presentation: Executive dysfunction Retrieval deficits on memory testing Psychomotor retardation Gait abnormalities Vascular parkinsonism Apathy
Depression in the Elderly: Mechanisms
Lower likelihood of family history, a prodrome to Alzheimers, a manifestation of cerebrospinal vascular disease, caused by a GMC, psychosocial context (end of life)
Specific features of depression in older adults
cognitive impairment more common, psychotic features more common, more somatic sx, more neurovegetative sx, more disability
Patients DO NOT endorse sadness or depressed mood, but rather feel ANXIOUS or have LOST INTERESTS
Alzheimers vs depression
Apathy, agitation vs anhedonia, anxiety
Sundowning vs insomnia
Weight loss without loss of appetite vs weight loss with loss of appetite
Minimizing of cognitive decline despite impaired memory and executive function vs subjective complaints of cognitive impairment that exceed objective deficits
Guesses and wrong answers during testing vs “I don’t know, I can’t”
Aphasia and apraxia vs language and motor skills intacts
Depression in the Elderly: Dx Clues
ANXIETY,
ANHEDONIA
SOMATIZATION
Delayed recovery, treatment refusal, discharge refusal, high utilization of services
Depression in the Elderly: Suicide
Old white males, higher likelihood to complete suicide, more violent methods (hanging, firearms)
Anxiety Disorders in the Elderly: New Onset of Sx
R/O depression
R/O medical cause
Agoraphobia can be seen
Anxiety Disorders in the Elderly: Risk Factors
Female, depression, cognitive impaired, physical impairment, psychosocial stress, functional limitations
Anxiety Disorders in the Elderly: Protective Factors
social support, physical activity, cognitive stimulation
Anxiety Disorders in the Elderly: GAD
most common (with phobias), less severe, higher percentage of health worries and worries of well-being of family
Anxiety Disorders in the Elderly: Panic Disorder
Late onset is uncommon (less NE), search for depression
Anxiety Disorders in the Elderly: Agoraphobia
Onset may be related to health status, falls, more common in women and widowed, often preceded by dep
Anxiety Disorders in the Elderly: PTSD
Early life traumas result in higher rates of PTSD than late life trauma
Less re-experiencing sx, more avoidance
Reactivation may be related to analogous historical events or triggered by age related loss
Anxiety Disorders in the Elderly: OCD
Lower prevalence
increases hand washing and fears of sinning
more hoarding
Risk factors for mania
CNS disorders especially cerebrovascular disease affecting the right orbital frontal cortex
Bipolar Disorders in the Elderly: Cognition
Associated with frontal executive dysfunction and language impairment, even in a euthymic state, increased risk of dementia
Characteristics that can differentiate between late onset and early onset schizophrenia
More women in late onset, more positive sx, more variability in the profile of cognitive deficits, respond to lower doses, larger thalamic doses, more paranoid, more organized delusions, more sensory deficits, more partition delusions, Several sensory perceptual disturbances at the same time. More delusional
Schizophrenia in the Elderly: Risk Factors
Psychosocial isolation and low social support, F, bereavement, sensory deficit, immigration, family history, childhood maladjustment, abnormal social functioning, abnormal premorbid personality, delusions in the absence of medical conditions, cerebrovascular abnormalities
Schizophrenia vs Alzheimer’s in the Elderly
Schizo: single, socially isolated, major mental illness in the family, auditory hallu,
Alz: not socially isolated, alz in te family, visual hallu, delusions someone stealing
Elder Abuse: Types
Neglect (+++), financial , physical, sexual, psychological
Self neglect
behaviours that threatens his/her own health and safety. At risk of consumer fraud. Hoarding, sever domestic squalor
Elder Abuse: Risk Factors
cognitive impairment, agressive behaviours and psychological distress, poor social network and support, low household income, need for ADL assistance, premorbid relationship with the abuser, shared living arrangements
Perpetuator risk factors for elderly abuse
family relations, substance abuse, mental illness, dependency, unemployment
Elder Abuse: Red Flags
bruises, pressure marks, broken bones, abraisons, burns, unexplained withdrawal from normal activities, sudden change in alertness, unexpected depression, bruises on breasts or genital area, sudden changes in financial situation, UNATTENDED MEDICAL NEEDS, poor hygiene, unusual weight loss, frequent arguments between caregiver and pt
Capacity: Definition
”The ability to understand and appreciate the nature and consequences of own’s decisions and to formulate and communicate decisions concerning a specific decision-making domain”.
Decision-making Domains Relevant to the Field of Psychiatry
Medical (treatment and research) Financial Housing Driving Testamentary
4 Abilities are required in order make decisions
C omprehension (of relevant information) A appreciation (of how this information applies to self) R easoning (compare information and infer consequences of choices) E xpression (of a consistent choice)
If a medical or psychiatric condition impairs ≥1 of these abilities -> increased risk of having impaired decision-making capacity
Examples of conditions commonly associated with impaired decision-making capacity in the elderly
NCD Delirium Parkinson’s disease Severe mental illness Systemic illness impacting brain function (eg vasculitis) Brain tumor or metastasis TBI End of life
Capacity: Key Facts
Capacity is task-specific
Ability to make a decision at a specific time regarding a specific situation)
Eg: Someone with NCD can be capable of deciding whether he wants surgery for his cataracts, but be incapable of making finance-related decisions at the exact same time
Capacity IS NOT
Determined by a Dx or committal statusD
Eg: Dx of schizophrenia ≠ loss of decisional capacity necessarily
The same as agreement with the clinician’s decision
Patients may agree with proposed treatment without understanding associated risks
Determined by an MMSE or MoCA score
