Geriatric Psychiatry Flashcards
Primary types of psychiatric illness in the elderly
Dementia (DSM 5 includes Major Neurocognitive Disorder [NCD], Mild Neurocognitive Disorder, Delirium)
Psychosis
Substance abuse
Depression
DSM criteria for dementia
Evidence of modest cognitive decline from a previous level of performance in 1+ cognitive domains (complex attention, executive function, learning/memory, language, perceptual motor, or social cognition) based on 2 factors: 1) Concern of the individual, a knowledgeable informant, or clinician, 2) modest impairment in cognitive performance documented by standardized neuropsychological testing or other clinical assessment
The cognitive deficits do NOT interfere with capacity for independence in everyday activities
Special considerations when treating geriatric patients
Multiple comorbidities
Varied diseases (more degenerative and certain types of cancer)
Unusual disease/illness presentations
Differentiating normal aging process vs. disease
Underreporting
Purpose of treatment - emphasis on palliative care
Medication - start low, go slow
Most common type of dementia; risk factors include female, family hx, head trauma, and Downs syndrome
Alzheimer’s
Types of dementia seen in elderly include Alzheimer’s, vascular, progressive disorders, and reversible causes. What are 2 progressive disorders causing dementia in elderly pts?
Pick’s disease (frontotemporal dementia)
Lewy body dementia (neurocognitive symptoms + Parkinson-like features + visual hallucinations)
What are some reversible causes of dementia in elderly?
Drug-induced
Thyroid disease
Metabolic disorders
Hematomas
Normal pressure hydrocephalus
What are some symptoms of dementia in elderly?
Depression (look for weight loss, anxiety, irritability, sadness, social withdrawal): pseudodementia
Memory loss
Communication
Difficulty with performing tasks, organization, and coordination
Problems with disorientation (e.g., getting lost)
Personality change
Inappropriate behavior (esp w/ frontotemporal dementia)
Psychotic sxs (i.e., hallucinations, delusions, paranoia)
Agitation
General steps in evaluation of dementia in elderly
H and P — most important (get info regarding onset and characterization - type/manner of cognitive deficit)
Progression
Determine comorbid conditions and other signs/symptoms
Neurologic exam and mental status exam
Functional status (OT) — dressing, bathing, cooking, financial organization, etc.
Neuropsych testing
Labs
Radiology
What part of evaluation of dementia in elderly attempts to establish a baseline (helpful in early disease) and quantifies results of cognitive deficit?
Neuropsychological testing
What labs and radiology are important to order in evaluation of dementia in elderly?
Labs — endocrine panels, B12, folate, CBC, CMP, HbA1C
Radiology — CT, MRI, PET scan
The first step in treatment of dementia in elderly is to attempt to determine and treat the cause (as well as rule out other potential conditions). It is also important to consider treatment of comorbidities like diabetes, HTN, etc.
There is no perfect treatment, but you can attempt to slow the progression and increase pt functionality. One pharmacologic option is ______ which is an acetylcholinesterase inhibitor, and another is ______ which is an NMDA antagonist
Donepezil; memantine
What medications should be avoided in the treatment of dementia (and most other conditions) in the elderly?
Anticholinergic medications — these can impair cognitive function, esp in the elderly!!!
AVOID DIPHENHYDRAMINE AND HYDROXYZINE
Black box warning regarding treatment of psychosis in geriatric pts with dementia
Antipsychotic meds are associated with increased mortality — including olanzapine, aripiprazole, risperidone, quetiapine, and others.
Most deaths were either due to heart-related events or infections (mostly PNA)
Third most common cause of psychosis in elderly outpatients; characterized by thought disturbance with themes that tend to be from the current environment and situations, with poverty of thinking and irrationality, and with hallucinations (often visual)
Psychosis due to Delirium
What are some causes of psychosis due to delirium in the elderly?
Inappropriate drug use Withdrawal from drugs Infection Urinary retention Constipation Physiologic abnormalities CV problems Intracranial strokes Seizures Hemorrhages Sensory/sleep deprivation