Psychiatric Conditions in Geriatric Patients

Question 1

What are the 4 primary types of psychiatric illnesses in the elderly?

Answer 1

Dementia: major neurocognitive disorder (MND)

Pychosis

Substance abuse

Depression

Question 2

What is mild neurocognitive disorder?

Answer 2

A less severe form of cognitive impairment (formerly mild cognitive impairment)

Question 3

What is the DSM5 definition of dementia?

Answer 3

Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains, based on:

• concern of the individual, informant or clinician.
• a modest impairment in cognitive performance, preferably documented by standardized neurophysical testing or another quantified clinical assessment.

The cognitive deficits do not interfere w/ capacity for independence in everyday activities.

Question 4

What designation is given to all types of dementias?

Answer 4

Mild or moderate

Question 5

Which types of diseases exist in patients with dementia?

Answer 5

Alzheimer’s disease: 50-60% of pts. with dementia

Vascular disease: 15-30% of pts. with dementia

Progressive disorders: Pick’s disease (frontotemporal dementia), Lew body dementia

Question 6

What are examples of reversible dementia?

Answer 6

Drug-induced
Thyroid disease
Metabolic disorders
Hematomas
Hydrocephalus - normal pressure variant

Question 7

Most important in the initial evaluation of dementia in the elderly is…

Answer 7

History and physical

Question 8

What must be ruled out in a patient with dementia?

Answer 8

Psychiatric and neurological conditions, drugs, metabolic disorders, trauma-induced dementia, hormone imbalance, etc.

Question 9

What is the goal of pharmacotherapy in patients with dementia?

What 2 meds can be given? MOA?

Answer 9

Attempt to slow progression and increase patient functionality.

Donepezil - ACh inhibitor
Memantine - NMDA antagonist

Question 10

Which meds must be avoided in elderly patients with dementia? (2)

Answer 10

1. Avoid anticholinergic meds, because they impair cognitive function.
   Ex: Benadryl, hydroxyzine*
2. Antipsychotics

Question 11

What is Psychosis Due to Delirium?

How common is it?

Answer 11

Thought disturbance with themes that tend to be from current environments and situations, with poverty of thinking and irrationality and with hallucinations.

3rd most common cause of psychosis in elderly

Question 12

What is Psychosis Due to Major Depressive Disorder with Psychotic Features? (4)

How common is it?

Answer 12

Somatic troubles
Persecution
Guilt
Poor self-esteem

2nd most common cause of psychosis in elderly

Question 13

What is the most common cause of psychosis in the elderly?

What causes these delusions?

What are common symptoms/thoughts of these patients?

Answer 13

Psychosis due to Alzheimer’s type Dementia

Cognitive impairments that preclude to elaboration of complex ideas

Paranoia, pts. believe they are being stolen from, or that family is being disloyal

Question 14

What are risk factors for substance abuse in the elderly? (4)

Answer 14

Female

Living alone/single marital status

Lack of hobbies and socialization

Poor health

Question 15

What are general consequences of substance abuse in the elderly?

Answer 15

Cognitive impairment
Depression
Sleep alterations
Balance/vestibular problems
Delirium
Increased risk for developing other medical conditions

Question 16

What is the treatment of substance abuse in the elderly?

What is the concern if the drug is EtOH?

Answer 16

It depends on the substance being abused. Treat withdrawal signs/symptoms.
-ex: diazepam taper

Cannot go “cold turkey” with intense and chronic EtOH abuse, due to possible delirium tremors and death.

Question 17

What is needed for the diagnosis of Major Depression in the elderly?

Answer 17

Anhedonia or depressed mood for 2 weeks and 4 of the following:

• feelings of worthlessness or guilt
• poor concentration
• fatigue
• psychomotor agitation
• insomnia
• wt. or appetite changes
• recurrent thoughts of suicide and/or death

Question 18

What do the following score in the Geriatric Depression Scale mean?
> 5 pts.
>/ 10 pts.

The scale should be used with caution in which patients?

Answer 18

> 5 pts. = suggests depression and a follow-up assessment is warranted.
/ 10 pts. = almost always indicative of depression

Use GDS cautiously in pts. with dementia

Question 19

What would make you think an elderly patient’s depression is from an underlying non-medical cause?

Answer 19

Recent and abrupt onset of depression in the elderly with absence of social factors should raise suspicion for a non-psychiatric cause.

Question 20

Which other medicine must be avoided in elderly patients?

Why?

Answer 20

Diphenhydramine - may cause serotonin syndrome

Question 21

What should be focused on to determine if an older patient has depression or dementia?

How do you differentiate?

Answer 21

Focus on “insight” in the mental status exam.

Depressed patients will have insight, though little effort.
Demented patients will have little to no insight.

Question 22

What are treatment modalities for depression in elderly patients?

Answer 22

Meds
Psychotherapy
CBT***
Exercise
Diet
Lifestyle mods