Psychiatric Conditions in Geriatrics - Hill Flashcards
what is considered a major neurocognitive disorder (NCD)?
dementia
what was formerly known as mild cognitive impairment?
mild NCD
what are the special conditions to keep in mind when treating geriatric patients?
- multiple comorbidities
- varied diseases (more degenerative disease and certain cancers)
- unusual presentation of illnesses
- differentiating normal aging processes vs. disease
- under-reporting (elderly pts often fail to recognize sx)
- purpose of tx (emphasis on palliative care)
- medication start low and go slow
what are the risk factors for Alzheimers?
female, family hx, head trauma, Down’s syndrome
what are the risk factors for vascular dementia?
male, advanced age, hypertension, other CV disease
what are the two progressive dementia disorders outlines?
- Pick’s disease (frontotemporal dementia)
2. Lewy body dementia (visual hallucinations, memory loss, parkinson-like sx)
what are some reversible causes of dementia?
- drug induced
- thyroid disease
- metabolic disorders
- hematomas
- hydrocephalus
what are the sx of dementia?
depression -> pseudodementia memory loss communication difficultly performing tasks, organization, coordination problems w/disorientation *personality changes* inappropriate behavior agitation psychotic symptoms
what is most important in evaluation of dementia in the elderly?
H&P
- onset
- character
- progression
- comorbid conditions
neurologic exam
functional status
neuropsychological testing
what labs should be drawn in evaluation of dementia in the elderly?
endocrine panels **B12** if <400 -> give B12 shot! folate CBC/CMP HbA1C
CT,MRI, PET scans
what meds can be used to treat dementia?
- donepezil (ACEI)
- memantine (NMDA antagonist)
what meds should be avoided in treating dementia?
- *ANTICHOLINERGIC meds**
- they impair cognitive function, especially in the elderly
- ex: benadryl, hydroxyzine
- he wants us to KNOW this
what is the black box warning associated with dementia patients?
antipsychotic medications are associated with increased mortality
- olanzapine, aripiprazolem risperidone, quetiapine
what is the main difference between delirium and depression?
delirium = hours-days dementia = weeks-months
what is the third most common cause of psychosis in elderly patients?
delirium due to:
- inappropriate drug use
- drug withdrawal
- infection
- urinary retention
- constipation
- physiologic abnormalities
- intracranial strokes
- seizures
- hemorrhages
- sensory/sleep deprivation
what is the second most common diagnosis in elderly patients?
psychosis due to major depressive disorder with psychotic features
- somatic troubles
- persecution
- guilt
- poor self-esteem
what is the most common diagnosis accounting for psychosis in elderly patients?
psychosis due to alzheimer’s type dementia
- delusions (because of cognitive impairments, often of a paranoid nature)
why is substance abuse often under-diagnosed in the elderly?
physicians are too afraid to ask
- must maintain high index of suspicion
physicians are unaware of the HIGH prevalence rate
- unaware of the increased impact certain substances have on the elderly
- the effects of mood-altering chemicals are often magnified much more due to patient age and condition of body
what are the risk factors for substance abuse in the elderly?
- female
- marital status (single, separated, divorced)
- absence of hobbies and socialization
- health concerns
- possible pharmacokinetic changes that take place in older individuals may lead to increased potential for abuse of benzodiazepines or opiates
what are the general consequences of substance abuse in the elderly?
- cognition impairment
- depression and other mood alterations
- sleep alteration
- balance and vestibular problems
- delirium
- increase risk for developing other medical conditions
what is the tx of substance abuse in the elderly?
treat withdrawal sx!
- cannot go “cold turkey” with intense and chronic alcohol abuse -> possible DT and death
- gradual taper is effective
meds: benzo’s (diazepam)
what is the percentage of people over 65 showing depressive symptoms?
20%
what is the percentage of demented 75+ year olds that are suffering from moderate-mild depression?
36%
what is the percentage of people over 85 that are affected by a depressive condition?
40%
what are the primary causes of depression?
deteriorating health
cognitive decline
loss of independence
loss of spouse and friends
- anxiety
- fatigue, hypersomnolence
- somatic complaints
- cognitive impairment
- weight loss
- insomnia
- anhedonia
- agitation
sy/sx of depression in eldery
what is the diagnosis criteria for major depression in the elderly?
anhedonia or depressed mood for TWO weeks and 4 of the following:
- feelings of worthlessness/guilt
- decreased ability to concentrate
- fatigue
- psychomotor agitation
- insomnia, hypersomnolence
- weight/appetite changes
- recurrent thoughts of suicide/death
on the geriatric depression scale, a score >5 points is suggestive of what?
depression
- warrants a follow-up comprehensive assessment
on the geriatric depression scale, a score >10 points is almost ALWAYS suggestive of what?
depression
what are the ddx of depression in the elderly?
- dementia
- normal bereavement
- adjustment disorder w/depressed mood
what medication interactions should be avoided in treating depression in the elderly?
- *AVOID DIPHENHYDRAMINE**
- *monitor for SEROTONIN SYNDROME when giving SSRI**
- may increase falls, GI effects, insomnia, agitation
how do you differentiate between dementia and depression in the elderly?
- *MENTAL STATUS EXAM**
- depressed pt: will often have INSIGHT, though little effort
- dementia pt: little/no insight
what is the tx for depression in the elderly?
- meds
- psychotherapy
- CBT (replace negative perspective/irrational thinking with rational/positive cognition)
- exercise
- diet
- lifestyle modification when possible
what is the initial antidepressant trial period for the elderly?
4-6 weeks
what medication used to treat depression in the elderly has a side effect of increasing appetite?
mirtazapine
what medication used to treat depression in the elderly promotes sleep, but should be used in low doses due to orthostatic effects in the elderly?
trazodone
what medication used to treat depression in the elderly may cause seizures?
bupropion
what medication used to treat depression should be used with caution in cardiac patients?
TCA’s
