Geriatric Psychiatry

• Usually acute and fluctuating
• Altered state of consciousness (reduced awareness of and ability to respond to the environment)
• Cognitive deficits in attention, concentration, thinking, memory, and goal-directed behavior are almost always present

Features of Delirium

• May be accompanied by
  • Hallucinations
  • Illusions
  • Emotional lability
  • Alterations in the sleep-wake cycle
  • Psychomotor slowing or hyperactivity
• Usually abrupt

Causes of Delirium

• Infectious
• Withdrawal
• Acute metabolic
• Trauma
• CNS Pathology
• Deficiencies
• Endocrinopathies
• Acute vascular
• Toxins/drugs
  • Heavy Metals
• Hypoxia
• Note that prescribed medicines may cause delirium e.g. benzodiazepines and anticholinergics

Treatment of Delirium

• Look for underlying cause - "always be suspicious"
• Close supervision, especially by family
• Reorient frequently
• Adequate lighting
• Use consistent personnel
• Try not to use restraints, as it can worsen confusion
• Medication only if behavioral attempts fail
• Avoid polypharmacy
• Low dose neuroleptic is treatment of choice, unless the delirium is due to withdrawal
• If due to withdrawal, use a short-acting benzodiazepine

• Differs from delirium and dementia because the major problem is short-term memory only.
• Impairment may be due to hemorrhage in mamillary bodies, or degenerative changes.
• Most common cause is alcoholism.

• Transient inability to learn new information
• Variable retrograde amnesia that "shrinks" following recovery
• Level of consciousness and personal identity intact
• Due to transient vascular insufficiency of the temporal lobe, or medicines, tumors, arrhythmias, cerebral embolism
• Also have risk problems for stroke

• Follows a history of head trauma resulting in cerebral concussion
• Posttraumatic amnesia
• Less commonly, post-traumatic seizures
• Impairment in attention, concentration, performing simultaneous cognitive tasks, and in learning new information, or recalling information shortly after the injury
• Not a form of dementia

• 5% have severe dementia, and 15% mild dementia in those over 65
• Over 80, 20% have severe dementia
• Most common causes: Alzheimer's disease, vascular dementia, alcoholism, and a combination of these 3
• Risk factors are age, family history, and female sex

Noncognitive Symptoms Accompanying Dementia (BPSD)

• Mood disorders - dementia and depressive symptoms can coexist and the depression responds to treatment
• Pathological laughter and crying occurs
• Irritability and explosiveness
• Also psychotic symptoms and disorganized behaviors

Other Noncognitive Symptoms in Dementia

• Excessive emotional outbursts that occur after task failure are "catastrophic reactions" and can be avoided by educating family members to avoid confrontation
• Delusions or hallucinations occur during the course of dementias in nearly 75%

Behavior Problems in Dementia (BPSD)

• Agitation, restlessness, wandering, violence, shouting
• Social and sexual disinhibition, impulsiveness
• Sleep disturbances

Changes in Dementia

• Cognition, memory, language
• Personality change
• Abstract thinking
• Aphasias
• Visuospatial functioning
• However, level of awareness and alertness usually intact in early stages (differentiates dementia from delirium)
• Chronic versus acute

"MA" Mnemonic for Dementia

• Memory impairment; and one of the following four items:
  • Apraxia (impairment in performing tasks or movement)
  • Aphasia (impairment of linguistic capabilities)
  • Agnosia (inability to understand objects or people)
  • Abstraction and other executive functioning
• Plus:
• Absence of clouding of consciousness
• Ability to function is impaired

Types of Common Dementias

• Alzheimer - the commonest
• Vascular - second commonest
• HIV (AID) related dementia
• Dementia due to Parkinson's disease

Dementia and Treatable Conditions

• 10-15% from:
  • Heart disease, renal disease, and congestive heart failure
  • Endocrine disorder, vitamin deficiency, medication misuse
  • Primary mental disorders

Dementia of the Alzheimer's Type (DAT)

• 50-60% of patients with dementia
• 5% of those who reach 65 have DAT
• 15-25% of those 85 or older
• More common in women
• Occupies 50% of all NH beds

DAT:

• General sequence is memory, language, then visuospatial functions
• Death occurs in about 7 yrs
• On autopsy: neurofibrillary tangles and neuritic plaques with an amyloid core and deposition of amyloid in blood vessels
• Involves cholinergic system arising in basal forebrain, nucleus basalis of Meynert - reductions in brain acetylcholine

Vascular Dementia

• Second most common type
• Can reduce known risk factors: hypertension, diabetes, cigarette smoking, and arrhythmias

Dementia due to Parkinson's Disease

• Motor dysfunction, frontal lobe symptoms, and memory deficit
• Nearly 1/2 are depressed, and depression is most common mental disturbance in Parkinson's
• Increased risk for anxiety
• Levodopa, amantadine, and bromocriptine can cause psychosis and delirium

HIV (AIDS)-Related Dementia

• Involvement of CNS is a primary symptom of the illness and may occur before signs of systemic infection
• In later stages may be result of fungal, parasitic, viral, or neoplastic disease
• Initial infection involves the brain - headache, bells palsy, seizures, flu symptoms, or aseptic meningitis
• Later stages may show abnormal reflexes

Diagnostic Evaluation of Dementia

• B12 and folate
• VDRL
• CT/MRI
• EEG is sensitive for delirium
• Consent and counseling for HIV

Treatment of Behavior Problems

• Antipsychotics should not be first choice, unless the patient is psychotic and should be on a short-term basis
• Consider the likelihood of depression and anxiety first or pain and environmental discomfort
• Consider using behavioral methods if at all possible

Social Recommendations

• Refer to Alzheimer's group or other support groups
• Continue preventive care - vision, dental, etc.
• Consider caregiver stress

Drug Treatment for DAT

• Most current ones affect acetylcholine (cholinesterase inhibitors)
• Donepezil
• Memantine
• Rivastigmine
• Galantamine
• Early intervention may prevent or slow decline

• 15% of all older adult community residents and nursing home patients
• Accounts for 50% of older adult admissions to a psychiatric facility
• Age is not a risk factor, but widowhood and chronic medical illness are

Depression:

• May have more somatic complaints such as decreased energy, sleep problems, pain, weakness, GI disturbances
• Increases use of primary care medical resources
• For those with a medical condition, depressive symptoms significantly reduce survival
• Increases risk of suicide

Depression is the most frequent cause of emotional suffering in later life and frequently diminishes quality of life.

• A key feature of depression in later life is COMORBIDITY, e.g., with physical illness such as stroke, myocardial infarcts, diabetes, and cognitive disorders (possibly bi-directional causality)

Depression in Medical Illness

• Medicines or the medical illness may cause depression
• Rule out medical causes
• Use psychological symptoms such as hopelessness, worthlessness, guilt
• Pseudodementia occurs in about 15% of depressed older patients, and 25 to 50% of patients with dementia are depressed

Depression in Older Adults

• May have delusions which are usually persecutory or hypochondriacal in nature
• Need treatment with both an antidepressant and an antipsychotic
• ECT may be treatment of choice

Similar across lifespan but there may be some differences. Among older adults:

• Psychomotor disturbances more prominent (either agitation or retardation)
• Higher levels of melancholia (symptoms of non-interactiveness, psychological motor retardation or agitation, weight loss)
• Tendency to talk more about bodily symptoms
• Loss of interest is more common
• Social withdrawal is more common
• Irritability is more common
• Somatization (emotional issues expressed through bodily complaints) is more common

Bereavement

• Normal grief starts with shock, proceeds to preoccupation, then to resolution
• May be prolonged in elderly, but consider major depression if there is marked psychomotor retardation, lasts over 2 months, marked impairment, or if suicidal ideation

• Episodes persist into old age
• Do organic workup if onset is over 65
• Usually more irritable than euphoric, and paranoid rather than grandiose
• May have dysphoric mania, with pressured speech, flight of ideas, and hyperactivity, but thought content is morbid and pessimistic

Treatment of Bipolar

• Lithium is an effective treatment, but decreased renal clearance and neurotoxic effects may be more common
• Valproic acid is also helpful for behavioral disturbances
• They can be treated like the adults on the newer medications but doses are started lower and titration upward slower until clinical response

• Usually before 45, but there is a late onset type beginning after age 65
• More likely in women
• Paranoid type more common
• Psychopathology less marked with age
• Residual type occurs in 30% of those affected: Emotional blunting, social withdrawal, eccentric behavior, and illogical thinking predominate
• Outcome is said to be better

• Onset between 40 and 55
• Persecutory or somatic delusions most common
• In one study of people older than 65, 4% had pervasive persecutory ideation
• May be precipitated by stress, loss, social isolation, visual impairment, deafness, immigrant status

• Very common in elderly
• May occur first time after age 60, but not usually
• Most common are phobias, especially agoraphobia
• Elderly more likely to use anxiolytics
• May be due to medical causes or depression

• 20% of nursing home patients have alcohol dependence
• Sudden onset delirium in hospitalized patients usually from withdrawal
• Consider in patients with GI problems
• May misuse OTC
• 35% use analgesics, and 30% use laxatives

Alcohol Metabolism

• Brain more sensitive as ages
• Due to changes in metabolism, a given amount may produce a higher blood alcohol level than in a younger individual
• May worsen normal changes in sleep and sexual functioning
• Interacts with other medicines

Alcohol Detoxification

• Use lorazepam and oxazepam if needed for detox in elderly because of rapid metabolism