delirium, dementia, depression and competency common issues in geriatric and consultation psychiatry...


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  • DELIRIUM, DEMENTIA, DEPRESSION AND COMPETENCY COMMON ISSUES IN GERIATRIC AND CONSULTATION PSYCHIATRY Paul B. Rosenberg, M.D. Geriatric and Consultation-Liaison Psychiatry Department of Veterans Affairs Medical Center Washington, DC
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  • DELRYUM Bilin ve dikkatte bozulma Bilisel ilevlerde (bellek, dil, ynelim) veya algda bozulma Hzla geliir ve dalgal seyreder Tbbi bir durum nedeniyle olur
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  • Deliryumun Klinik zellikleri Bilisel bozulma Tbbi hastalktr Akut/ani balar Ynelim bozulur Varsanlar Sanrlar Grsel-uzamsal bozulma Apraksiler Szck bulmada glk Anlama ve deerlendirmede glk Uykulu (hepatik, remik, ila nedenli) Ajite (alkol yoksunluu)
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  • Deliryumun Eanlamlar Akut konfzyonel durum Toksik-metabolik ansefalopati Organik beyin sendromu ICU psychosis
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  • EPIDEMIOLOGY AND RISK FACTORS Dahiliye servislerinde yatan hastalarn %25inde Elderly Dementia Renal failure Liver failure Immobilization Foley catheter Infected Anticholinergic medications Polypharmacy Narcotics Benzodiazepines
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  • METABOLIC CAUSES Hypernatremia Hypercalcemia Hypo-, hyper-glycemia Hyperosmolar state Uremia (uremic encephalopathy) Liver failure (hepatic encephalopathy)
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  • INFECTIOUS CAUSES Urinary tract infection Pneumonia Sepsis Delirium may be the first sign of infection, predating fever, leukocytosis, CXR findings
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  • MEDICATIONS Anticholinergics (Cogentin, Artane) Psychotropic medications (Thorazine, Mellaril, TCAs, Paxil, benzodiazepines) Lithium toxicity Steroids Narcotics
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  • ANTICHOLINERGIC EFFECT AND DELIRIUM Cholinergic transmission declines with age Cerebral cortex widely innervated by cholinergic neurons in basal forebrain Risk of delirium correlates with serum anticholinergic levels Anticholinergic levels associated with diminished ability to perform ADLs Anticholinergic levels normalize as delirium resolves.
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  • ANTICHOLINERGIC EFFECTS OF MEDICATIONS Usual Cogentin, Artane TCAs Mellaril, Thorazine Paxil Narcotics Antihistamines OTC cold medications Surprising Furosemide Digoxin Theophylline Ranitidine Cimetidine Isordil Nifedipine
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  • CNS CAUSES OF DELIRIUM Alcohol withdrawal (delirium tremens) -- very agitated delirium Barbiturate/benzo withdrawal (rare) Post-ictal Increased intracranial pressure Head trauma Encephalitis/meningitis Vasculitis
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  • DIAGNOSTIC STUDIES IN DELIRIUM Metabolic studies (CBC, Chem-18, TFTs) Urinalysis CXR EEG = diffuse slowing; normal EEG makes delirium less likely CT/MRI to r/o bleed, tumor (coagulopathies, head trauma) LP to r/o infection (febrile, leukocytosis) Fish where the fish are
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  • MANAGEMENT OF DELIRIUM Find the cause(s) Usually multifactorial Look for medication toxicity Re-orient patient Quiet, unstimulating environment Antipsychotic medications for agitation Benzodiazepines often makes delirium worse 1:1 observation/restraints only when needed
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  • DEMENTIA Pathognomic deficit is in short-term recall Deficits in at least three cognitive areas Insidious onset Stable level of consciousness, not fluctuating Major cause of institutionalization in the elderly Current treatment is largely for psychiatric complications, not underlying dementia
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  • COMMON DEMENTIAS Alzheimers disease Vascular dementia AIDS dementia Alcoholic dementia (Korsakoffs) Frontotemporal dementia
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  • PSYCHIATRIC ASPECTS OF DEMENTIA Agitation Wandering Pacing Insomnia Hoarding Catastrophic reactions Capgras syndrome Psychosis Depression Anxiety Agnosia Aphasia Apraxia Deficits in abstract thinking
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  • EVALUATION OF DEMENTIA Interviewer caregiver and patient together and separately Clinical course ADLs, IADLs Premorbid level of function B12 TSH RPR Brain imaging (CT, MRI) EEG/LP only when indicated
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  • PSYCHOSIS IN DEMENTIA Prevalence of hallucinations is about 30% Hallucinations may be selectively associated with more rapid decline in Alzheimers 25% of patients have misperceptions May be due to recall problems or agnosia Delusions are often fixed confabulations May be associated with more rapid neuronal loss Particularly common in Dementia with Lewy Bodies -- fluctuating cognition with recurrent VH that are detailed, contain formed elements. Dementia with Lewy Bodies -- very sensitive to parkinsonian effects of medications Psychosis is a major source of caregiver stress
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  • ALZHEIMERS -- NEUROSCIENCE Amyloid plaques (extraneuronal) Neurofibrillary tangles and tau protein (intraneuronal) Loss of cholinergic innervation (nucleus basalis of Meynert) Cerebral atrophy (nonspeciific) Decreased perfusion and metabolism in temporoparietal cortex and hippocampus Deficits may predate cognitive impairment Abnormal extraneuronal processing of -amyloid precursor protein ( -APP) to 42- a.a. instead of 40-a.a. fragment Familial AD -- single-point mutations in -APP Transgenic mice Presenilins (chromosome 14 and 1) may be -APP secretases Apolipoprotein E4 -- risk factor for sporadic AD. Subtle deficits in younger life - decreased idea density
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  • ALZHEIMERS -- TREATMENT Cholinergic Aricept (donepizil) start 5 mg, increase to 10 mg Modest but consistent effect at all stages of AD No effect on MMSE, but ADLs, memory, attention, and neuropsychiatric symptoms often improve Suggest 3-month trial Exelon (rivastigmine) Reminyl (galantamine) Neuroprotective Antioxidants (Vitamin E, L- Deprenyl) Anti-inflammatories (steroids, NSAIDs) Inhibitors of secretases Vaccines against -amyloid Need to find pre-morbid markers of AD
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  • BEHAVIORAL INTERVENTIONS IN DEMENTIA Calm consistent environment Cuing and reminding Emphasize cognitive strengths Music Light therapy Safe environment for wandering Daytime exercise, minimize naps
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  • OTHER MEDICATIONS IN DEMENTIA Antidepressants -- watch for agitated depression, need caregivers assessment Use benzodiazepines sparingly -- watch for sedation, paradoxical agitation/stimulation Benzos best saved for last except for restless legs/myoclonus Trazodone is good for sleep in demented as well as non- demented patients -- 25 mg q hs Buspirone -- a drug looking for a use
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  • VASCULAR DEMENTIA Risk factors of HTN, diabetes, hyperlipidemia, smoking (same as CVA) Stepwise deterioration Preserved personality Multi- or large single-infarct Lacunar state -- basal ganglia, thalamus, internal capsule Subcortical dementia -- psychomotor slowing Binswangers -- ischemic injury of frontal hemisphere white matter -- preserved visuospatial functions No specific treatment Quit smoking Control BP Platelet inhibition
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  • ALCOHOLIC DEMENTIA Prevalence of 6-25% in elderly alcoholics Often termed Korsakoffs dementia Overlap with AD Associated with peripheral neuropathy Speech functions often preserved Confabulatory Relatively subtle to diagnose Case reports of improvement with cholinesterase inhibitors
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  • FRONTOTEMPORAL DEMENTIA Degeneration of frontal and temporal lobes Apathetic and disinhibited personality changes predate cognitive deficits Executive functions and naming selectively impaired Visuospatial skills preserved These patients are often initially misdiagnosed as depressed, manic, or psychopathic Subtypes include Picks disease, dementia of ALS. Decreased serotonin Decreased metabolism in frontal and temporal lobes Familial type with mutations in tau gene on chromosome 17
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  • WHAT DO CAREGIVERS DO Cognitive supervision IADLs Bathing Dressing Feeding Transfer Monitoring medical condition
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  • WHAT KEEPS CAREGIVERS GOING Love Money Habit Cultural beliefs Spirituality
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  • STRESSES ON CAREGIVERS 24-hour supervision Lack of appreciation Implied or overt criticism Feeling conflicted regarding changes in roles and power relationships Feeling uncared-for Worry about when they need caregiving later on Perseveration and aggression Best laymens resource The 36-hour day, by Peter Rabins
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  • ASSESSMENT OF AGITATION Incidents, episodes, and other euphemisms Tell me the worst part Nature of agitation Wandering Disordered day-night cycle Verbal aggression Physical aggression Perseveration, stimulus-seeking Inappropriate disrobing and sexual advances
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  • COGNITIVE SUPERVISION For many demented patients, the greatest need is to have a non-demented person present Remembering to take medications Remembering to perform time- dependent IADLs (cooking, shopping, bills, home maintenance) Caregiver supplies an intact sense of time passing and short- term recall Spouses often approach subtly and diplomatically, avoiding confrontation regarding cognitive deficits Biggest stresses is perseveration and verbal/physical aggression Adult Day Health Care supplies respite for cognitive supervision
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