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

DELİRYUM

• Bilinç ve dikkatte bozulma

• Bilişsel işlevlerde (bellek, dil, yönelim) veya algıda bozulma

• Hızla gelişir ve dalgalı seyreder

• Tıbbi bir durum nedeniyle olur

Deliryumun Klinik Özellikleri

• Bilişsel bozulma

• Tıbbi hastalıktır

• Akut/ani başlar

• Yönelim bozulur

• Varsanılar

• Sanrılar

• Görsel-uzamsal bozulma

• Apraksiler

• Sözcük bulmada güçlük

• Anlama ve değerlendirmede güçlük

• Uykulu (hepatik, üremik, ilaç nedenli)

• Ajite (alkol yoksunluğu)

Deliryumun Eşanlamları

• Akut konfüzyonel durum

• Toksik-metabolik ansefalopati

• Organik beyin sendromu

• ICU psychosis

EPIDEMIOLOGY AND RISK FACTORS

• Dahiliye servislerinde yatan hastaların %25’inde

• Elderly• Dementia• Renal failure• Liver failure• Immobilization

• Foley catheter

• Infected

• Anticholinergic medications

• Polypharmacy

• Narcotics

• Benzodiazepines

METABOLIC CAUSES

• Hypernatremia

• Hypercalcemia

• Hypo-, hyper-glycemia

• Hyperosmolar state

• Uremia (uremic encephalopathy)

• Liver failure (hepatic encephalopathy)

INFECTIOUS CAUSES

• Urinary tract infection

• Pneumonia

• Sepsis

• Delirium may be the first sign of infection, predating fever, leukocytosis, CXR findings

MEDICATIONS

• Anticholinergics (Cogentin, Artane)

• Psychotropic medications (Thorazine, Mellaril, TCAs, Paxil, benzodiazepines)

• Lithium toxicity

• Steroids

• Narcotics

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.

ANTICHOLINERGIC EFFECTS OF MEDICATIONS

Usual• Cogentin, Artane• TCAs• Mellaril, Thorazine• Paxil• Narcotics• Antihistamines• OTC cold medications

Surprising• Furosemide• Digoxin• Theophylline• Ranitidine• Cimetidine• Isordil• Nifedipine

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

DIAGNOSTIC STUDIES IN DELIRIUM

• Metabolic studies (CBC, Chem-18, TFT’s)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’

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

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

AGING AND DEMENTIA

05

101520253035404550

60-69 70-79 80+ 90+

Incidence (per 1000) Prevalence (%)

COMMON DEMENTIAS

• Alzheimer’s disease

• Vascular dementia

• AIDS dementia

• Alcoholic dementia (Korsakoff’s)

• Frontotemporal dementia

PSYCHIATRIC ASPECTSOF DEMENTIA

• Agitation• Wandering• Pacing• Insomnia• Hoarding• Catastrophic reactions• Capgras’ syndrome

• Psychosis• Depression• Anxiety• Agnosia• Aphasia• Apraxia• Deficits in abstract

thinking

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

PSYCHOSIS IN DEMENTIA

• Prevalence of hallucinations is about 30%

• Hallucinations may be selectively associated with more rapid decline in Alzheimer’s

• 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

ALZHEIMER’S -- 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”

ALZHEIMER’S -- 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

NEW IDEAS IN ALZHEIMER’S TREATMENT

Idea Treatment Comments

Inflammation is part ofAD pathology

NSAIDs, steroids Steroids not safe (ulcers),Vioxx not effective, ?ibuprofen may be best

Elevated homocysteineassociated with AD

Folate May be associated withvascular dementia

Abnormal lipoproteinmetabolism in AD

Statins Statins decrease -amyloidexpression in vitro

Vaccine against -amyloid

Intrathecal or intranasalvaccine

Adverse event (mening-encephalitis)

BEHAVIORAL INTERVENTIONS IN DEMENTIA

• Calm consistent environment

• Cuing and reminding

• Emphasize cognitive strengths

• Music

• Light therapy

• Safe environment for wandering

• Daytime exercise, minimize naps

TREATING AGITATION WITH MEDICATIONS

Haldol 2-3 mg 2-3 mg better than .5-.75 mg forparanoia/suspiciousness, but (+) EPS

Risperdal 1-2 mg Largest study (n=625) , particularlygood for paranoia/suspiciousness, (+)EPS at 2 mg

Olanzapine 5 mg 5 mg better than higher doses, good forparanoia/suspiciousness, minimal sideeffects

Seroquel 25-50mg No published studies but my clinicalexperience has been very (+)

Depakote Level =50-100

Some response for generalizedimpulsivity, but nausea/sedation is aproblem in elderly

OTHER MEDICATIONS IN DEMENTIA

• Antidepressants -- watch for agitated depression, need caregiver’s 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

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

• Binswanger’s -- ischemic injury of frontal hemisphere white matter -- preserved visuospatial functions

• No specific treatment

• Quit smoking

• Control BP

• Platelet inhibition

ALCOHOLIC DEMENTIA

• Prevalence of 6-25% in elderly alcoholics• Often termed Korsakoff’s dementia• Overlap with AD• Associated with peripheral neuropathy• Speech functions often preserved• Confabulatory• Relatively subtle to diagnose• Case reports of improvement with cholinesterase

inhibitors

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 Pick’s disease, dementia of ALS.

• Decreased serotonin

• Decreased metabolism in frontal and temporal lobes

• Familial type with mutations in tau gene on chromosome 17

WHAT DO CAREGIVERS DO

Cognitive supervision IADLs Bathing Dressing Feeding Transfer Monitoring medical condition

WHAT KEEPS CAREGIVERS GOING

LoveMoneyHabitCultural beliefs Spirituality

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 laymen’s resource The 36-hour day, by Peter Rabins

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

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

HOW CAN WE HELP CAREGIVERS

Treat sundowning and agitation – most important pragmatic intervention

Treat depression when you can – but apathy/amotivation is more cognitive than mood and may be hard to treat

Education re dementia – insidious onset, progressive nature, limited efficacy of treatments.

Tell them what they already know (“clarification”) Support groups Anticipatory grief – i.e., the demented person is slowly leaving

us Empathy with anger, fear, anxiety, “wishing him dead”

RESPITE

Home health aides Other family members Adult Day Health Care (“daycare”) Respite Care Nursing home

CAREGIVER BURNOUT

Burn-out often determines the timing of nursing home placement, despite our supposedly explicit (“DelMarva”) criteria

Physical limitations – poor health of caregiver Depression Dementia Financial limitations May need permission to “give up”

THE RELUCTANT CAREGIVER

Loss of freedom Financial constraints Change of role No respite Cultural beliefs Habit Feeling forced into caregiving (and most people are)

COUNTERTRANSFERENCE

The feelings caregivers arouse in us Sympathy Depression Hopelessness Admiration Frustration Anger Suspicion of abuse

DEPRESSION IN THE MEDICALLY ILL

• Fewer than 1/2 of depressed patients are identified and treated in primary care clinics

• Prevalence of 10-15% in medical inpatient and outpatient populations

• Must be distinguished from dementia, delirium, effects of substance abuse

CLINICAL FEATURES OF DEPRESSION

• Depressed mood

• Diminished interest/pleasure (anhedonia)

• Significant weight loss (or gain)

• Insomnia (or hypersomnia)

• Psychomotor retardation or agitation

• Fatigue, loss of energy

• Feelings of worthlessness, guilt

• Diminished concentration, indecisveness

• Suicidal ideation

UNDERDIAGNOSIS OF DEPRESSION

• Emphasis on somatic rather than cognitive/mood complaints

• Belief that depression is a natural reaction to circumstance (countertransference)

• Reluctance to stigmatize patient with psychiatric diagnosis

• Nonspecific symptoms, overlap with medical illness

• Time limitations in primary care

MORBIDITY AND MORTALITY

• Depression signficantly increases morbidity and mortality

• Increased risk of MI, angioplasty, and death following cardiac cath

• Independent risk factor for mortality post-MI• Increased mortality post-CVA• Similar results in dialysis, cancer, and general acute

illness• Possible neuroendocrine mind-body connection

DEPRESSION AS A MEDICAL SYMPTOM/SIGN

• Up to 20% of major depressive episodes turn out to be initial manifestation of medical illness

• Cushing’s

• Addison’s

• Hypo-, hyper-thyroidism

• Huntington’s

• Parkinson’s

• Similar overlap as in delirium

MEDICAL CONSIDERATIONS

• Anorexia -- GI illness, chronic disease, cancer, side effects of chemotherapy.

• Weight loss with normal appetite -- hyperthyroidism, DM, malabsorption.

• Insomnia -- sleep apnea (daytime somnolence), nocturnal myoclonus.

• Early morning awakening is more typical of depression

• Pain

• Delirium

• Anxiety

• Mania

PSYCHOSOCIAL FACTORS

• Death and dying

• Disfigurement

• Disability

• Pain

• Loss of role

• Family conflict

• Lifelong issues

CARDIAC DISEASE

• 20% of patients with CAD or post-MI are depressed

• Risk factors female, prior depression, disabled• Frasure-Smith followed depressed patients post-

MI. • 6-month mortality was 17% for depressed, 3%

non-depressed

CANCER

• About 50% of cancer patients feel depressed

• Uncontrolled pain• Delirium• Brain metastases• Death and dying• Disability and

independence

• Disfigurement• Life cycle issues --

dying young, unfinished business

• Chemotherapy -- steroids, procarbazine, l-asparaginase, ARA-C, vinca alkaloids, interferon

STROKE

• 30-50% depressed, about half with major depression

• More common with left anterior lesions

• Not merely secondary to neurological disability

• Antidepressant treatment is effective

• High-risk period is 1st 2 years post-stroke

• Depression associated with higher morbidity and mortality

• Treatment probably improves rehabilitation

OTHER DISEASES ASSOCIATED WITH

DEPRESSION

• Parkinson’s• Huntington’s• Multiple sclerosis• ALS• Epilepsy• AIDS

• Hypothyroidism• Hyperthyroidism• Hyperparathyroidism• Cushing’s• Chronic fatigue

syndrome

MEDICATIONS CAUSING DEPRESSION

• Reserpine• Methyldopa• Inderal (rare)• High-dose (older) oral

contraceptives• Corticosteroids

• Benzodiazepines• Alcohol• Opioids• Opiate analgesics• Cocaine withdrawal

PSYCHOSOCIAL TREATMENTS

• Supportive psychotherapy

• Listen!• Clarification• Fight stigma• Family issues• Substance abuse rehab

• Optimize level of care• Home health aides• Meals on wheels• Adult Day Health Care• Partial Hospitalization

ANTIDEPRESSANT MEDICATIONS

• Tricyclics• Selective serotonin

reuptake inhibitors (Prozac, Paxil, Zoloft, Celexa)

• Effexor (venlafaxine)• Wellbutrin

(buproprion)

• Remeron (mirtazapine)

• Reboxetine• Ritalin• Thyroid supplement• MAO inhibitors• ECT

CAPACITY

• Cognitive capacity to understand the risks/benefits of decisions

• Patients are competent until proven otherwise

• Psychiatric consultation can help with medical competency to make current medical decisions

• Consent passes to next-of-kin

LEGAL ISSUES IN CAPACITY

• Medical incompetence now included in DC, MD, Virginia statutes; no court order needed.

• Guardianship is legal competency over funds alone or all medical/legal decisions (court order)

• Fiduciary refers to control of VA disability check (VA hearing).

• Payee refers to control of Social Security disability check (Soc. Security hearing).

ELEMENTS OF COMPETENCY

• Capacity to understand risks/benefits (dementia)

• Capacity to appreciate consequences (psychosis)

• Capacity to come to a decision (delirium)

• Capacity to communicate a decision (aphasia, intubation, ENT surgery)

PSYCHOSTIMULANTS

• FDA-approved for ADD, narcolepsy• Not approved for mood disorders• However, widely used for depressed medically ill

patients• Advantages -- well tolerated, rapid onset (1-2

days)• Disadvantages -- not well studied, probably don’t

work in severe mood disorders

PSYCHOSTIMULANTS - II

• Ritalin (methylphenidate) is most popular

• Dexedrine (dextroamphetamine) less so

• Modafinil + several long-acting methylphenidate preparations available

• I prefer short-acting drugs (Ritalin) for safety and close titration

• Used more in medically ill patients than in routine psychiatric care

PSYCHOSTIMULANTS -- IIIDay Breakfast Lunch

1 5 mg None

2 5 mg 5 mg

3 10 mg 5 mg

4 10 mg 10 mg

Watch for TachycardiaInsomnia

AgitationDyskinesia

PSYCHOSTIMULANTS -- IV

• Target symptoms– depressed mood– lack of motivation for therapies (particularly

PT, speech therapy)– anorexia (paradoxical)– attention

SIDE EFFECTS AND CONTRAINDICATIONS

• Tachycardia

• Insomnia

• Anorexia

• Mania

• Contraindications– unstable cardiac condition– history of cocaine or stimulant abuse

NEW USES FOR PSYCHOSTIMULANTS

• Difficult-to-wean ventilator patients

• Fatigue and cognitive slowing in AIDS

• Cognitive impairment and poor rehab effort after liver transplant

• Post-stroke rehabilitation

• Depression in very fragile elderly patients

• Palliative care -- motivation, energy, alertness, improving tolerance to opioids

• Augmentation of antidepressants in major depression