Geriatric Neropsychiatric Assessment Seyed Kazem Malakouti, MD Geriatric Medicine Department Iran...

Geriatric Neropsychiatric Assessment

Seyed Kazem Malakouti, MDGeriatric Medicine Department

Iran University of Medical Sciences

Seyed Kazem Malakouti, MD

Element of clinical interview

• Gestation and birth history• Development of milestones• Handedness• Genetic history of the parents and sibling• School history: academic and disciplinary• History of violence or criminal behavior• history of head injury• Psychiatric history• Substance abuse history• Behavioral and cognitive baseline• Occupational history• Medical and surgical history• Medication regimen• Review of systems• Survey of vegetative functions• Assessment of activities of daily living• History of recent changes in behavior and cognition


childhood

• ADHD: it is not known whether residual ADHD extends into senescence

» Difficulty being organized» Low frustration tolerance» Impulsivity» Restlessness» Mood swings

• Gilles de la tourette’s syndrome


Adolescence, risk-taking behaviorAdulthood

• Substance abuse• Cocaine: precipitate stroke• LSD: visual hallucination• MPTP: parkinson’s• Alcohol: dementia, Wernicke-Korsakoff syndrome

• Reckless driving

• Head trauma


Adulthood

Neurological problems that have particular relevance to the neuropsychiatric evaluation– Brain tumors– Huntington’s disease– Lupus Erythematosus– Multiple sclerosis– Nicotine dependence– Hypertension– Diabetes– hypercholesterolemia


senescence

• Cohesive sense of integrity• Parkinson’s disease• Alzheimer’s • Frontotemporal dementia• Lewy body dementia• NPH• Subdural hematoma


Cognitive domain assessment in geriatrics

• Attention• Arousal• Concentration

• Memory• Learning• Recall• Recognition

• Language• Spontaneous output, fluency• Comprehension• Repetition• Naming

• Visuospatial skills• Calculation• Praxis• Executive skills

• Drive• Programming• Response control• synthesis


Social history

• Vocation & education• Habits & life style• Exercise• Sleep• Sexual activity• recreation


Variables Males femalesSexual fantasizing at least once 109 (54.8%) 30 (15.7%)

Feeling desire to masturbate at least one time 64 (32.2%) 17 (8.9%)

Having desire to intercourse at least one time 160(80.4%) 48 (25.1%)

Having at least one sexual night dreams 101(50.8%) 25 (13.1%)

Masturbating for at least once 44 (22.1%) 14 (7.3%)

Feeling pleasure in most of sexual activities 118 (59.3%) 16 (8.4%)

Usually or mostly having Difficulty in achieving orgasm

69 (34.7%) -

Experiencing at least one orgasm during sexual intercourse

146 (73.4%) 33 (17.3%)

Difficulty or inability to communicate sexual desire with the partner

58 (29.1%) -

Inability to experience partial of full erection 44 (22.1%) -

Not experiencing firm enough erection for penetration 43 (22.6%) -

Premature ejaculation 26 (13.1%) -

Retarded ejaculation 16 (8.0%) -

No ejaculation 18 (9.0%) -

sexual profile of the study subjects during the preceding month


Variables Medical diseases(Odds ratio)

Using medication(Odds ratio)

GHQ(Odds ratio)

Sexual fantasizing at least once

1.29 (0.70-2.36) 1.34 (0.73-2.45) 1.90 (1.05-3.44)

Feeling desire to masturbate at least one time

1.71 (0.92-3.17) 1.82 (0.98-3.38) 0.87 (0.47-1.62)

Having desire to intercourse at least one time

1.07 (0.50-2.31) 1.10 (0.51-2.37) 2.19 (1.05-4.56)

Having at least one sexual night dreams

0.93 (0.51-1.69) 0.97 (0.54-1.77) 1.03 (0.57-1.85)

Masturbating for at least once 1.47 (0.73-2.93) 1.42 (0.71-2.84) 0.92 (0.46-1.83)

Feeling pleasure in most of sexual activities

1.18 (0.65-2.16) 1.23 (0.67-2.24) 2.14 (1.18-3.87)

Experiencing at least one orgasm during sexual intercourse

1.51 (0.71-3.19) 1.35 (0.65-2.81) 1.47 (0.73-2.94)

Difficulty or inability to communicate sexual desire with the partner

0.88 (0.43-1.60) 0.80 (0.41-1.54) 0.40 (0.21-0.75)

Inability to experience partial of full erection

1.05 (0.52-2.14) 0.95 (0.74-1.92) 2.06 (1.04-4.07)

analysis of association of variables with sexual function in male subjects


Variable Male †N (%)

Female†N (%)

p.value

Usually taken to fall sleep (minute) 5 to 20 21 to 30 31 to 60 60 +Usually gotten up in the morning 1.30 to 3.59 4 to 5.59 6 to 7.59 8 to 8.59 9 to 10.59Hours of actual sleep at night 2 to 5.30 6 to 9 9.30 +

117 (58.8) 26 (13.1) 15 (7.5) 41 (20.6)

20 (11.9) 78 (46.4) 58 (35.5) 5 (3.0) 7 (4.2) 59 (36.2)102 (62.6) 2 (1.2)

105 (55.0) 23 (12.0) 31 (16.2) 32 (16.8)

14 (7.8) 61 (34.1) 80 (44.7) 16 (8.9) 8 (4.5) 72 (40.9)102 (58.0) 2 (1.1)

0.06

0.01

NS


Variable Male (N,%) † Female (n, %)† P.value

Legs twitching or jerking No Less than once a week More than once a weekcannot get to sleep within 30 minute No Less than once a week More than once a week Wake up in the middle of the night or early morning No Less than once a week More than once a weekHave to get up to use the bathroom No Less than once a week More than once a weekCannot breathe comfortably No Less than once a week More than once a week

Cough or snore loudly No Less than once a week More than once a week

145 (79.7) 14 (7.7) 23 (12.6)

101 (53.4) 44 (23.3) 44 (23.3)

52 (29.4) 49 (22.6) 85 (48.0)

64 (35.6) 37 (20.6) 79 (43.9)

151 (80.3) 19 (10.1) 18 (9.6)

117 (66.6) 22 (11.6) 51 (26.8)

152 (90.4) 9 (5.4) 7 (4.2) 59 (31.4) 49 (26.1) 80 (42.5)

31 (17.0) 47 (25.8)104 (57.2)

42 (23.2) 50 (27.6) 89 (49.1)

151 (81.6) 14 (7.6) 19 (10.2)

114 (62.3) 27 (14.8) 41 (22.4)

0.01

0.001

0.01

0.07

NS

NS


Variable P.value Odds ratio 95% CI*

Sex (male=reference) 0.02 2.52 1.14-5.56

Marital

(married=reference)

0.36 0.66 0.27-1.5

Chronic disease

(no=reference)

0.19 1.52 0.80-2.86

GHQ (<10=reference) 0.005 4.14 1.93-8.87

Factors independently related to sleep quality by Pittsburg cutoff point of 5.0*Confidence interval


Geriatric Assessment Tools: Dementia and Delirium

• Clock Drawing Test

• Confusion Assessment Method

• Short Portable Mental Status Questionnaire

• Time and Change Test


Cognitive assessment battery (CAB)

• Symbol Digit Modalities Test (speed & attention)

• Text recall (learning and episodic memory)

• Clox test (Visuospatial functions)• Token test and naming 30 items (language)

• Stroop test (executive function)


Arousal, alertness, level of consciousness: the patient awareness of stimuli

• Fully alert• Lethargy• Obtundation• Stupor• Semi coma• Deep coma


Glasgow coma scaleto monitor arousal state

• Eye opening (E)• Spontaneous 4• To loud voice 3• To pain 2• Nil 1

• Best motor response (M)• Obeys 6• Localizes 5• Withdraws (flexion) 4• Abnormal flexion posturing 3• Extension posturing 2• Nil 1

• Verbal response (V)• Oriented 5• Confused, disoriented 4• Inappropriate words 3• Incomprehensible sounds 2• Nil 1


Geriatric neuropsychiatric assessment in GM

1. cognition1. MMSE

2. Mood1. GDS

3. substance


• GDS-15, CUT OFF SCORE= 7/8

• GDS-11, CUT OFF SCORE=6


concentration

• Digit span: 5 digit

• Reverse digit span: 3 digit

• Serial 7s• Reverse sequence: week, year…• Continuous performance: A’s letters, 30 second

• Reticular activating system• Originated from pons and midbrain• Thalamus• Project to cortex and subcortical areas• Frontal, limbic system


Memory8 – 10 words

• Learning: word list test (immediate, working memory

• Retaining: (recognition) with clue

• Recall: (retrieve) w/o clue

• Verbal memory: word list, left temporal

• Visuospatial memory: right temporal, hidden object in the room.

• Limbic system• Medial temporal lobe• Fornix• Dorsomedial thalamic nuclei• Mammillary body


Language, aphasia

Aphasia type

Writing Repetition Fluency Comprehension

Naming Reading Cerebral lesion

Receptive - - + - + - - I

Conduction - - + + + - -+ III

Expressive - - - + + - -+ II

Global - - - - - - I,II,III

PrecentralTranscortical sensory

- + + - - - A

Anomic - + + + - + - B

Transcortical motor

- + - + - -+ C

Isolation - + - - - -+ A,B,C


Anatomic regions of aphasia


Visuospatial impairment

• Getting lost in familiar places• Difficulty estimating distances• Difficulty orienting objects to complete a

task• Drawing a picture


visuospatial drawing


Executive function• Drive

» Spontaneous» Motivation» Sustained performance

• Programming» Recognizing pattern» Time sequence» Rhythmic pattern

• Response control» Divided attention» Inhibition of incorrect response» Planning» Mental flexibility: changing strategy» Use feedback» Resist stimulus bound behavior

• Synthesis» Abstraction: similarities, proverb interpretation» Monitoring cognitive performance» anticipation


Programming exam

• Alternative program

• Hand sequence: slap, fist, cut


Response control

• Divided attention: 1-A, 2-B, 3-C, …• Verbal fluency: 12 animal or 10 F words in 1 minute initiation, strategy,

perseveration

• Reciprocal programs (go/no-go). Changing mind, stimulus inhibition

• Tap1-tap2, tap 2-tap1• Tap 1 –tap 2, tap2-tap 0

• Multiple loops• Clock drawing • Stimulus boundedness: put the clock hands. 11:10, brown word.

• Imitation behavior


synthesis

• Similarities

• Proverbs

• monitoring


Assessment of activities of daily living

• Bathing• Toileting• Eating• Transporting• Dressing

• Cooking• Paying bills• Household chores• Shopping• Driving• Telephone calling


Recent cognitive changes

Major neuropsychiatric syndroms affects cognitive conditions

– Age-related problem– Prefrontal system dysfunction– Generalized cortical systems disorders– Focal cortical dementia syndromes– Subcortical systems disorders


cognition• Validation of a Mini-Mental State Examination (MMSE) for the Persian

population: a pilot study.• Ansari NN, Naghdi S, Hasson S, Valizadeh L, Jalaie S.• Faculty of Rehabilitation, Tehran University of Medical Sciences, Enghelab Ave.,

Pitch-e-shemiran, Tehran, Iran. [email protected]• Abstract• The objective of the study was to develop and validate a translated and culturally adapted Mini-

Mental State Examination (MMSE) for the Persian-speaking population. The MMSE was translated into Persian. Two groups of neurologically intact subjects (n = 100) and subjects with Alzheimer's disease (n = 13) were studied. The difference between groups on the mean total scores of the Persian MMSE was statistically significant (control = 28.62 +/- 2.09; subjects with Alzheimer's disease = 11.77 +/- 5.66; p < .001). The cutoff score of 23 was the best cutoff score for our subjects with a sensitivity and specificity of 98% and 100%, respectively. There was a significant correlation between the Persian MMSE score and the level of education (r = .46) and with age (r = -.77). There was no significant correlation between the Persian MMSE and gender. The Persian MMSE was found to be valid for discrimination of cognitive impairment in the Persian-speaking community.


http://www.ncbi.nlm.nih.gov/pubmed?term=%22Ansari%20NN%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Naghdi%20S%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Hasson%20S%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Valizadeh%20L%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Jalaie%20S%22%5BAuthor%5D

عملکردی مراحل Functional Assessment Stagingارزیابیمانند ( فراموشاست بیماری جز به دیگری موضوع بیمار، برای مشکل ایجاد علت که کنید می فکر قسمت هر در اگر

. " بنویسید .....) " مربوطه قسمت کنار را عامل آن و بزنید عالمت را خیر گزنیه لطفا و ارتریت فلح،

کد قسمت عنوان بله این قبل وقت چند ازداشته وجود مشکل

است؟

خیر

نرمال 1 در که وی خانواده اعضای نظر از چه و بیمار نظر از چهندارد مشکلی هیچ او دارند، قرار بیمار زندگی جریان

Pre-MCIMMSE=28-29

2 در و کند می شکایت اشیاء محل کردن فراموش از بیماردارد مشکلی خود شغلی وظایف ذهنی -انجام احساس

دارد وجود بیمار در فراموشی

MCIMMSE=24-28

3 مشخص بیمار همکاران برای شغلی عملکرد در اختالل . ظرفیت دارد مشکل جدید های مکان به رفتن در و است

. کرده پیدا تقلیل کارها سازماندهی های

MILD DEMENTIAMMSE=19-20

4 است یافته کاهش پیچیده امور انجام در بیمار تواناییمشکل( صیحیح طور به مالی، امور به رسیدگی مانند

( مغازه از کردن خرید غذا، کردن حاضر دارد،

5 نیاز مناسبتها و فصل با متناسب لباس انتهاب برای بیماردارد راهنمایی به

6a دکمه، بستن یا و صحیح طور به کفش و لباس پوشید دردارد مشکل حیحی طور به بند کمر و کفش بند

6b کردن حمام برای کند، حمام درستی به تواند نمیترسد می رفتن حمام از یا و کند می مقاومت

6c تواند نمی کند، استفاده درستی به توالیت از تواند نمیدارد نگه تمیز را توانلت یا کند تمیز درمستی به را خود

6d ادار اختیاری بی گذشته های هفته طی در اغلب بیماراست داشته

6e داشته دفع در اختیاری بی گذشته های هفته طی در اغلباست

7a تا ( یک است شده محدود کردن صحبت در بیمار توانایی( روز در کلمه شش

7b کم شدیدا یا یافته کاهش بیمار فهم قابل لغات میزان . تکارکند دائما در کلماتی است ممکن است شدشده

7c برود راه افراد کمک بدون تواند نمی بیمار

7d بنشیند مستقل بصورت تواند نمی

7e بزند لبخند تواند نمی

7f دارد نگه باال را سرش نمیتواند


تشخیص Stage عالیم

دمانس فقدانStage 1: No Cognitive Decline

از ندارد، فراموشی دارد، طبیعی عملکرد بیمار. است طبیعی روانی نظر

دمانس فقدانStage 2: = PRE MCI

مانند است، مشاهده قابل طبیعی فراموشیبرای عالیم این اشیاء، گذاشتن جابچا اسامی،

نیست ملموس پزشک و خانواده اعضاء

دمانس فقدانStage 3: MCI

احتمال کاهشعملکرد؛ فکر، تمرکز در اشکاللغات کردن پیدا در اشکال مسیر، کردن گم

شود، می اختالل متوجه خانواده عضو صیحیح،مرحله دمانسظاهر 7این شروع از قبل سال

. شود می

دمانس اول مرحلهStage 4: = MILD DEMENTIA

اخیر، کاهشحافظه فکر، تمرکز در اشکالدر شدن جابجا انجام و مالی مدیریت در اختالل

کارهای انجام در اختالل شهر، در تنهایی به شهرو دوست از انزوا اختالل، این انکار و پیجیده

توسط شناختی واضح اختالل کشف خانواده،مرحله این متوسط مدت .2پزشک، سال

دمانس مرحله MILD خفیف

Stage 5: Mild to moderate dementia

کارهای در کمک به نیاز حافظه؛ بارز اختالل ( ، پوشیدن لباس کردن، حمام مانند روزمره

در اختالل ادرس، و تلفن شماره گفتن در اختالل . زمان مدت ساعت و روز ساعت 1.5شناسایی

متوسط مرحلهدمانس

Stage 6: moderate dementia

خود روزمره کارهای انجام برای زیادی کمکمیدهد، دست از را خود خانواده اعضاء نام دارد،

از اعداد شمردن در اختالل 10اختالل پایین، بهاختالل هذیان، بروز مدفوع، یا ادرار کنترلو اضطراب وسواسی، رفتارهای شخصیت،

دوره. متوسط .2.5بیقراری سال

نهایی مرحلهStage 7: severe dementia

ارتباط برقراری با قادر نیست، تکلم به قادربه نیاز روزمره کارهای از بسیاری در نیست،

مانند هایی مهارت حرکت، در اختالل دارد، کمک . دوره متوسط رفتن . 2.5راه سال


Prefrontal system dysfunction

Dorsal convexity dysexecutive sydrome• Cognitive Flexibility• Ordering recent events• Planning ahead• Regulating actions based on environmental stimuli• Learning from experience

• Concrete• Perseverative• Impairment in reasoning and flexibility• Pay bills on time• Organize daily activities• Keep a tidy house• Cook balance meals


Orbitofrontal disinhibition syndrome, Mania, witzelsucht

• Connection with limbic

• Behavioral response to various environmental stimuli and anticipate the consequences

• Poor impulse control• Aggressive outburst• Jocularity

• Lack interpersonal sensitivity


Mesial frontal apathetic syndrome

• Balance between the cingulum and supplementary motor area

• Dysemotional sydrome ranging from apathy to akinetic mutism

• Neurovegetative of depression• Exist ideas for activity but no motivation• Perceived as a willful indifference


Generalized cortical systems disorders

• Alzheimer’s disease• Frontotemporal dementia• Lewy body dementia


focal cortical dementia syndromes

• Progressive frontal lobe syndromes• Progressive aphasia

• motor aphasia, naming, mixed

• Progressive perceptual motor syndromes• progressive bi-temporal syndrome


Fluent aphasia

• Wernike’s aphasia• Nonsensible speech• Not able to comprehend others speech• Damage to unimodal association cortex in

area 22• Superior temporal gyrus


Non-fluent aphasia

• Broca’s aphasia• Agrammatic• Telegraphic speech• Difficulty using the words: but, if, or, to ,

from


Progressive perceptual-motor syndromes

Visual syndromes• Occipitoparietal network• Occipitotemporal network• Asimultagnosia

• Able to describe the details• unable to integrate entirely • Visual disorientation

• Balint’s syndrome• Asimultagnosia• Optic apraxia• Optic ataxia

• Visual agnosia (bilateral occipitotemporal)• Inability to name the objects• prosopagnosia

Motor syndromes First one(frontoparietal)

• Hemispasticity• Hemiparesis• Hemisensoryimpairment

» Astereognosis» agraphesthesia, myoclonus

• Second one• Mixed apraxia• Limb apraxia: combing, brushing• Gestural apraxia: imitating• Constructional apraxia: drawing• Writing apraxia


Progressive bitemporal syndromes

• Progressive amnesia• Progressive prosopagnosia• Kluver-Bucy syndrome

– Bilateral amygdala destruction– Hyperorality– Emotional placidity– Hypersexuality– Compulsive exploration of the environment– Psychic blindness


Subcortical system disorders5 neural loop (Alexander, Crutcher-1990

• Striatum

• Globus pallidus

• Dorsomedial thalamus

• Supplementary motor area

• Frontal eye fields

• Dorsolateral prefrontal (cognition)

• Orbitofrontal (social comportment)

• Anterior cingulate (motivation)


Movement manifestation of BG dysfunction

• Tremor• Agitation• Akatisia• Shuffling gait• Bland expression• Striatal hand: ulnar deviation, flexion of fingers at the metacarpal phalangeal joints• Pill rolling tremor• Loss of agility• Involuntary movements• chorea


Localizing neuropsychiatric findingsbiparietal

History Mental status Sensorimotor

•Spatial disorientation •Asimultagnosia •Inferior quadrantanopia•Ocular apraxia•Optic ataxia


Cognitive manifestation of BG dysfunction

• Cognitive problem: mental torpor, cognitive dilapidation, apathy, depression. Learning, speech and language, praxis, calculation are intact.

• Retrieved material impaired. Required number of prompt indicate the degree of impairement.

• Impersistence and slowed completion of task

• Huntington’s disease

• Parkinson’s disease

• Lacunaire syndrome

• Tumors

• Progressive supranuclear palsy

• Multisystem atrophy

• Wilson’s disease

• Corticobasal degeneration


Localizing neuropsychiatric findingsfrontal

History

DisorganizationDisinhibitionapathy

Mental status

High-level attention deficitLuria motor sequences deficitGo/no-go task deficitDecrease in verbal fluencyPerseverationLosses of setConfabulationWitzelsuchtdilapidation

Sensorimotor

Gait apraxiaMitgehenIpsilateral gaze preferencePrimitive reflexes


Localizing neuropsychiatric findingsBG

History•Motor impairment•Social withdrawal•Cognitive impairement

Mental status•Dilapidation•Mental torpor•Retrieval deficit

sensorimotor

•Hypokinesia•Masked facies•Stooped posture•Festinating gait•abnormal movement•Muscular rigidity•Cogwheeling•Gegenhalten/negativism•Downward gaze palsy


Localizing neuropsychiatric findingsparietal

History Mental status Sensorimotor

•Spatial disorientation•Inconvenient view test•Butters test•Benton test (spatial memory)

•Localizing things (where)•Dyslexia•Visual & touching disharmony

•hemiagnosia•Anosognosia (rt)•Autotopagnosia (lt)•Simultaneous extinction (rt)•Asteregnosia•Rt & lt disorientation (lt)•Acalculia (lt)•Agraphestesia •Agraphia (lt)•Apraxia, dressing•Constructional apraxia (rt)•Painting problem

•Inferior quadrantanopia•Ocular apraxia•Optic ataxia•Sensory deficit (opposite)


Localizing neuropsychiatric findingsright hemisphere

History•Confusion state•Delusions•Spatial disorientation•Neglect•Denial of deficit•Dressing difficulties•Left-sided motor impairment

Mental status•Dysprosodia•Visuoconstructive deficit•Spatial analysis deficit•Left hemineglect•Visual memory deficit•Dressing apraxia

sensorimotor•Left hypertonus•Left babinsky sign•Left astereognosis•Left dysgraphesthesia•Double simultaneous extinction•Posturing of left hand/arm with tandem gait•Left pronator drift•left quadrantanopia


Localizing neuropsychiatric findingsleft hemisphere

History•Right-sided motor impairment•Language impairment•Math impairment

Mental status•Ideomotor apraxia•Dysphasia•Dyslexia•Dyscalculia•Dysgraphia•Right/left disorientation•Finger agnosia

sensorimotor•Right hypertonus•Right babinski sign•Right asterognosis•Right dysgraphestesia•Posturing of right hand/arm with tandem gait•Right pronator drift•Right quadrantanopia


Localizing neuropsychiatric findingsbitemporal

History

•Placidity•Hyperorality•Hypersexuality

Mental status

•Amnesia•Agnosia•Visual: right•Auditory: left•Anomia•Prosopagnosia

Sensorimotor

•Superior quadrantanopia


Geriatric Neropsychiatric Assessment Seyed Kazem Malakouti, MD Geriatric Medicine Department Iran...

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Transcript of Geriatric Neropsychiatric Assessment Seyed Kazem Malakouti, MD Geriatric Medicine Department Iran...