Overview of Dementia, Depression and Schizophrenia in the ElderlyPeter Betz, M.D.

Hierarchical Levels of Human Mental Life

Components of Modes of TreatmentPsychological Life Mental Disorder Initiatives

Personal Chronicle Disruptive Life Stories Rescript

Constitutional Problematic Dispositions GuideDimensions

Motivational Rhythms Behavior Disorders Interrupt

Cerebral Faculties Psychiatric Diseases Remedy

McHugh and Slavney

Dementia is now ‘Neurocognitive Disorder’(NCD)Further Defined as ‘Major’ or ‘Minor’

What’s in a name?

Greater phenomenological correctness – especially with the growing base of literature defining specific aetiologies

Broader term - can include syndromes with only one cognitive domain affected (e.g. ‘amnestic d/o’)

NCD is often the preferred term in the literature and in practice – such as in younger individuals or those with TBI

Dementia is ok to still use if it helps communicate the nature of the illness

Neurocognitive DisorderMajor

Concern of the individual, informant or clinician

‘significant’ cognitive decline – needs IADL assistance

Not due to delirium or another mental disorder

Minor

Concern of the individual, informant or clinician

‘modest’ cognitive decline – preserved IADLs but needs compensatory strategies or accommodation

Not due to delirium or another mental disorder

Alzheimer Disease

Probable – all 3331.0 +

294.10 or 294.11

Possible – not all 3331.9

No coding +/- behavioral disturbance

Insidious onset and gradual progression without plateaus

Impairment in Memory/Learning and one other area

No mixed etiologies

Vascular NCD*Onset temporally related to cerebrovascular event(s)

-or-

Prominent impairment in complex attention (processing speed) or executive function (planning, organizing, sequencing, abstraction)

Hx, PE &/or *Imaging shows evidence of sufficient vascular disease

Probable (290.4) if * is present in your decision tree

Possible (331.9) if no *

No coding +/- behavioral disturbance for either possible or probable

NCD with Lewy Bodies

Core FeaturesFluctuating cognition

Well defined VH

Parkinsonism onset subsequent to cognitive decline

Suggestive FeaturesREM sleep disorder

Severe neuroleptic sensitivity

Probable2+ bullets including at least one core feature

331.82 + 294.10/294.11

Possible1 bullet

331.82

No coding +/- behavioral disturbance

Frontotemporal NCDBehavioral Variant

3 or more bullets:Behavioral disinhibition

Apathy or inertia

Loss of sympathy or empathy

Perseverative, stereotyped or compulsive/ritualistic behavior

Hyperorality and dietary changes

Relative sparing of learning /memory and perceptual-motor function

Language Variant

Prominent decline in one:Form of speech production

Word finding

Object naming

Grammar

Word comprehension

Relative sparing of learning /memory and perceptual-motor function

Frontotemporal NCD

ProbableEvidence of disproportionate frontal &/or temporal involvement

331.19 +

294.10/294.11

Possible331.9

No coding +/- behavioral disturbance

Common Complications of ADAnosognosia (50%)

e.g. unawareness of illness, not “psychological” denial

Apathy (25-50%)inanition, poor persistence

Psychosisdelusions (20%), hallucinations(15%)

Mood Disordersdepression (20%), anxiety (15%)

Agitation / Aggression (50-60%)wandering, restlessness, verbal and physical attacking

Sundowning (25%)

Textbook of Alzheimer Disease and Other Dementias, Weiner & Lipton, 2009

Interventions - Medication

Cholinesterase Inhibitorstacrine, donepezil, rivastigmine, galantamine

Memantine

Vitamin E

Monoamine Oxidase Inhibitorselegeline

Ginko Biloba

Anti-Inflamatory Agents

Estrogen Replacement Therapy

Lipid Lowering Agents

‘Non-Medicinal’ Interventions

Education, support, counseling, community resourcesfor the patient AND the caregiver

Long-Term Planningstate and private resourceswilldurable power of attorneyadvance directive

‘Non-Medicinal’ Interventions

Environmental / Home Safetyremove dangerous objects

Medications, clutter

beware:water temperature, stairs, sharp furniture, glassware, windows, locks, kitchen equipment

assess activities of daily livinginstitutionalizationdriving

FDA Approved Treatments for Complications of AD

Behavioral Management

Environmental vs. Medicationmeds are a last resort

The “4D Approach”adapted from Practical Dementia Careby Rabins, Lyketsos, and Steele

Our Assumptions:

Behavioral dyscontrol can have multiple etiologies.

They can be distinguished from each other.

Identifying the cause can directly lead to treatment strategies.

There is rarely “one-best” approach to address these issues.

Directed “trial and error” is the rule, not the exception.

The “4D Approach”

Define and Describe

Decode

Devise a treatment plan

Determine “does it work?”

Behavioral Management

Environmental vs. Medicationmeds are a last resort

If you chose a medication… Which One? antipsychotics

typical vs. atypical

benzodiazepine

othere.g valproate

CATIE-ADLon S. Schneider et. Al.

Primary outcome – time to discontinuation for any reasongreat “real world” approach to study design

Atypicals were no better “tolerated”

Big media spin after data released:Known higher mortality per FDA.Now evidence of “lack of efficacy.”Therefore, doctors are abusing elderly patients.

Actually, study shows:Placebo stopped more due the lack of benefit than S.E.Atypicals stopped more due to S.E. than lack of benefit.

What you (and your patients) should watch for:

EPS

Dystonia

Akathisia

NMS

TD

Glucose Dyscontrol

Cholesterol Dyscontrol

Delirium

Torsades de pointes

Postural hypotension

Weight gain

Agranulocytosis

Increased risk of all cause death

What About Anticonvulsants?

Initial trials were promising, but…

Most recent studies show far less benefit if not more behavioral discontrol

However, can be helpful in some augmenting strategies or in catastrophic reactions.

What NOT To Use

Benzodiazepine Side Effects

Sedation

Deliriogenic

Behavioral disinhibition

Emotional lability

Cognitive impairment – particularly amnesia

Ataxia

Respiratory depression

Rebound insomnia and anxiety

Withdrawal / Physiologic dependence

Major DepressionDSM-5 – 5 of 9

*Depressed mood (reported or observed)

*Markedly diminished interest /pleasure

>5% weight loss or gain

Insomnia or hypersomnia

Psychomotor slowing or agitation (observable)

Fatigue or loss of energy

Worthlessness or inappropriate guilt (not of being sick)

Poor concentration

Recurrent thoughts of death

Betz – 2 of 3

Dysphoric change in mood sadness, irritability, no ‘yeah’

Impaired self-attitudelow self-esteem, worthlessness, guilt, etc.

Neurovegitative symptom impairment

eating, sleeping, energy, conc., sex drive, etc.

Dysthymia (>2 years)DSM – 5

Depression

2 of 6Poor appetite or overeating

Insomnia or hypersomnia

Low energy or fatigue

Low self-esteem

Poor concentration or difficulty making decisions

Feelings of hopelessness

Betz – 2 of 3

Dysphoric change in mood sadness, irritability, no ‘yeah’

Impaired self-attitudelow self-esteem, worthlessness, guilt, etc.

Neurovegitative symptom impairment

eating, sleeping, energy, conc., sex drive, etc.

Premenstrual Dysphoric Disorder

At least one:Affective liability

Depressed mood, hopelessness

Anxiety, tension

At least one:Apathy

Poor concentration

Anergia, lethargy

Sense of being overwhelmed

Physical symptoms (e.g. bloating, breast tenderness, joint pain etc.)

5 of 9 symptoms present in week before menses

Improves within a few days of onset of menses

Absent (or minimal) the week post menses

My Most Worrisome Issues

Hopelessness

SuicideNIMH

18% of total in those ≥ 65yo (only 13% of pop)6x higher risk if ≥ 80yo

suicidal thoughts in 7% of elderlysuicidal thoughts in 30% of elderly with MDD20% saw physician within 24 hours41% saw physician within 1 week75% saw physician within 1 month

Acute Management:

Antidepressant + psychotherapyAlternate:

Mild – meds alone or psychotherapy alone

Severe – meds alone or ECT

What Antidepressants?

SSRIescitalopram, citalopram, sertraline(avoid paroxetine, fluoxetine, fluvoxamine)

SNRIvenlafaxine, duloxetine

buproprion

mirtazapine

TCANTP, protriptyline, desipramine(avoid others such as amytriptyline)

What NOT To Use

ECT

Psychosocial Interventions

Psychotherapysupportive, cog-behav, problem solving, interpersonal

Education

Family Counseling

Visiting nurse to help with meds

Bereavement groups

Senior citizen center

Schizophrenia

1 Month: Two or More (has to include 1 of first 3):Delusions

Hallucinations

Thought Disorder

Catatonia

Negative SymptomsAmbivalence, Autism, Affect, Associations

Functional Impairment

Continued disturbance for 6 months may be just negative symptoms

No longer has subtypes (except w or w/o catatonia)

Psychosocial Interventions

Psychotherapysupportive, cog-behav, problem solving, interpersonal

Education

Family Counseling

Visiting nurse to help with meds

Bereavement groups

Senior citizen center

Lets Define the Atypicals

Atypical: “Deviating from what is usual or common or to be expected” – Websters

So, what are Typical Antipsychotics?Drugs that had high probability of inducing Extrapyramidal Side Effects (EPS)

EPS ≡ Parkinsonismvia high D2 antagonism

High Potency vs. Low PotencyEPS generally mitigated by anticholinergic activityexception is risperidone which uses 5HT2 antagonism

Examples: high: haloperidol, fluphenazine, droperidol, pimozidelow: chlorpromazine, thioridazine,

Lets Define the Atypicals – not a class created of equals

Clozapine (Clazaril)

Risperidone (Risperdal)

Olanzapine (Zyprexa)

Quetiapine (Seroquel)

Ziprasidone (Geodon)

Aripiprazole (Abilify)

Paliperidone (Invega)

Asenapine (Saphris)

Iloperidone (Fanapt)

Lurasidone (Latuda)

Clinical Recepterology

Receptor we antagonize: What we watch for:

D2 EPS, (+) symptom relief, hyperprolactinemia

5-HT2a (-) symptom relief, mitigates EPS

5-HT2c Antidepression

α1 Postural hypotension

H1 Weight gain, sedation

M1 Weight gain, sedation, urinary retention, confusion, constipation, dry mouth etc…

Drug D1 D2 D3 D4 5-HT2a 5-HT2c α1 H1 ACh

Haloperidol 210 1 2 3 45 >10,000 6 440 5,500

Clozapine 85 160 170 50 16 10 7 1 2

Olanzapine 31 44 50 50 5 11 19 3 2

Quetiapine 460 580 940 1,900 300 5,100 7 11 >1,000

Risperidone 430 2 10 10 0.5 25 1 20 >1,000

Ziprasidone 525 4 7 32 0.4 1 10 50 >1,000

Aripiprazole 410 0.52 7.2 260 20 15 57 61 >1,000

Asenapine 1.4 1.3 0.42 1.1 0.06 0.03 1.2 1.0 8128

Iloperidone 216 6.3 7.1 25 5.6 42.8 36 473 >1000

Lurasidone 262 0.99 15.7 29.2 0.47 262 >1000 >1000

Dissociation Constants