Overview of Dementia, Depression and Schizophrenia in the E - PowerPoint Presentation

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Overview of Dementia, Depression and Schizophrenia in the Elderly

Peter Betz, M.D.Slide2

Hierarchical Levels of Human Mental Life

Components of Modes of Treatment

Psychological Life Mental Disorder Initiatives

Personal Chronicle Disruptive Life Stories RescriptConstitutional Problematic Dispositions GuideDimensionsMotivational Rhythms Behavior Disorders InterruptCerebral Faculties Psychiatric Diseases Remedy

McHugh and SlavneySlide3

Dementia is now ‘Neurocognitive Disorder’(NCD)

Further Defined as ‘Major’ or ‘Minor’Slide4

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 TBIDementia is ok to still use if it helps communicate the nature of the illnessSlide5

Neurocognitive Disorder

Major

Concern of the individual, informant or clinician

‘significant’ cognitive decline – needs IADL assistanceNot due to delirium or another mental disorderMinorConcern of the individual, informant or clinician‘modest’ cognitive decline – preserved IADLs but needs compensatory strategies or accommodationNot due to delirium or another mental disorderSlide6

Alzheimer Disease

Probable

– all 3

331.0 +294.10 or 294.11Possible – not all 3331.9No coding +/- behavioral disturbanceInsidious onset and gradual progression without plateausImpairment in Memory/Learning and one other areaNo mixed etiologiesSlide7

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 diseaseProbable (290.4) if * is present in your decision treePossible (331.9) if no *No coding +/- behavioral disturbance for either possible or probableSlide8

NCD with Lewy Bodies

Core Features

Fluctuating cognition

Well defined VHParkinsonism onset subsequent to cognitive declineSuggestive FeaturesREM sleep disorderSevere neuroleptic sensitivityProbable2+ bullets including at least one core feature331.82 + 294.10/294.11Possible1 bullet331.82No coding +/- behavioral disturbanceSlide9

Frontotemporal NCD

Behavioral Variant

3 or more bullets:

Behavioral disinhibitionApathy or inertiaLoss of sympathy or empathyPerseverative, stereotyped or compulsive/ritualistic behaviorHyperorality and dietary changesRelative sparing of learning /memory and perceptual-motor functionLanguage VariantProminent decline in one:Form of speech productionWord findingObject namingGrammarWord comprehensionRelative sparing of learning /memory and perceptual-motor functionSlide10

Frontotemporal NCD

Probable

Evidence of disproportionate frontal &/or temporal involvement

331.19 +294.10/294.11Possible331.9No coding +/- behavioral disturbanceSlide11

Common Complications of AD

Anosognosia

(50%)

e.g. unawareness of illness, not “psychological” denialApathy (25-50%)inanition, poor persistencePsychosisdelusions (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, 2009Slide12

Interventions - Medication

Cholinesterase Inhibitors

tacrine

, donepezil, rivastigmine, galantamineMemantineVitamin EMonoamine Oxidase InhibitorselegelineGinko BilobaAnti-

Inflamatory AgentsEstrogen Replacement TherapyLipid Lowering AgentsSlide13

‘Non

-

Medicinal’ Interventions

Education, support, counseling, community resourcesfor the patient AND the caregiverLong-Term Planningstate and private resourceswilldurable power of attorneyadvance directiveSlide14

‘Non-Medicinal’ Interventions

Environmental / Home Safety

remove dangerous objects

Medications, clutterbeware:water temperature, stairs, sharp furniture, glassware, windows, locks, kitchen equipmentassess activities of daily livinginstitutionalizationdrivingSlide15

FDA Approved Treatments for Complications of ADSlide16

Behavioral Management

Environmental vs. Medication

meds are a last resortSlide17

The “4

D

Approach

”adapted from Practical Dementia Careby Rabins, Lyketsos, and SteeleSlide18

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.Slide19

The “4

D

Approach

”Define and Describe DecodeDevise a treatment planDetermine “does it work?”Slide20

Behavioral Management

Environmental vs. Medication

meds are a last resort

If you chose a medication… Which One? antipsychoticstypical vs. atypicalbenzodiazepineothere.g valproateSlide21

CATIE-AD

Lon S. Schneider et. Al.

Primary outcome – time to discontinuation for any reason

great “real world” approach to study designAtypicals 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.Slide22

What you (and your patients) should watch for:

EPS

Dystonia

AkathisiaNMSTDGlucose DyscontrolCholesterol DyscontrolDeliriumTorsades de pointesPostural hypotensionWeight gainAgranulocytosisIncreased risk of all cause deathSlide23

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.Slide24

What NOT To UseSlide25

Benzodiazepine Side Effects

Sedation

Deliriogenic

Behavioral disinhibitionEmotional labilityCognitive impairment – particularly amnesiaAtaxiaRespiratory depressionRebound insomnia and anxietyWithdrawal / Physiologic dependenceSlide26
Slide27
Slide28

Major Depression

DSM-5 – 5 of 9

*Depressed mood (reported or observed)

*Markedly diminished interest /pleasure>5% weight loss or gainInsomnia or hypersomniaPsychomotor slowing or agitation (observable)Fatigue or loss of energyWorthlessness or inappropriate guilt (not of being sick)Poor concentrationRecurrent thoughts of deathBetz – 2 of 3Dysphoric change in mood sadness, irritability, no ‘yeah’Impaired self-attitudelow self-esteem, worthlessness, guilt, etc.Neurovegitative symptom impairmenteating, sleeping, energy, conc.,

sex drive, etc.Slide29

Dysthymia (>2 years)

DSM – 5

Depression

2 of 6Poor appetite or overeatingInsomnia or hypersomniaLow energy or fatigueLow self-esteemPoor concentration or difficulty making decisionsFeelings of hopelessnessBetz – 2 of 3Dysphoric change in mood sadness, irritability, no ‘yeah’Impaired self-attitudelow self-esteem, worthlessness, guilt, etc.Neurovegitative symptom impairmenteating, sleeping, energy, conc., sex drive, etc.Slide30

Premenstrual Dysphoric Disorder

At least one:

Affective liability

Depressed mood, hopelessnessAnxiety, tensionAt least one:ApathyPoor concentrationAnergia, lethargySense of being overwhelmedPhysical symptoms (e.g. bloating, breast tenderness, joint pain etc.)5 of 9 symptoms present in week before mensesImproves within a few days of onset of mensesAbsent (or minimal) the week post mensesSlide31

My Most Worrisome Issues

Hopelessness

Suicide

NIMH18% 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 monthSlide32

Acute Management:

Antidepressant + psychotherapy

Alternate:

Mild – meds alone or psychotherapy aloneSevere – meds alone or ECTSlide33

What Antidepressants?

SSRI

escitalopram, citalopram, sertraline

(avoid paroxetine, fluoxetine, fluvoxamine)SNRIvenlafaxine, duloxetinebuproprionmirtazapineTCANTP, protriptyline, desipramine(avoid others such as amytriptyline)Slide34

What NOT To UseSlide35

ECTSlide36

Psychosocial Interventions

Psychotherapy

supportive, cog-behav, problem solving, interpersonal

EducationFamily CounselingVisiting nurse to help with medsBereavement groupsSenior citizen centerSlide37

Schizophrenia

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

Delusions

HallucinationsThought DisorderCatatoniaNegative SymptomsAmbivalence, Autism, Affect, AssociationsFunctional ImpairmentContinued disturbance for 6 months may be just negative symptomsNo longer has subtypes (except w or w/o catatonia)Slide38

Psychosocial Interventions

Psychotherapy

supportive, cog-behav, problem solving, interpersonal

EducationFamily CounselingVisiting nurse to help with medsBereavement groupsSenior citizen centerSlide39

Lets Define the Atypicals

Atypical:

“

Deviating from what is usual or common or to be expected” – WebstersSo, what are Typical Antipsychotics?Drugs that had high probability of inducing Extrapyramidal Side Effects (EPS)EPS ≡ Parkinsonismvia high D2 antagonismHigh Potency vs. Low PotencyEPS generally mitigated by anticholinergic activityexception is risperidone which uses 5HT2 antagonismExamples: high: haloperidol, fluphenazine, droperidol, pimozide

low: chlorpromazine, thioridazine, Slide40

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)Slide41

Clinical Recepterology

Receptor we antagonize:

What we watch for:

D2

EPS, (+) symptom relief, hyperprolactinemia

5-HT2a

(-) symptom relief, mitigates EPS

5-HT2c

Antidepression

α

1

Postural hypotension

H1

Weight gain, sedation

M1

Weight gain, sedation, urinary retention, confusion, constipation, dry mouth etc…Slide42

Drug

D1

D2

D3

D4

5-HT2a

5-HT2c

α

1

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