Overview of Dementia, Depression and Schizophrenia in the Elderly Peter 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
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
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.
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.
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)
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