DELIRIUM, DEMENTIA, DEPRESSION AND COMPETENCY

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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

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DELIRYUM

• Bilinç ve dikkatte bozulma
• Bilissel islevlerde (bellek, dil, yönelim) veya
  algida bozulma
• Hizla gelisir ve dalgali seyreder
• Tibbi bir durum nedeniyle olur

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Deliryumun Klinik Özellikleri

• Bilissel bozulma
• Tibbi hastaliktir
• Akut/ani baslar
• Yönelim bozulur
• Varsanilar
• Sanrilar
• Görsel-uzamsal bozulma

• Apraksiler
• Sözcük bulmada güçlük
• Anlama ve degerlendirmede güçlük
• Uykulu (hepatik, üremik, ilaç nedenli)
• Ajite (alkol yoksunlugu)

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Deliryumun Esanlamlari

• Akut konfüzyonel durum
• Toksik-metabolik ansefalopati
• Organik beyin sendromu
• ICU psychosis

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EPIDEMIOLOGY AND RISK FACTORS

• Dahiliye servislerinde yatan hastalarin 25inde
• Elderly
• Dementia
• Renal failure
• Liver failure
• Immobilization

• Foley catheter
• Infected
• Anticholinergic medications
• Polypharmacy
• Narcotics
• Benzodiazepines

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METABOLIC CAUSES

• Hypernatremia
• Hypercalcemia
• Hypo-, hyper-glycemia
• Hyperosmolar state
• Uremia (uremic encephalopathy)
• Liver failure (hepatic encephalopathy)

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INFECTIOUS CAUSES

• Urinary tract infection
• Pneumonia
• Sepsis
• Delirium may be the first sign of infection,
  predating fever, leukocytosis, CXR findings

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MEDICATIONS

• Anticholinergics (Cogentin, Artane)
• Psychotropic medications (Thorazine, Mellaril,
  TCAs, Paxil, benzodiazepines)
• Lithium toxicity
• Steroids
• Narcotics

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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.

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ANTICHOLINERGIC EFFECTS OF MEDICATIONS

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

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

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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

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DIAGNOSTIC STUDIES IN DELIRIUM

• Metabolic studies (CBC, Chem-18,
  TFTs)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

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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
• 11 observation/restraints only when needed

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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

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AGING AND DEMENTIA
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COMMON DEMENTIAS

• Alzheimers disease
• Vascular dementia
• AIDS dementia
• Alcoholic dementia (Korsakoffs)
• Frontotemporal dementia

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PSYCHIATRIC ASPECTSOF DEMENTIA

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

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

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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

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PSYCHOSIS IN DEMENTIA

• Prevalence of hallucinations is about 30
• Hallucinations may be selectively associated with
  more rapid decline in Alzheimers
• 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

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ALZHEIMERS -- 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 b-amyloid
  precursor protein (b-APP) to 42- a.a. instead of
  40-a.a. fragment
• Familial AD -- single-point mutations in b-APP
• Transgenic mice
• Presenilins (chromosome 14 and 1) may be b-APP
  secretases
• Apolipoprotein E4 -- risk factor for sporadic AD.
• Subtle deficits in younger life - decreased idea
  density

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ALZHEIMERS -- 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 b-amyloid
• Need to find pre-morbid markers of AD

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NEW IDEAS IN ALZHEIMERS TREATMENT
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BEHAVIORAL INTERVENTIONS IN DEMENTIA

• Calm consistent environment
• Cuing and reminding
• Emphasize cognitive strengths
• Music
• Light therapy
• Safe environment for wandering
• Daytime exercise, minimize naps

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TREATING AGITATION WITH MEDICATIONS
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OTHER MEDICATIONS IN DEMENTIA

• Antidepressants -- watch for agitated depression,
  need caregivers 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

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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

• Binswangers -- ischemic injury of frontal
  hemisphere white matter -- preserved visuospatial
  functions
• No specific treatment
• Quit smoking
• Control BP
• Platelet inhibition

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ALCOHOLIC DEMENTIA

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

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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 Picks disease, dementia of ALS.
• Decreased serotonin
• Decreased metabolism in frontal and temporal
  lobes
• Familial type with mutations in tau gene on
  chromosome 17

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WHAT DO CAREGIVERS DO

• Cognitive supervision
• IADLs
• Bathing
• Dressing
• Feeding
• Transfer
• Monitoring medical condition

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WHAT KEEPS CAREGIVERS GOING

• Love
• Money
• Habit
• Cultural beliefs
• Spirituality

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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 laymens resource The 36-hour day, by Peter
  Rabins

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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

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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

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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

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RESPITE

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

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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

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THE RELUCTANT CAREGIVER

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

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COUNTERTRANSFERENCE

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

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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

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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

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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

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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

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DEPRESSION AS A MEDICAL SYMPTOM/SIGN

• Up to 20 of major depressive episodes turn out
  to be initial manifestation of medical illness
• Cushings
• Addisons
• Hypo-, hyper-thyroidism
• Huntingtons
• Parkinsons
• Similar overlap as in delirium

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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

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PSYCHOSOCIAL FACTORS

• Death and dying
• Disfigurement
• Disability
• Pain
• Loss of role
• Family conflict
• Lifelong issues

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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

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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

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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

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OTHER DISEASES ASSOCIATED WITH DEPRESSION

• Parkinsons
• Huntingtons
• Multiple sclerosis
• ALS
• Epilepsy
• AIDS

• Hypothyroidism
• Hyperthyroidism
• Hyperparathyroidism
• Cushings
• Chronic fatigue syndrome

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MEDICATIONS CAUSING DEPRESSION

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

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

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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

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ANTIDEPRESSANT MEDICATIONS

• Tricyclics
• Selective serotonin reuptake inhibitors (Prozac,
  Paxil, Zoloft, Celexa)
• Effexor (venlafaxine)
• Wellbutrin (buproprion)

• Remeron (mirtazapine)
• Reboxetine
• Ritalin
• Thyroid supplement
• MAO inhibitors
• ECT

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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

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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).

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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)

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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 dont
  work in severe mood disorders

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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

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PSYCHOSTIMULANTS -- III
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PSYCHOSTIMULANTS -- IV

• Target symptoms
• depressed mood
• lack of motivation for therapies (particularly
  PT, speech therapy)
• anorexia (paradoxical)
• attention

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SIDE EFFECTS AND CONTRAINDICATIONS

• Tachycardia
• Insomnia
• Anorexia
• Mania
• Contraindications
• unstable cardiac condition
• history of cocaine or stimulant abuse

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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