Overview of Dementia, Depression and Schizophrenia in the Elderly

1. Overview of Dementia, Depression and Schizophrenia in the Elderly Peter Betz, M.D.

2. Hierarchical Levels of Human Mental Life Components of Modes of Treatment Psychological Life Mental Disorder Initiatives Personal Chronicle Disruptive Life Stories Rescript Constitutional Problematic Dispositions Guide Dimensions Motivational Rhythms Behavior Disorders Interrupt Cerebral Faculties Psychiatric Diseases Remedy McHugh and Slavney

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

4. 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

5. Neurocognitive Disorder Major 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 • Concern of the individual, informant or clinician • ‘significant’ cognitive decline – needs IADL assistance • Not due to delirium or another mental disorder

6. Alzheimer Disease • Probable – all 3 • 331.0 + • 294.10 or 294.11 • Possible – not all 3 • 331.9 • No coding +/- behavioral disturbance • Insidious onset and gradual progression without plateaus • Impairment in Memory/Learning and one other area • No mixed etiologies

7. 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

8. NCD with Lewy Bodies • Core Features • Fluctuating cognition • Well defined VH • Parkinsonism onset subsequent to cognitive decline • Suggestive Features • REM sleep disorder • Severe neuroleptic sensitivity • Probable • 2+ bullets including at least one core feature • 331.82 + 294.10/294.11 • Possible • 1 bullet • 331.82 • No coding +/- behavioral disturbance

9. Frontotemporal NCD Behavioral Variant 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 • 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

10. Frontotemporal NCD • Probable • Evidence of disproportionate frontal &/or temporal involvement • 331.19 + • 294.10/294.11 • Possible • 331.9 • No coding +/- behavioral disturbance

11. Common Complications of AD • Anosognosia (50%) • e.g. unawareness of illness, not “psychological” denial • Apathy (25-50%) • inanition, poor persistence • Psychosis • delusions (20%), hallucinations(15%) • Mood Disorders • depression (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

12. Interventions - Medication • Cholinesterase Inhibitors • tacrine, donepezil, rivastigmine, galantamine • Memantine • Vitamin E • Monoamine Oxidase Inhibitor • selegeline • GinkoBiloba • Anti-Inflamatory Agents • Estrogen Replacement Therapy • Lipid Lowering Agents

13. ‘Non-Medicinal’ Interventions • Education, support, counseling, community resources • for the patient AND the caregiver • Long-Term Planning • state and private resources • will • durable power of attorney • advance directive

14. ‘Non-Medicinal’ Interventions • Environmental / Home Safety • remove dangerous objects • Medications, clutter • beware: • water temperature, stairs, sharp furniture, glassware, windows, locks, kitchen equipment • assess activities of daily living • institutionalization • driving

15. FDA Approved Treatments for Complications of AD

16. Behavioral Management • Environmental vs. Medication • meds are a last resort

17. The “4D Approach” adapted from Practical Dementia Care by Rabins, Lyketsos, and Steele

18. 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.

19. The “4D Approach” • Define and Describe • Decode • Devise a treatment plan • Determine “does it work?”

20. Behavioral Management • Environmental vs. Medication • meds are a last resort • If you chose a medication… Which One? • antipsychotics • typical vs. atypical • benzodiazepine • other • e.g valproate

21. CATIE-ADLon S. Schneider et. Al. • Primary outcome – time to discontinuation for any reason • great “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.

22. 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

23. 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.

24. What NOT To Use

25. Benzodiazepine Side Effects • Sedation • Deliriogenic • Behavioral disinhibition • Emotional lability • Cognitive impairment – particularly amnesia • Ataxia • Respiratory depression • Rebound insomnia and anxiety • Withdrawal / Physiologic dependence

28. Major Depression DSM-5 – 5 of 9 Betz – 2 of 3 Dysphoric change in mood sadness, irritability, no ‘yeah’ Impaired self-attitude low self-esteem, worthlessness, guilt, etc. Neurovegitative symptom impairment eating, sleeping, energy, conc., sex drive, etc. • *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

29. Dysthymia (>2 years) DSM – 5 Betz – 2 of 3 Dysphoric change in mood sadness, irritability, no ‘yeah’ Impaired self-attitude low self-esteem, worthlessness, guilt, etc. Neurovegitative symptom impairment eating, sleeping, energy, conc., sex drive, etc. • Depression • 2 of 6 • Poor appetite or overeating • Insomnia or hypersomnia • Low energy or fatigue • Low self-esteem • Poor concentration or difficulty making decisions • Feelings of hopelessness

30. 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

31. My Most Worrisome Issues • Hopelessness • Suicide • NIMH • 18% of total in those ≥ 65yo (only 13% of pop) • 6x higher risk if ≥ 80yo • suicidal thoughts in 7% of elderly • suicidal thoughts in 30% of elderly with MDD • 20% saw physician within 24 hours • 41% saw physician within 1 week • 75% saw physician within 1 month

32. Acute Management: • Antidepressant + psychotherapy • Alternate: • Mild – meds alone or psychotherapy alone • Severe – meds alone or ECT

33. What Antidepressants? • SSRI • escitalopram, citalopram, sertraline • (avoid paroxetine, fluoxetine, fluvoxamine) • SNRI • venlafaxine, duloxetine • buproprion • mirtazapine • TCA • NTP, protriptyline, desipramine • (avoid others such as amytriptyline)

34. What NOT To Use

35. ECT

36. Psychosocial Interventions • Psychotherapy • supportive, cog-behav, problem solving, interpersonal • Education • Family Counseling • Visiting nurse to help with meds • Bereavement groups • Senior citizen center

37. Schizophrenia • 1 Month: Two or More (has to include 1 of first 3): • Delusions • Hallucinations • Thought Disorder • Catatonia • Negative Symptoms • Ambivalence, 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)

38. Psychosocial Interventions • Psychotherapy • supportive, cog-behav, problem solving, interpersonal • Education • Family Counseling • Visiting nurse to help with meds • Bereavement groups • Senior citizen center

39. 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 ≡ Parkinsonism • via high D2 antagonism • High Potency vs. Low Potency • EPS generally mitigated by anticholinergic activity • exception is risperidone which uses 5HT2 antagonism • Examples: • high: haloperidol, fluphenazine, droperidol, pimozide • low: chlorpromazine, thioridazine,

40. 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)

41. Clinical Recepterology

42. Dissociation Constants