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We have a burgeoning population of patients who are going to be over 65. Between 28 million and 58 million predicted in the year 2030 and 506 million and 11 million predicted in the year 2030 of people over the age of 85. Many more people are living into their 100 years. The prevalence of illness increases with old age. Some people are relatively healthy at 101 years old, but there is an increase in co-morbidity, multiple medications. Most older patients are probably on at least 10 or 15
Another important aspect is that presentation of illness in the elderly is often different, particularly psychiatric illness. I rarely have anybody over 70 or 80 who comes in and says, "I’m depressed." If they do come in saying they’re depressed it’s usually because their children have convinced them that they have depression. So the presentation is often atypical. They will come in maybe having had multiple falls and I think this is not only true in psychiatry but also in general medicine. People
Classically, behavioral changes, families will come and say that their grandfather was always very nice, loved his grandchildren. Now he is grumpy, irritable, aggressive, isolates himself. So behavioral changes are very important. Cognitive deficits are common and a lot of patients will say, "Well, I’m 90. I should be forgetting things." And I’ll remind them that, " Well, six months ago were you forgetting things when you were 89 ½?" Well, no. But now they are forgetting things. They may have a major depression. Adequately treated their memory disorder … their memory comes back. Functional losses - I’ll go over later on - is a very important aspect of
So, on to delirium. Delirium is not reported or documented usually by physicians. We did a study on the consult service awhile ago just looking for the frequency of the diagnosis of delirium. There’s a lot of confusion diagnosed, there’s a lot of acute confusional state, but we were consulted on patients that we gave a diagnosis of delirium and we would look at the discharge diagnoses. There’s no diagnosis in the majority of cases, not even a diagnosis of confusion. It’s documented, according to the
So the clinical features, what you see, is usually a prodrome which is often missed. This rapid fluctuating course, decreased attention, altered arousal. The decreased attention can present as a sort of distractibility, that you can’t really get this person to focus on what you want to talk about, and the altered arousal - although Neurology has a little bit of a disagreement with us - altered arousal, people can be very very active, energetic, doing cartwheels down the hallways or they can be almost lifeless and be delirious. And both of those types of presentations should be treated aggressively. Treating the underlying illness and also treating with medication. I had
The psychomotor abnormality again is either agitated or almost comatose. The sleep-wake cycle is disturbed so a lot of times people will, in an older patient, will misdiagnose delirium because they’ll say the patient is "sundowning." Happens to happen around 4 or 5 o’clock and when this happens to older patients they sundown in the afternoon. So it’s an important factor to look for delirium when patients have this and be sure to treat this aggressively. Impaired memory is also part of
Let’s talk about psychosis in older patients because I think it’s different. The DSM diagnosis or the DSM definition is "One or more of the following: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior" and that’s a lot of what we’ve talked about with delirium, similar symptoms. Types of psychosis certainly are delirium, dementia, depression and mania. Charles-Bonnet is probably not a psychosis but a visual hallucination. And it’s a very detailed visual hallucination in somebody who has had some sort of an ophthalmologic procedure. After they’ve had cataract surgery, maybe a detached retina, macular degeneration, that has impaired their vision. So here we have somebody who cannot see, who is seeing quite vividly images. Usually it’s people pleasantly dressed, oftentimes quite sparkly, gold, silver kind of detailed to their hallucinations. Detail you normally would not get. It responds minimally to neuroleptics but certainly not increasing neuroleptics. If you get a minimal response, oftentimes increasing a neuroleptic doesn’t give you any more benefit. Some people think that some of the anticonvulsives, Tegretol, valproate, lometraline work better on this, thinking that it may be some sort of a kindling activity.
Capgras is a delusion that patient’s will think that their family member is actually an impostor. A familiar person is actually an impostor … an impostor is actually posing as a familiar person. So that this is quite distressing to family members, that a daughter will come in and he will - father or husband - will say, "What are you doing here?" It’s very distressing to the family. But it is a delusion and it does respond usually to anti-psychotics. Frijoles (?) is that there is a persecutor who actually is posing as somebody else and coming in to kind of fool the patient. And these patients with these fixed delusions will be very very adamant about this as actually going on. There is no way of convincing them. The children will say, "Look Dad, it’s me" pull out my license, pull out my passport, it’s me. There is no way of convincing them so it’s really medication.
So the differential diagnosis is bipolar disorder, delirium, delusional disorders, there’s also this long list of major depression with psychotic features. Parkinsonism has about a 10% incidence of psychosis and particularly in medications that are used. A lot of the medications that are used to treat Parkinson’s disease cause an increase in dopamine or psychosis. Schizophrenia, late onset is called paraphrenia or somebody who has had lifelong schizophrenia and now it presents. Actually I had a very very difficult patient in my office the other day who had lifelong schizophrenia and now she is diagnosed with Alzheimer’s disease. It was our visit and she was very very agitated and disruptive. Her husband had her belt and he would have to hold her belt or she would just run out the door. So they came into my office. He quickly closed the door and locked and put a chair against it and sat down. It was just to sort of maintain her in the office. Because otherwise she would leave. I thought what a very dedicated husband, obviously cared for her a great deal. And after about ten or 15 minutes she was much more calm, although not calm but much more calm than she had been when she came into the office. Schizophrenic form disorder is the schizoaffective disorder although usually early onset into late life.
Dementias have a lot of psychoses associated with them. Alzheimer’s disease, vascular Lewy body dementia actually is an interesting type of dementia because it looks like Alzheimer’s disease. It has more visual hallucinations associated with it and due to the pathology of the disorder it is much more sensitive to neuroleptics. So people have much more sensitivity to neuroleptics, to the side effects of neuroleptics. So you have to be very careful to get a good diagnosis and also monitoring them. Pick’s disease and Parkinson’s disease as I mentioned. Psychosis in dementia has a high prevalence of incidence and it is episodic or persistent. It can appear early or late and it can come and go rapidly. Psychosis in dementia has three general categories I usually see; delusions, hallucinations, and misconceptions. This is very good when you are trying to establish target symptoms. The delusions usually center around, as I said before, impostors, stolen items … I talk to my friends about "Where’s my pocketbook?" In older women, "Where’s my pocketbook? Where’s my pocketbook?" They always think that someone has stolen their pocketbook. Good to find out though sometimes it may be true. Or the spouse is not faithful, or that there is a fear of being abandoned. In some instances the caretaker can’t even leave the room. Have to be in the room with the patient at all times because they fear that they are going to be abandoned, or that they are not in their home. They’ll look around and say, "Well, this does look like my home and these are my pictures and these are things that I’ve had for years but it’s not my home."
Hallucinations, visual, auditory, are very very common and more common in patients who have sensory loss. The misconceptions that I find actually are somewhat entertaining at times with my patients. Like they think that the television is real so a patient will come in and say that "David Letterman was in my bedroom last night." And really believe it. That the designs on the wallpaper are real. That the designs on the napkins or tablecloth are actually real flowers or real animals. They don’t recognize themselves in a mirror. They look in a mirror and think that there is somebody else in the room and can be quite frightened by that. I had a woman who was a twin, actually, and she thought that her sister was there and visiting. She was very comforted by the fact that her sister was there because every time she looked in the mirror she thought it was her sister.
The other thing is that objects can be misperceived or not recognized. So patients can be very frightened by something that they think is a knife, a gun or that you have their pocketbook when you are holding something different.
I just wanted to go through a little bit of Alzheimer’s disease. It’s a slow, progressive, and behavioral outward agitation and confusion are very disturbing to family members. It’s essential to educate the family and the caregivers because some of these things they are not going to be able to treat. Establish a structured environment, realistic expectations, medications as needed but always give the lowest possible dose, and knowing that the drugs may cause a greater decline neurologists state consistently that if you put your father on this medicine his ability to communicate with you is going to decline. If the communication is agitation, aggression and causing a lot of disruption, then if your ability to communicate declines it’s sort of a trade-off there. You have to weigh the risks and benefits.
In Parkinson’s disease dementia affects about 30% of the patients and psychosis is only about 10%. Management of psychosis, again, establish target symptoms, treat underlying disorders. Be sure that the medical, neurological and psychologic treatment are all adequate. That you are not the neurologist and you may not be their primary care doctor but review everything that is being done to make sure that it is being done correctly. Primary care doctors and neurologists do appreciate the fact when you find something, if somebody is taking the medicine wrong, if things are defined, a telephone call or a letter is really helpful to them and also helpful to you in the management of the patient. When you are working with psychosis consider a diagnosis of dementia, and that’s really important once the psychosis is cleared to actually have a complete workup for dementia. I consider some other type of non-pharmacological intervention. Or a medicine other than a neuroleptic and a judicious choice of medications. Start very slow, give them the lowest possible dose even though it may seem homeopathic. If you over-shoot the patient or family will never go back to the medicine, which might be the only medicine that is going to work. Choose the drug on the basis of the side effects. If somebody is really active or energized to give them a medicine that’s going to calm them down. Choose medications that have the least possible drug-to-drug interaction and treat until the symptoms have resolved. I had a patient discharged from the inpatient unit the other day with a very severe psychotic depression and she went to see her primary care doctor three days later and he stopped her neuroleptic and came to see me two weeks later, and I thought maybe it would be okay but I certainly wouldn’t have stopped it that quickly, relatively high dose and just stopped it. So, decide a time when to take or to stop the drug and particularly when there is no response.
Atypical antipsychotics treat the positive symptoms of psychosis. The motor system is effected so you have people who have extra-paramental side effects and that does limit their use. Sometimes you have to use them but it will limit how high you can push the dose. Typical antipsychotics, high potency is usually the drug of choice. Common problems are parkinsonism, sedation, falls, cardiovascular problems, and anticholinergic effects. High potency is better because lower potency has more anticholinergic side effects. The atypical antipsychotics have a high 5HT2 and D2 blockade. They are selective; therefore, you don’t have as much motor involvement and don’t have as much extra-paramental side effects. And there is also a reduction in negative symptoms. There’s also some L2 receptors that’s important. The atypical antipsychotics, clozapine or Clozaril, olanzapine, Zyprexa, quetiapine, Seroquel and Risperidone, Risperdal are pretty much, as far as treatment, about the same. Clozapine I’ve used for years in patients who have Parkinson’s disease but recently quetiapine or Seroquel actually has worked quite well without extra-paramental side effects in patients with Parkinson’s disease. However, it’s extremely sedating. I had an incident where I used it - we didn’t have it on the formulary in the hospital for awhile and I brought up some medicinesfound that it worked so effectively in this patient that they just increased the dose and the patient slept for four days. So you have to be really careful about it. Again, it’s just judiciously using medications in older patients.
Clozapine is highly sedative and anticholinergic, so those are two things that you want to think about, whereas olanzapine is not so, quetiapine even less and Risperidone the lowest. Clozapine has a low extra-paramental effect but it is hypotensive so if you have a patient who is getting up and down a lot and having problems maintaining blood pressure, you want to be careful of that. Olanzapine has very few extra-paramental side effects but as I mentioned, in patients who have Lewy body disease I’ve used this frequently in patients with Lewy body disease and have had the appearance of extra-paramental side effects. So still Clozapine and quetiapine would be the two that I would use.
So aggression and agitation, careful assessment, underlying illness again, define the symptoms. Alternative drugs may be more beneficial. These are very difficult things to treat: wandering, screaming, personality changes and sleep disturbances. Wandering is almost impossible to treat. I think that it’s good exercise for older patients. Let them wander but have somebody wander with them. The more you try not to have them wander the more aggressive they will become. Keeping people busy and occupied can prevent screaming. Screaming is a very difficult behavior to treat. Depression, agitation, anger, anxiety and psychosis really work well with medications. Anger and agitation oftentimes with SSRI’s. So I sometimes use a serotonin reuptake inhibitor and it works well, or trazodone. That’s another one that works quite well for anger and agitation. Family support is really important to explain the behavior. No driving, no cooking, no smoking, no firearms. You would be amazed at how many older men have guns at home, loaded guns at home.
Bipolar illness, first onset in older patients is rare. Secondary mania I’ve seen much more so. Older patients with dementia who actually become manic and the treatment is pretty much the same. They are more irritable and they are more aggressive usually. But first onset in elderly is low. Lithium is effective and not usually