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DELIRIUM, DEMENTIA, DEPRESSION AND COMPETENCY

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DELIRIUM, DEMENTIA, DEPRESSION AND COMPETENCY COMMON ISSUES IN CONSULTATION PSYCHIATRY Paul B. Rosenberg, M.D. Geriatric and Consultation-Liaison Psychiatry – PowerPoint PPT presentation

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Title: DELIRIUM, DEMENTIA, DEPRESSION AND COMPETENCY


1
DELIRIUM, DEMENTIA, DEPRESSION AND COMPETENCY
  • COMMON ISSUES IN CONSULTATION PSYCHIATRY
  • Paul B. Rosenberg, M.D.
  • Geriatric and Consultation-Liaison Psychiatry

2
DELIRIUM
  • Disturbed level of consciousness with deficits in
    attention
  • Change in cognition (memory, language,
    orientation) or perceptual disturbance
  • Develops rapidly and fluctuates
  • Caused by a medical condition

3
CLINICAL FEATURES OF DELIRIUM
  • Cognitively impaired
  • Medically ill
  • Acute/sudden onset
  • Disorientation
  • Hallucinations
  • Delusions
  • Visuospatial deficits
  • Apraxias
  • Word-finding deficits
  • Comprehension deficits
  • Somnolent (hepatic, uremic, medications)
  • Agitated (alcohol withdrawal)

4
SYNONYMS FOR DELIRIUM
  • Acute confusional state
  • Toxic-metabolic encephalopathy
  • Organic brain syndrome
  • ICU psychosis

5
EPIDEMIOLOGY AND RISK FACTORS
  • 25 of medical inpatients are delirious
  • Elderly
  • Dementia
  • Renal failure
  • Liver failure
  • Immobilization
  • Foley catheter
  • Infected
  • Anticholinergic medications
  • Polypharmacy
  • Narcotics
  • Benzodiazepines

6
METABOLIC CAUSES
  • Hypernatremia
  • Hypercalcemia
  • Hypo-, hyper-glycemia
  • Hyperosmolic
  • Uremia (uremic encephalopathy)
  • Liver failure (hepatic encephalopathy)

7
INFECTIOUS CAUSES
  • Urinary tract infection
  • Pneumonia
  • Sepsis
  • Delirium may be the first sign of infection,
    predating fever, leukocytosis, CXR findings

8
MEDICATIONS
  • Anticholinergics (Cogentin, Artane)
  • Psychotropic medications (Thorazine, Mellaril,
    TCAs, Paxil, benzodiazepines)
  • Lithium toxicity
  • Steroids
  • Narcotics

9
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.

10
ANTICHOLINERGIC EFFECTS OF MEDICATIONS
  • Usual
  • Cogentin, Artane
  • TCAs
  • Mellaril, Thorazine
  • Paxil
  • Narcotics
  • Antihistamines
  • OTC cold medications
  • Surprising
  • Furosemide
  • Digoxin
  • Theophylline
  • Ranitidine
  • Cimetidine
  • Isordil
  • Nifedipine

11
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

12
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

13
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

14
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

15
AGING AND DEMENTIA
16
COMMON DEMENTIAS
  • Alzheimers disease
  • Vascular dementia
  • AIDS dementia
  • Alcoholic dementia (Korsakoffs)
  • Frontotemporal dementia

17
PSYCHIATRIC ASPECTSOF DEMENTIA
  • Agitation
  • Wandering
  • Pacing
  • Insomnia
  • Hoarding
  • Catastrophic reactions
  • Capgras syndrome
  • Psychosis
  • Depression
  • Anxiety
  • Agnosia
  • Aphasia
  • Apraxia
  • Deficits in abstract thinking

18
ALZHEIMERS -- NEUROSCIENCE
  • Amyloid plaques (extraneuronal)
  • Neurofibrillary tangles and tau protein
    (intraneuronal)
  • Loss of cholinergic innervation (nucleus basalis
    of Meynert)
  • Cerebral atrophy (nonspeciific)
  • EEG changes
  • 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

19
ALZHEIMERS -- TREATMENT
  • Cholinergic
  • Aricept (doniepizil) 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
  • Excelon is new/similar drug
  • 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

20
TREATMENT OF AGITATIONIN DEMENTIA
  • Behavioral measures
  • Calm consistent environment
  • Cuing and reminding
  • Emphasize cognitive strengths
  • Music
  • Light therapy
  • Safe environment for wandering
  • Daytime exercise, minimize naps
  • Medications
  • Typical antipsychotics (Haldol)
  • Atypical antipsychotics (Risperdal) --
    improvement of agitation and violence
  • Antidepressants -- watch for agitated depression,
    need caregivers assessment
  • Be careful with benzodiazepines
  • Trazodone, Buspar

21
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

22
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

23
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

24
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

25
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

26
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

27
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

28
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

29
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

30
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

31
PSYCHOSOCIAL FACTORS
  • Death and dying
  • Disfigurement
  • Disability
  • Pain
  • Loss of role
  • Family conflict
  • Lifelong issues

32
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

33
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

34
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

35
OTHER DISEASES ASSOCIATED WITH DEPRESSION
  • Parkinsons
  • Huntingtons
  • Multiple sclerosis
  • ALS
  • Epilepsy
  • AIDS
  • Hypothyroidism
  • Hyperthyroidism
  • Hyperparathyroidism
  • Cushings
  • Chronic fatigue syndrome

36
MEDICATIONS CAUSING DEPRESSION
  • Reserpine
  • Methyldopa
  • Inderal (rare)
  • High-dose (older) oral contraceptives
  • Corticosteroids
  • Benzodiazepines
  • Alcohol
  • Opioids
  • Opiate analgesics
  • Cocaine withdrawal

37
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

38
ANTIDEPRESSANT MEDICATIONS
  • Tricyclics
  • Selective serotonin reuptake inhibitors (Prozac,
    Paxil, Zoloft, Celexa)
  • Effexor (venlafaxine)
  • Wellbutrin (buproprion)
  • Remeron (mirtazapine)
  • Reboxetine
  • Ritalin
  • Thyroid supplement
  • MAO inhibitors
  • ECT

39
COMPETENCY
  • 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

40
LEGAL ISSUES IN COMPETENCY
  • 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).

41
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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