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Title: REVIEW OF PSYCHIATRY Geriatrics


1
Everything You Need to Know About Geriatric
Psychiatry in 75 Minutes
Andrea Stewart, MD, FRCPC Writer of LMCC, 2002
2
Aged 80 years in 1994 Aged 80 years in 2020
AGE DEPENDENCY RATIO
Proportion of population aged 80 years ()
3
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4
Challenges of Late Life
  • Co-morbid medical illness / cognitive disorders
  • Sensory loss
  • Financial worries
  • Retirement
  • Dependency
  • Dying and death
  • Bereavement

5
OVERVIEW
  • Dementia - BPSD
  • Late Onset Psychosis
  • Depression in late life
  • Anxiety in late life
  • Delirium
  • Other types of dementia (Lewy Body, FTD)

6
Case 2
7
Approach to Memory Loss
  • Speaking to the person (safety first)
  • Speaking to the family (safety first)
  • History, physical examination
  • Create a differential and then direct
    investigations (bloodwork, urinalysis, ECG,
    imaging) to firm up the diagnosis
  • Investigations
  • Follow-up Plan

8
Differential Diagnosis
  • Delirium
  • Cognitive Impairment but not dementia/ Mild
    Cognitive Impairment/ Age Associated Memory
    Decline
  • Dementia - subtypes
  • Depression or other psychiatric illness
  • Other CNS disease (cancer, demyelination, etc.)
    or a dementia secondary to GMC

9
Alzheimers Dementia
  • Memory Impairment
  • One or more other cognitive impairment
  • Aphasia, apraxia, agnosia, executive functioning
    deficit
  • Gradual onset and continual decline
  • Impairments cause significant social or
    occupational functional decline compared to
    previous level of functioning
  • Impairments are not delirium, substance-induced,
    or caused by another GMC or psychiatric illness

10
Defining the Diagnostic Threshold
Normal Cognition
MCI/ CIND
Dementia
11
Screening Tools
  • MMSE score lt24/30
  • MOCA score lt26/30
  • Mini-Cog (3 word registration recall, CDT)

12
Work-up1
  • CBC, Cr, urea, electrolytes, TSH, vitamin B12
  • Neuroimaging if the onset is recent (lt1 year),
    early (lt65), or the presentation is atypical or
    suggestive of another neurological disease
  • Other tests prn (VDRL, HIV, carotid U/S, EEG,
    chest Xray, urinalysis, LP)
  • ECG prior to medication management

1Burns A, BMJ
13
Bars show 25th to 75th ile of patients losing
independent performance.
Activities of Daily Living
25
20
15
10
5
0
30
MMSE
Mild AD Moderate AD
Severe AD
Adapted from Galasko. Eur J Neurol. 19985(suppl
4)S9-S17 Galasko et al. Alzheimer Dis Assoc
Disord. 199711(suppl 2)S33-S39.
14
Cognitive Enhancers
  • May improve
  • ADLs- activities of daily living, time to
    institutionalization
  • Behaviour/Mood- decreased concomitant
    psychotropics
  • Cognitive enhancement
  • Types
  • Acetylcholine-esterase inhibitors (boost ACh)
  • NMDA antagonists (Block glutamate)

15
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16
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17
Other Medications/ CAM
  • Nimodipine (Ca channel blocker) at 90 to 180
    mg/day
  • General BP lowering
  • Vitamin B12
  • Extract of Ginkgo biloba 761
  • Vitamin E no longer used due to bleeding risk
  • DHEA may be harmful to memory
  • Cognitive training, reminiscence therapy

18
Case 2
19
Behavioural and Psychological Symptoms of Dementia
20
ABC Approach
A Antecedents
B Behaviours
C Consequences
21
  • Physical delirium, diseases, drugs, discomfort,
    disability
  • Intellectual dementia cognitive
    abilities/losses
  • Emotional depression, psychosis
  • Capabilities environment not too demanding yet
    stimulating enough, balancing demands and
    capabilities
  • Environment noise, relocation, schedules
  • Social, cultural, spiritual life story,
    relationships family dynamics, personality
    traits...

www.piecescanada.com
22
Pharmacological Management of BPSD
  • Atypical antipsychotics1
  • RSP OZP reduce aggression, RSP reduces
    psychosis
  • Higher risk CVEs, EPS, death
  • Antidepressants2,3
  • db trials show CIT RSP with fewer SEs
  • Trazodone has trend of effectiveness in FTD
  • Benzodiazepines

1Cochrane, 2008 2Pollock, BG Am J Ger Psych
3Cochrane, 2008
23
The following is NOT true of Alzheimers
  1. Insidious, gradual and progressive decline
  2. Motor symptoms are absent until later in the
    disease
  3. A dramatic presentation is not the same as an
    abrupt onset
  4. Behavioural symptoms are often the most
    distressing symptom for families and caregivers
  5. The head turning sign refers to sexual
    disinhibition
  6. Vascular events may co-occur and cause cognitive
    dysfunction

24
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25
Case 6
26
Psychosis in the Elderly1
  • 4 in the community
  • 15 presenting to a geriatric medicine clinic
  • 10-38 of people in LTC (21 of new admissions to
    LTC)

1Holyrood S, Int J Ger Psych 1999
27
Approach
  • Speaking to the family (safety first)
  • Speaking to the person (safety first)
  • History, physical examination
  • Create a differential and then direct
    investigations (bloodwork, urinalysis, ECG,
    imaging) to firm up the diagnosis
  • Investigations
  • Follow-up Plan

28
Differential Diagnosis
  • Psychosis in People lt45
  • MDE or Mania
  • SZP/SZA/ delusional D/O
  • 2 GMC/subs
  • Delirium
  • Personality disorder
  • Psychosis in People gt45
  • Cognitive Disorders (delirium, dementia)
  • 2 GMC/ Subs
  • Psychotic Disorder (SZP, SZA, Del D/O) or
    paraphrenia
  • MDE, Mania

29
Differentiating the Dx
Dementia MDE Delirium Mania LO SZP
Memory loss, impaired function, insidious onset progress Prominent mood and anxiety sx, past hx MDD, somatic/ guilt/ nihilistic delusions Acute, fluctuates, clouded sensorium sleep reversal, delusions from env., vulnerablehost Mixed states more common, less grandiosity confusion irritability Delusions may be bizarre, no dis- orientationbaseline paranoid or schizoid PD traits
30
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31
Outcomes and Associated Factors
  • Elderly with psychosis are more likely to have a
    history of psychosis, live in LTC, and have lower
    MMSE scores1

1Holyrood S, Int J Ger Psych 1999
32
Case 6
33
Which of the following is not true in LLP?
  1. Most paranoid disorders of old age are due to
    schizophrenia
  2. More women develop late onset schizophrenia
  3. With ageing, schizophrenia tends to give less
    severe positive symptoms
  4. Patients with schizophrenia live 10-30 years less
    on average

34
Case 7
What is in your differential diagnosis? What kind
of investigations would you order? Assuming you
believe her to be depressed what would be your
plan of treatment? Is there a reason for
suggesting one antidepressant over
another? Assuming she does not have any response
to treatment after 3 weeks what would you do?
35
Approach to Mood Complaint
  • History (with collateral) and physical
    examination
  • Make the diagnosis considering the differential,
    assess severity (psychosis) and suicidality
  • Thorough medication review
  • Investigate causes (bloodwork, urinalysis, ECG,
    imaging) and remove promoting factors
  • Review past episodes and treatments

36
Differential Diagnosis
  • Depressive Disorder (dysthymia, MDE, BP with MDE,
    personality disorder)
  • Bereavement
  • Dementia
  • Delirium
  • Substance (drug of abuse, medication) or GMC

37
Epidemiology1
  • Lifetime risk 11
  • Incidence in the general population 4/ year
  • Incidence in people gt 65 1-3/ year
  • Incidence in hospitalized people 11
  • Incidence in people in LTC 12-22

1Narrow WE, NIMH ECA prospective data
38
Predisposers Precipitators Perpetuators
Female gender, widowed or divorced, PHx MDD, CeVD, Personality type, major physical or disabling illness, some meds, alcohol abuse, social disadvantage, Caregiver stress Recent bereavement, moving to an institution, adverse life events (separation, loss, financial crisis), declining health, relationship problems Persistent sleep problems, chronic stress, social isolation, stigma, adverse effects of medication therapies
39
Diagnostic Criteria
Mood depressed/irritable or anhedonia for gt 2
weeks and 4/8
  • Sleep change
  • Interests lost
  • Guilty or worthless feelings
  • Energy lost
  • Concentration impaired
  • Appetite changed/ wt change
  • Psychomotor symptoms
  • Suicidal or death-related thinking

DSM-IV-TR
40
Late Life Depression
Less More
Complaints of sadness Somatic symptoms, Anxiety, Cognitive symptoms, Medical comorbidity
CCSMH, Assessment and Treatment of Depression 2006
41
Subtypes
  • With or without psychosis, graded severity,
    recurrent or first episode, bipolar depression
  • Secondary to something else
  • Dysthymia
  • Co-morbid with dementia or substance abuse

42
MDE vs Grief
  • Grief
  • Onset after death of loved one
  • Symptoms improve with time
  • Passive wishes to have died 1st or with person
  • Self esteem preserved
  • Sadness comes in waves
  • Functional impairment lt2 mo.
  • MDE
  • /- onset after trigger
  • Symptoms worsen with time
  • SI/ preoccupation with death
  • Intense guilt worthlessness
  • Persistent mood state
  • Functional impairment
  • Psychosis

APA, 2000
43
Management
  • Mild bibliotherapy, exercise, close follow-up or
    supportive therapy
  • Moderate antidepressants /- psychotherapy, or
    psychotherapy alone
  • Severe refer to psychiatry, /- hospitalization
    for safety, ECT, antipsychotics with
    antidepressants, psychotherapy alone only
    effective for specific patients if done by
    experts - otherwise in combination

44
Suicide Risk
Fixed RFs Modifiable RFs V. High Risk Behaviours
Old age Male gender Widowed or divorced Previous attempt Losses (health, status, role, independence, relations) Social isolation, Presence of chronic pain (OR moderate pain 1.9, severe pain 7.5) Presence and severity of MDE Hopelessness, Suicidal ideation Access to means, especially firearms Agitation Giving away possessions Reviewing ones will Increase use alcohol Non-compliance with treatment Taking unnecessary risks Preoccupation with death
CCSMH, Assessment of Suicide Risk and Prevention
of Suicide, 2006
45
Language of Treatment
46
Antidepressants
  • Meta-analysis of trials of 2nd generation
    antidepressants in people gt60 with non-psychotic
    depression and no dementia

Medication Placebo
Response 44 35
Remission 33 27
Discontinuation 24 20
1American Journal of Geriatric Psychiatry, 2008
47
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48
Antidepressant
No change after 4wks
Works
gt20 better
Maintenance
Go to 8 wks
Reassess diagnosis, increase dose, switch to
escitalopram, sertraline, mirtazapine, effexor
gt20 better after above Li, antipsychotic,
psychotherapy
49
Clinical Use of Antidepressants
  • If anything protective for suicide in elderly
  • Elderly more likely to die of overdose if taken
  • Electrolytes pre and post (1 week to 1 month)
  • Risk of GI bleed, especially with concurrent
    NSAID or ASA use - monitor, add gastroprotective
    agent
  • Follow q2 weeks for the first 1-3 months, keep on
    medication gt1 yr post remission

50
Psychotherapy
  • Cognitive Behavioural Therapy
  • Problem Solving Therapy
  • Interpersonal Therapy

51
The following is true regarding depression
  1. it is a treatable condition that with
    antidepressants has a remision rate of 30-40 and
    response rates of 67-90
  2. the neurotransmitters serotonin and noradrenaline
    are involved
  3. Psychotherapy is effective in severe depression
  4. an association between early life trauma,
    hippocampal atrophy and depression can be seen
  5. it often presents with multi-system physical
    complaints
  6. it is associated with coronary artery disease,
    stroke, diabetes, cancer, Parkinsons, and MS.
  7. ECT should be considered only when all other
    treatments have failed

52
The following is true regarding depression
  1. it is a treatable condition that with
    antidepressants has a remission rate of 70-80
    and response rates of 67-95
  2. the neurotransmitters serotonin and noradrenaline
    are involved
  3. Psychotherapy is effective in severe depression
  4. an association between early life trauma,
    hippocampal atrophy and depression can be seen
  5. it often presents with multi-system physical
    complaints
  6. it is associated with coronary artery disease,
    stroke, diabetes, cancer, Parkinsons, and MS.
  7. ECT should be considered only when all other
    treatments have failed

53
Which of the following are true of depression in
old age
  1. Is more prevalent in women than men
  2. Prevalence rates rise sharply with age
  3. Is accompanied by a much lower suicide risk than
    in younger adults
  4. Is unresponsive to treatment in half of cases.
  5. Is often precipitated by a loss
  6. Both b) and d)

54
Which of the following are true of depression in
old age
  1. Is more prevalent in women than men
  2. Prevalence rates rise sharply with age
  3. Is accompanied by a much lower suicide risk than
    in younger adults
  4. Is unresponsive to treatment in half of cases.
  5. Is often precipitated by a loss
  6. Both b) and d)

55
Which of the below options are true for psychotic
depression
  1. Is more frequent in elderly.
  2. Remits with antidepressants in 50 of cases
  3. Remits with antidepressants antipsychotics in
    75 of cases
  4. Responds and remits best with ECT
  5. Should prompt thorough search for symptoms of
    bipolar illness in pt and family members.
  6. All of the above except b)
  7. All of the above except b) and c)

56
Which of the below options are true for psychotic
depression
  1. Is more frequent in elderly.
  2. Remits with antidepressants in 20 of cases
  3. Remits with antidepressants antipsychotics in
    45 of cases
  4. Responds and remits best with ECT
  5. Should prompt thorough search for symptoms of
    bipolar illness in pt and family members.
  6. All of the above except b)
  7. All of the above except b) and c)

57
Which of the following are frequent reasons for
consultation by elderly who have an episode of
depression
  1. Nerves
  2. Excessive fatigue
  3. Hypersomnia (sleeping too much)
  4. Digestive problems
  5. Fear of Alzheimers disease
  6. All of the above except C

58
Which of the following are frequent reasons for
consultation by elderly who have an episode of
depression
  1. Nerves
  2. Excessive fatigue
  3. Hypersomnia (sleeping too much)
  4. Digestive problems
  5. Fear of Alzheimers disease
  6. All of the above except C

59
Which of the following would go against a
diagnosis of normal grief
  1. Active suicidal ideation
  2. Prominent psychotic symptoms
  3. Crying spells when she thinks of her deceased
    husband.
  4. Being less active socially
  5. Being unable to attend to her usual daily
    activities 3 months after the death of her husband

60
Which of the following would go against a
diagnosis of normal grief
  1. Active suicidal ideation
  2. Prominent psychotic symptoms
  3. Crying spells when she thinks of her deceased
    husband.
  4. Being less active socially
  5. Being unable to attend to her usual daily
    activities 3 months after the death of her husband

61
Case 3
  • 81 year old widow, lives alone in her home,
    presents with 2 year history of insidious
    increase in worrying, indecisiveness, isolation,
    insomnia, and feeling tense. Her husband
    recently died in a NH after having dementia for 8
    years. Her kids say she is increasingly
    dependent on them for running errands, and she
    has stopped doing her own taxes and driving.
  • She appears nervous, with a smile that doesnt
    match her words.

62
Anxiety Disorder
Mood Disorder
  • Fear
  • Apprehension
  • Panic attacks
  • Chronic pain
  • GI complaints
  • Excessive worry
  • Agitation
  • Difficulty concentrating
  • Sleep disturbances
  • Depressed / irritable mood
  • Anhedonia
  • Euphoria
  • Weight gain/loss
  • Loss of interest
  • Hypervigilance
  • Agoraphobia
  • Compulsive rituals

APA 1994 Keller MB 1995 Clayton PJ et al 1991
Coplan JD, Gorman JM 1990
63
  • As many as 90 of depressed patients suffer from
    anxiety symptoms1-3
  • More severe illness at baseline
  • More psychosocial impairment
  • Greater likelihood of chronic illness
  • Poorer, slower response to treatment
  • Greater likelihood of committing suicide

1. Richou H. et al. Human Psychopharmacol 1995
10263-71 2. Coplan JD et al. J Clin Psych 190
51(Suppl 10)9-13 3. Kasper S. et al. Primary
Care Psych 1997 37-16
64
Anxiety Disorders in the Elderly
  • Secondary anxiety disorders more common in
    elderly
  • Primary anxiety disorders generally do not have
    an onset in the elderly (same for personality
    disorders)
  • High co-morbidity with depression
  • Overall less common in the elderly.
  • Phobias and GAD are the most common. Panic
    disorder is relatively rare, less than the 1-3
    described in younger populations (Flint AJP
    1994).
  • Caution with anxiolytics
  • can cause paradoxical disinhibition
  • Diphenylhydramine (Benadryl), Dimenhydrinate
    (Gravol), Chlorpromazine, Amitriptyline, chloral
    hydrate and barbiturates are not good anxiolytics
    due to their side effects
  • Elderly are more sensitive to benzodiazepines.
    Associated with an increased risk for falls and
    MVAs

65
Anxiolytic Side Effects
  • Cognition
  • Amnesia (esp. alcoholics with benzos)
  • Memory and visuospatial impairment
  • Psychomotor
  • Accentuate postural sway and incoordination
  • Increase risk for MVAs and falls
  • Paradoxical dysinhibition
  • Respiratory Depression
  • avoid benzos in sleep apnea
  • Sleep
  • Decreased sleep latency but also decreased stage
    3 and 4 sleep with Benzos

66
  • Which of the following is NOT true of anxiety
    disorders in old age
  • a) It is more often secondary to another axis 1
    condition like depression or medical condition
  • b) Anxiolytics can worsen not only anxiety but
    can cause sleep disruption, falls, and MVAs.
  • c) Benzodiazepines are safe in the elderly
  • Benadryl, Gravol, Chlorpromazine, Amitriptyline
    and other anticholinergic medications can be
    dangerous in the elderly because of delirium and
    associated other receptor effects (orthostatic
    hypotension)
  • Primary anxiety disorders and personality
    disorders, including dependent personality
    disorder, do not begin in old age

67
MCQ9
  • a) Prevalence rates increase with ageing.
  • b) Phobias are the most common anxiety disorder
  • c) Overall prevalence rates for all anxiety
    disorders in old age is around 10
  • d) Panic disorder affects approx. 5 of elderly.

68
MCQ9
  • a) Prevalence rates increase with ageing.
  • b) Phobias are the most common anxiety disorder
  • c) Overall prevalence rates for all anxiety
    disorders in old age is around 10
  • d) Panic disorder affects approx. 5 of elderly.

69
Case 8
70
Differential Diagnosis
  • Generalized Anxiety Disorder
  • Dysthymia
  • MDE
  • Anxiety secondary to GMC, substance
  • Bereavement

71
Anxiety in Late Life
  • Less common, 5-10 in the community
  • FgtM, peak onset adolescence
  • Agoraphobia alone as having a second peak
  • Late life onset usually heralds another
    condition
  • MDD, dementia, medication toxicity, withdrawal,
    GMC (cardio and cerebrovascular disease)

72
Presentations of Anxiety Disorders in Late Life1
  • Autonomic hyper-arousal pronounced
  • palpitations, dry mouth, dizziness, hot flashes,
    GI distress
  • Low prevalence of panic disorder and OCD
  • Onset after therapy with DA agonists, steroids,
    sympathomimetics, Beta-adrenergic agonists
    (salbutamol), theophylline, digoxin, thyroxine

Flint AJ, Comprehensive Textbook of Geriatric
Psychiatry Anxiety Disorders, 2004
73
Agoraphobia
  • Most prevalent anxiety disorder in the community1
  • Onset not uncommon after 601
  • Late onset related to abrupt onset physical
    illness or trauma (fall, being mugged)2
  • Associated with early parental loss3

1,3Lindesay J, Br J Psych, 1991 2Burvill PW, Br
J Psych, 1995
74
Depressive Disorder
Anxiety Disorder
  • Fear
  • Apprehension
  • Panic attacks
  • Chronic pain
  • GI complaints
  • Excessive worry
  • Agitation
  • Difficulty concentrating
  • Sleep disturbances
  • Depressed / irritable mood
  • Anhedonia
  • Euphoria
  • Weight gain/loss
  • Loss of interest
  • Hypervigilance
  • Agoraphobia
  • Compulsive rituals

APA 1994 Keller MB, 1995 Clayton PJ, 1991
Coplan JD,1990
75
Management
  • Diagnose, initiate treatment or refer
  • Investigate /- treat co-morbid illness
  • Psychotherapy CBT
  • Pharmacotherapy SSRI (sertraline)

76
Outcome
  • More severe illness at baseline
  • More psychosocial impairment
  • Poorer, slower response to treatment
  • Greater likelihood of committing suicide
  • Greater likelihood of morbidity (cardiovascular,
    respiratory, GI diseases) and mortality
    (cardiovascular, COPD, neoplastic causes)

Flint AJ, Comprehensive Textbook of Geriatric
Psychiatry Anxiety Disorders, 2004
77
Which of the following is NOT true of anxiety
disorders in old age
  1. It is more often secondary to another axis 1
    condition like depression or medical condition
  2. Anxiolytics can worsen not only anxiety but can
    cause sleep disruption, falls, and MVAs.
  3. Benzodiazepines are safe in the elderly
  4. Benadryl, Gravol, Chlorpromazine, Amitriptyline
    and other anticholinergic medications can be
    dangerous in the elderly because of delirium and
    associated other receptor effects (orthostatic
    hypotension)
  5. Primary anxiety disorders and personality
    disorders, including dependent personality
    disorder, do not begin in old age

78
Which of the following is NOT true of anxiety
disorders in old age
  1. It is more often secondary to another axis 1
    condition like depression or medical condition
  2. Anxiolytics can worsen not only anxiety but can
    cause sleep disruption, falls, and MVAs.
  3. Benzodiazepines are safe in the elderly
  4. Benadryl, Gravol, Chlorpromazine, Amitriptyline
    and other anticholinergic medications can be
    dangerous in the elderly because of delirium and
    associated other receptor effects (orthostatic
    hypotension)
  5. Primary anxiety disorders and personality
    disorders, including dependent personality
    disorder, do not begin in old age

79
Which of the following is true regarding anxiety
disorders in old age
  1. Prevalence rates increase with age
  2. Phobias are the most common anxiety disorder
  3. Overall prevalence rates for all anxiety
    disorders in old age is around 20
  4. Panic disorder affects around 5 of elderly.

80
Which of the following is true regarding anxiety
disorders in old age
  1. Prevalence rates increase with age
  2. Phobias are the most common anxiety disorder
  3. Overall prevalence rates for all anxiety
    disorders in old age is around 20
  4. Panic disorder affects around 5 of elderly.

81
Case 1
82
Approach
  • History (with collateral) and physical
    examination
  • Make the diagnosis considering the differential
  • Thorough medication review
  • Investigate causes (bloodwork, urinalysis, ECG,
    imaging) and remove promoting factors
  • Consult prn (OT, PT, RD, SW, other MD)

83
Differential Diagnosis
  • Delirium
  • Dementia
  • Depression, Mania, Psychotic disorder
  • Other CNS disease (cancer, demyelination, etc.)

84
Delirium
  • 20 of hospitalized patients gt651
  • 10-30 of people gt65 it is the presenting symptom
    of a life-threatening illness1
  • LOS approximately doubled to 8 days2
  • Mortality doubled, morbidity increased3
  • Unrecognized in 704

1Centers for Medicare and Medicaid Services, 2004
CMS Statistics 2Agostini JV, Principles of
Geriatric Medicine and Gerontology 3McCusker J,
Arch Intern Med 4Gillis AJ, Can Nurse
85
Delirium
  • C - Consciousness fluctuates
  • C - Course has an acute onset
  • C - Cognition disturbed
  • C - Cause is a GMC

86
Subtypes of Delirium
Meagher (1996), BJP
87
Predisposers Precipitators Perpetuators
Old age Visual loss Hearing loss Hx delirium Dementia Functional dependence Medical morbidities Polypharmacy EtOH/ drugs Med change Trauma (IV, restraints, foley, fall) UTI, pneumonia MI, CVA Low BP or O2 AbN lytes GI or GU disease Periop. factors Poor nutrition Environmental changes Pain IV/Foley Dehydration Sensory deprivation/ overstimulation Poor sleep Hypothermia
88
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89
Causes of Delirium
  • I - Infections
  • W - Withdrawal
  • A - Acute metabolic Encephalopathy
  • T - Trauma
  • C - CNS pathology
  • H - Hypoxia
  • D - Deficiencies
  • E - Endocrine Disorders
  • A - Acute Vascular Insufficiency
  • T - Toxins and drugs
  • H - Heavy metals

90
Case 1
91
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92
Treatment of Delirium1,2,3
  • Psychological/ Social/ Environmental
  • Ensure pt wears glasses, hearing aid, dentures,
    encourage independence regular activity, allow
    adequate sleep
  • Support family, enlist their help in decreasing
    distress and providing frequent reorientation
  • Place person near NS station in single room with
    adequate lighting, reorientation cues, and LIMIT
    RESTRAINTS
  • Biological
  • Treatment related to cause of delirium
  • Manage sx (low dose neuroleptics)
  • Ensure adequate hydration, stop unneeded lines

1Cole MG, J Geriatr Psychiatr Neurol 2Simon I,
Geriatr Nurs 3Meagher DJ, Br J Psychiatry
93
Antipsychotics in Delirium1
  • Evidence suggests modest benefits in decreasing
    duration and severity of delirium with use of
    antipsychotic
  • Low dose haldol (0.25-1.5 mg/24h) is equivalent
    to low dose risperidone (0.25 -1/24h) or
    olanzapine (1.25-5 mg/24h) in efficacy, but may
    cause more akathisia, definitely costs less

Cochrane Collaboration, 2009
94
Delirium Outcomes
  • Delirium in the elderly patient is associated
    with increased mortality, longer hospital stays,
    and increased risk of institutional placement
  • It is a reversible syndrome, that improves or
    resolves with treatment of the precipitating
    illness and addressing precipitating and
    perpetuating factors

95
MCQ The following is true for delirium
  1. It is characterized by problems and fluctuations
    with attention and consciousness
  2. In the elderly, it is most often completely
    reversible
  3. Hypoactive subtypes are more often missed
  4. Environmental interventions do not help
  5. It is a significant independent risk factor for
    death
  6. It can be superimposed on dementia or depression
  7. It is rare in the elderly
  8. It is better to use benzodiazepines than
    neuroleptics for psychotic and behavioural
    symptoms

96
The following is true for delirium
  1. It is characterized by problems and fluctuations
    with attention and consciousness
  2. In the elderly, it is most often completely
    reversible
  3. Hypoactive subtypes are more often missed
  4. Environmental interventions do not help
  5. It is a significant independent risk factor for
    death
  6. It can be superimposed on dementia or depression
  7. It is rare in the elderly
  8. It is better to use benzodiazepines than
    neuroleptics for psychotic and behavioural
    symptoms
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