Delirium
• Worsens prognosis- significant mortality
rate
• Lengthens stay in hospital- longer in bed,
falls, pneumonia
• Increased rates of institutionalisation
• Potentially treatable
• Up to 2/3 not detected
Delirium: Clinical Features
• Clouding of consciousness, attention,
memory, executive function all affected
• 2 types
• Apathetic
• Active, psychotic, behavioural symptoms
• Symptoms worse at night
Delirium:Risk Factors
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Increasing age
Dementia
Sensory deficits
Previous episode
Severe comorbidity
Immobility
Sleep Disturbance
Alcohol Consumption
Operation
Dehdration
Low albumin
Delirium-Medication Risk factors
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Benzodiazepines
Anticholinergics
Opiates
Digoxin
Warfarin
Delirium Causes
• Almost anything in combination with risk
factors
Delirium-Tips
• Sudden deterioration in mental state
consider delirium
• The greater the number of risk factors the
more delirium is likely
• Sometimes delirium can go on for weeks
Delirium:Treatment
• Identify and treat cause
• Modify risk factors
• Infections, metabolic, malignancy, cardiac,
vascular
• Consider hospital admission
Delirium:Treatment
The eight ates or Nice Coat
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Noise abate
Illuminate
Communicate
Environment manipulate
Carer participate
Orientate
Ambulate
Thermoregulate
Delirium:Medication
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If hyperactive and psychotic
Antipsychotic-haloperidol
Olanzapine, quetiapine
Lorazepam
The Dementias
• Normal Ageing
• Mild Cognitive Impairment (MCI)
• Dementia
The Dementias: Clinical Features
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Progressive
Impairment of cognition, personality and intellect
Orientation,
Memory,
Language(dysphasia)
Ability to carry out tasks(praxias)
Recognition (agnosia)
The Dementias-Executive Function
Impairment
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Planning
Organising
Abstract thinking
Multi tasking
The Dementias: Behavioural and
Psychological Symptoms in
Dementia- BPSD
• Why are they important?
• Predict carer distress and breakdown of
supportive network
• Predict institutionalisation
• Nearly 90% of admissions to Larch
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The Dementias: Behavioural and
Psychological Symptoms in
Dementia- BPSD
Mood
Anxiety as a presentation
Anxiety as a concomitant
Depression
Elation- often pre existing bipolar disorder
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The Dementias: Behavioural and
Psychological Symptoms in
Dementia- BPSD
Psychosis
Delusions
Phantom lodger
Misidentifications e.g.Capgras
Persecutory
The Dementias: Behavioural and
Psychological Symptoms in
Dementia- BPSD-Psychosis
• Hallucinations
• Auditory- music, voices
• Visual-people, animals
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The Dementias: Behavioural and
Psychological Symptoms in
Dementia- BPSD
Wandering
Agitation
Day night reversal
Verbal Aggression
Physical Aggression
Disinhibition
Apathy
The Dementias: Causes
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Subdural
Brain tumour
Normal pressure hydrocephalus
Hypothyroidism
Low B12/folate
Syphilis
Diabetes
Chronic infection
Uraemia
The Dementias: Causes
• Alzheimer’s Disease(AD) 50%
• Vascular Dementia(VaD) 10%
• Mixed Dementia-Alzheimer’s with
cerebrovascular disease AD/VaD 25%
• Dementia with Lewy Bodies(DLB) 10%
• Fronto Temporal Dementia (FTD) 2%
Alzheimer’s disease
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Plaques, tangles
Insidious onset
Gradual decline
Memory orientation difficulties early on
Executive function impairment
Later on dyshasia, dyspraxia, agnosia
Vascular Dementia
• Pure form not that common
• Single large infarct
• Multi infarct dementia
• Subcortical dementia
RISK FACTORS
• Male
• Stroke/TIA
Alzheimer’s with Cerebrovascular
disease
Gradual deterioration
• RISK FACTORS
1. Family history dementia
2. Increasing age
3. Atrial fibrillation
4. Hypertension
5. Hypercholesterolaemia
6. Diabetes
7. Homocysteine
8. ?Lack of Exercise
Modifying Risk
• NB long latency(10+ years) between modifying
risk factor and seeing effect on disease
• ANTIOXIDANTS
• Vitamins C & E in combination
• ?Vitamin E delaying institutionalisation
• ANTIANFLAMMATORIES
• Non steroidal antiinflammatory agents ?Some
benefit if taken over many years
Modifying Risk
• Tobacco- risk not reduced-stimulation of nicotinic
receptors offset by other deleterious effects
• Alcohol- mild drinking up to 3 units of wine per day
benefit
• Statins- beneficial in TIAs, stroke, hypercholesterolaemia,
dementia-mixed results. May increase alpha secretase
• B12 & folate long term to reduce homocysteine?
• Oestrogen?
• Increased exercise?
• Mental stimulation?
Modifying Risk
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Fish 3x/week
Curry-turmeric
Smart drugs?
Bandolier’s 10 Tips
Dementia and Parkinson’s
Disease(PD)
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PD and subcortical dementia
PD and AD
PD and hallucinations from treatment
Dementia with Lewy Bodies(DLB)
Dementia with Lewy Bodies
• Fluctuating course
• Visual hallucinations
• Spontaneous features of Parkinsonism
Dementia with Lewy Bodies
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Falls
Syncope
Systemised delusions
Hallucinations in other modalities
Neuroleptic sensitivity
Fronto Temporal Dementia
• 30% of younger onset dementia(45-65yrs)
• Duration 8yrs
1. Overactive-disinhibted, lack of
concern(orbitomedial frontal, anterior temporal)
2. Apathetic-perseveration, rigid thinking, lack of
volition(pan frontal)
3. Stereotyped ritualistic behaviour(striatum)
4. Semantic dementia-unable to understand
meaning of words, objects, sensations
5. Progressive non fluent dyshasia
Fronto Temporal Dementia
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Liking for sweet things
Emotional blunting
Striking loss of insight
Ability may be enhanced-artistic or musical
Tip-frontal lobe symptoms often precede
memory problems
Other Dementias
• Subdural haematoma-history of fall
• Creutzfeld-Jacob Disease-Classical-rapid
decline, myoclonus, abnormal EEG, death
in < 1 yr
• Normal pressure hydrocephalus- cognitive
change, gait abnormality, urinary
incontinence
The Dementias: Identify and
Diagnose
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History
Cognitive testing
Primary Care 6CIT MMSE
Physical examination
The Dementias: Dementia Screen
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FBC ESR
U&Es
LFT’s, Calcium, protein
Blood Sugar
Lipids
B12&folate
TFTs
Serological Tests for syphilis
ECG
Referral to Old Age Psychiatry
• Early for diagnosis, comprehensive
assesment
Treatment With A Cholinesterase
Inhibitor (CHEI)
• Mild to moderate AD, Mixed AD/VaD,
DLB
• Secondary Care
• Shared Care Protocol
Dementias:Treatment
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Memory clinic
History
Examination
Investigation
Diagnosis
Treatment
Memory Clinic
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Patient and carer(s)
Detailed assessment and review
Mini Mental State Examination
Clock Drawing Test
Demtect
Executive Function
Bristol Activities of Daily Living
Peripatetic
NICE Guidelines(2001)
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Mild to moderate Alzheimer’s Disease
>12 MMSE
Diagnosis in specialist clinic
Treatment initiated by specialist but may be continued by
primary care under shared care protocol
• Seek carers’ views
• Assess 2-4/12 after maintenance dose. Continue only if
improvement in MMSE score or no deterioration and
behavioural or functional improvement
• Review every 6/12- MMSE must remain >12 and
worthwhile effect on global functional and behavioural
condition
Goals of Treatment
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Enhance Cognition
Increase autonomy
Decrease behavioural symptoms
Slow or arrest progression of the disease
Primary prevention in the presymptomatic
stage
Memory Clinic- Indications for
CHEIs
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Dementia screen
ECG
Neuropsychological testing-if MMSE>19
CT Brain scan with medial temporal lobe
views
• One hit
Memory Clinic
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If AD, mixed dementia or DLB
MMSE >12
Compliance with medication
Regular observation of patient
No contraindications
Memory Clinic
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Prescribe CHEI
Patient and carer information
Support or care at home
Monitoring and treatment of BPSD
Review 3/12 after stabilisation
Memory Clinic
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Review
Usually every 6/12
MMSE, CDT, EF, BADL?
Continue if evidence of benefit- not so easy
to decide!
Memory Clinic
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Stopping CHEIs
MMSE <12
Marked deterioration
Withdraw over 2/52
Often severe relapse- need to restart within
4/52
The Dementias:CHEIs
• Side effects-cholinergic-nausea,
headache,sweating, bradycardia dizziness
• Cautions-asthma, sick sinus syndrome
• Outcome-actual improvement in behaviour
cognition, function, psychosis
• Slowing of deterioration
• Up to 18/12
• Stopping
The Dementias: Treatment
Memantine
• Licensed for moderate to severe dementia
• Not supported by Priorities Committee in W
Berks
• Modest evidence of benefit in cognition,
ADL, behaviour
Other Treatments
• NSAIDs-Low rates of AD in patients with
RA. Insufficient evidence
• HRT- no effect in established disease,
possibly preventative
Other Treatments: Antioxidants
• Vitamin E ? Delays institutionalisation.
Dose 1000 IU/day
Gingko Biloba- some benefit reported from
German studies
• May interact with anticoagulants
Possible FutureTreatments
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Prevent plaque formation
Vaccination –Beta amyloid
Nerve growth factor
Stem cells
The Dementias: Other
Pharmacological Treatments
• Agitation, irritability, anxiety and verbal
aggression
• Trazodone 50mgs/day up to 250mgs day
• Sedation, anticholinergic
• Citalopram 10-20mgs/day up to 40mgs/day
• palpitations., postural hypotension,
confusion
• Depression- antidepressant
The Dementias: Other
Pharmacological Treatments
• Acute severe anxiety or agitation
• Lorazepam 0.5 mgs up to tds
• Respiratory depression, sedation,
paradoxical agitation
• Chronic agitation and restlessnessclomethiazole
The Dementias: Other
Pharmacological Treatments
• Agitation, aggression-mood stabilisers
• Sodium valproate 200mgs up to 1200mgs
• Liver impairment, GI side effects, drowsiness or
aggression
• Carbamazapine 50mgs bd up to 1g/day
• AV conduction defects,blurred vision. Dizziness,
unstaediness GI side effects, confusion, agitation,,
rash(Stevens Johnson), blood dyscrasia
The Dementias: Other
Pharmacological Treatments
• Agitation & psychosis
• CHEIs
The Dementias: Antipsychotics
• Psychotic symptoms, agitation, sexual
disinhibition
• Typicals; haloperidol 0.5mgs up to tds
• Sedation, EPS,
• Benperidol: sexual disinhibition
The Dementias: Antipsychotics
Atypicals
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Quetiapine 25mgs/day up to 400mgs/day
sedation
Amisulpride 25mgs/day up to 300mgs/day
hypotension, sedation
Olanzapine 2.5mgs/day up to 20mgs/day
sedation weight gain, cves, mortality
Risperidone 0.5mg/day up to 2mgs/day
EPS,sedation, agitation, cves
Aripiprazole?-dopamine stabiliser
The Dementias: Non
Pharmacological treatments
• Behaviour therapy- antecedents, behaviour,
consequences
• Individuals preferences
• Context of behaviour
• Reinforcement strategies to reduce the
behaviour
• Limited application
The Dementias: Non
Pharmacological Treatments -Reality
orientation
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Signposts
Notices
Memory aids
effective
The Dementias: Validation therapy
• Retreat into inner world to avoid stress,
boredom & loneliness
• Validation-empathy with feelings and
hidden meanings behind the confusion
• ?Effective
The Dementias:Reminiscence
• May help social interaction, motivation, self
care and reduce behavioural symptoms
• At all severities of dementia
The Dementias: Art Therapy
• Self expression through painting not relying
on language
• Stimulation, communication, social
interaction
The Dementias:Music Therapy
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Active participation or listening
Social interaction
Can help those with abnormal vocalisations
Reductions in agitation for music tailored to
individual
The Dementias: Activity Therapy
• Dance, drama. Sport
• Physical activity, reduces falls, improves
sleep, mood and confidence
• Day time activity-reductions in agitaion and
restlessness at night
The Dementias:Complementary
Therapies
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Massage,
Reflexology,
Herbal medicine
Efficacy not known
The Dementias: Aromatherapy
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Lavandula augustifolia melissa officianalis
Inhalation, bathing or topical
Reductions in agitation
Well tolerated
The Dementias: Light and
Multisensory
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BrightLight Therapy
Beneficial in sleep disturbance
MultiSensory Approaches
Fibreoptics, cushions& vibrating pads,
liquid wheels
• ?improvements in agitation
The Dementias: Cognitive
Behaviour Therapy
• Early dementia
• Misinterpretations, biases, distortions,
erroneous problem solving strategies,
communication problems
• Benefit reported
The Dementias: Interpersonal
Therapy
• Individual distress within their own context
• Person Centred Approach
• Disputes, personality difficulties,
bereavements, life evenst/changes
• Little used in dementia
The Dementias: Vascular risk factors
• Diabetes
• Hypertension
• Hypercholesterolaemia
Prevention
• Treat vascular risk factors energetically in
Middle Age
• Exercise
• Diet
• Early life educational achievement
• Use it or lose it
• Reduce chronic stress?
Single Assessment Process (SAP)
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Contact
Overview
Specialist
Comprehensive
Old Age Psychiatry Services
• Acute treatment
• Rehabilitation
• Prevention
Old Age Psychiatry Services
• Consultant and other psychiatrists
• CPNs, Occupational therapy, psycchology,
speech and languauge therapy,
physiotherapy, dietetcis, support workers
• Home treatment Team
• Memory Clinic
• Day Hospital
Old Age Psychiatry Services
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Inpatients
OutPatients
Domiciliary and Home visits
Carer Support and training
Individual and Group therapies
Liaison Service
Old Age Psychiatry Services-Model
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Early intervention
Treatment in the community
Prevent admission where possible
Work closely with primary care
Joint working with Social services
Resource Centre of Knowledge and
expertise
Supporting the Carers
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Listening
Informing
Involving
Training-problem solving
Cognitive analytical therapy- dichotomies,
ethical & moral considerations
Changing the Environment
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Housing for cognitively impaired
Safety issues
Aids and adaptations
Smart technology
Levels of sheltered accomodation
Social Care
• Social services
• Voluntary Sector
• Private Sector
Social Care
• Support for personal care
• Help with shopping, housework
• Financial support- Enduring power of
attorney Court of Protection
• Allowances
• Clubs, day care
Care
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Respite Care-at home or away
Long term care
Care homes DE
Nursing Homes DE
Depressive Disorder: Risk Factors
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Disability
Handicap
Stroke
Parkinson’s disease
VaD
Heart Disease
COPD
Depressive Disorder- causative
Physical Disorders
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Endocrine/Metabolic
Thyroid disorder
Cushings syndrome
Hypercalcaemia
Pernicious anaemia
Folate deficiency
Depressive Disorder- causative
Physical Disorders
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Organic Brain disease
Cerebrovascular disease
CNS tumours
PD
AD
SLE
Occult Carcinoma
Pancreas
Lung
Chronic Infections
Neurosyphilis
Brucellosis
Herpes Zoster
Depressive Disorder-Medication
causing Depression
• Antihypertensives:Beta blockers, methyl dopa,
calcium channel blockers
• Prednisolone
• Analgesics: Codeine, opioids, COX2 inhibitors
• AntiParkinsonian: L Dopa, amantadine,
tetrabenazine
• Psychotropics: antipsychotocs, benzodiazepines
Depressive Disorder-Detection
• History
• Anorexia, weight loss and anergia difficult
to interpret
• Examination
• GDS
Depressive Disorders- Treatment
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Remission of all residual symptoms
Provide appropriate Rx- NICE guidelines
antidepressants, psychological ECT
Provide info & support for patient/carers
Depressive Disorders- Treatment
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Optimise FunctionRx physical conditions,
Attend to sensory deficits
Review medication
Enable Practical support
Sign posting to appropriate agencies
Depressive Disorders- Treatment
• Prevention of Relapse and Recurrence
• Continue medication during recovery
• Stay on medication for at least 1 yr after
recovery
• Maintenance treatment
Depressive Disorders- Treatment
• Antidepressants- NNT of 4
• SSRI-under 80yrs, avoid if patient taking aspirin
NSAIDs, history of peptic ulcer
• Over 80s-mirtazapine( sedation), venlafaxine
(hypo or hypertension, cardiac disease),
lofepramine
• Moclobamide=MAOI B reversible
• Phenelzine
• All –low sodium-inappropriate ADH secretion
• Discontinuation reactions- possible after 8 weeks
Depressive Disorders- Treatment
• Efficacy
• TCA=venlafaxine> SSRIs
• Often difficult to obtain a therapeutic dose
of TCA
Depressive Disorders- Psychological
Treatment
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Work in older people
CBT
Interpersonal therapy-relapse prevention
Problem solving
Psychoeducational techniques
Family therapy
In major depression-antidepressant +
psychological Rx
Depressive Disorders- Treatment
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ECT
Severe depression80% recover
Well tolerated
Broader spectrum of use
Not within 3/12 of stroke or heart attack
Memory imapirment
Depressive Disorders- Treatment
• Rapid transcranial magnetic stimulation- ?
Less effective in older patients
• Exercise in prevention
• Enhanced or stepped care- case mangement,
antidepressants+ problem solving+ close
links between primary & 2o care
Depressive Disorders- Treatment
Resistant Depression
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Medical cause for depression
Patient tolerates med
Compliance with medication
Proper dose
For long enough up to 8-12 weeks However
recovery unlikely if no response within 4
weeks
Depressive Disorders- Treatment
Resistance
• Substitute with another antidepressant (fewer
interactions, easier to attribute success or failure or
side effects)
• Augmentation-( do not need to withdraw, possible
synergy)
• TCA with SSRI
• SSRI+Mirtazapine
• Antidepressant + Lithium
• Up to 300mgs of venlafaxine
Depressive DisordersMaintainanceTreatment
• Single episode major depression-1 yr after
recovery
• > 3episodes continue indefinitely at
therapeutic dose
• TCA, citalopram
• Antidepressant+ psychological Rx
Depressive Disorders- Prognosis
• Thirds- 1/3 got better, 1.3 had relapses, 1/3
continuing sympotms
• Better than this with active interventionOAP-2/3 got better
• Psychotic depression lethal- excess
mortality from physical conditions
• Increased risk of heart attacks and stroke
• Vascular depression poor prognosis
Communication
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ROAPI
Emails
Template e referral
Web site: www.roapi.net
Final Thoughts
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Prepare for old age
Have good relationships with others
Eat well
Plenty of mental stimulation
Physical exercise
Earn enough money
When you Retire Don’t stop
• Si jeunesse savait; si vieillesse pouvait.
• [If only youth knew; if only age could.]
• H. Estienne, Les Prémices
• Picture