Geriatric Psychiatry:
A Review & Update
Medical and Neurologic
Aspects
J. Wesson Ashford
University of Kentucky
VAMC, Lexington
Dementia Definition
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Multiple Cognitive Deficits:
Memory dysfunction
 At least one additional cognitive deficit
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Cognitive Disturbances:
Sufficiently severe to cause impairment of
occupational or social functioning and
 Must represent a decline from a previous level of
functioning
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Geriatric Psychiatry:
A Review & Update
Differential Diagnosis: Top Ten
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Alzheimer Disease (pure ~40%, + mixed~70%)
Vascular Disease, MID (5-20%)
Drugs, Depression, Delirium
Ethanol (5-15%)
Medical / Metabolic Systems
Endocrine (thyroid, diabetes), Ears, Eyes, Environ.
Neurologic (other primary degenerations, etc.)
Tumor, Toxin, Trauma
Infection, Idiopathic, Immunologic
Amnesia, Autoimmune, Apnea, AAMI
Geriatric Psychiatry:
A Review & Update
Diagnostic Criteria For Dementia Of The
Alzheimer Type (DSM-IV, APA, 1994)
A. Multiple Cognitive Deficits
1. Memory Impairment
2. Other Cognitive Impairment
B. Deficits Impair Social/Occupational
C. Course Shows Gradual Onset And Decline
D. Deficits Are Not Due to:
1. Other CNS Conditions
2. Substance Induced Conditions
E. Do Not Occur Exclusively during Delirium
F. Not Due to Another Psychiatric Disorder
Geriatric Psychiatry:
A Review & Update
Vascular Dementia
(DSM-IV - APA, 1994)
A. Multiple Cogntive Impairments
B. Deficits Impair Social/Occupational
C. Focal Neurological Signs and Symptoms or
Laboratory Evidence Indicating
Cerebrovascular Disease Etiologically Related
to the Deficits
D. Not Due to Delirium
Geriatric Psychiatry:
A Review & Update
Factors Associated with Multi-infarct Dementia
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History of stroke (especially in Nursing Home)
Step-wise deterioration
Cardiovascular disease - HTD, ASCVD, & Atrial Fib
Depression (left anterior strokes), personality change
More gait problems than in AD
MRI evidence of T2 changes (?? Binswanger’s disease)
SPECT / PET show focal areas of dysfunction
Neuropsychological dysfunctions are patchy
Geriatric Psychiatry:
A Review & Update
Post-Cardiac Surgery
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53% post-surgical confusion at discharge (delirium)
42% impaired 5 years later
May be related to anoxic brain injury, apnea
May be related to narcotic/other medication
May occur in those patients who would have
developed dementia anyway (? genetic risk)
Cardio-vascular disease and stress may start
Alzheimer pathology
Any surgery may have a similar effect related to peri-op or
post-op anoxia or vascular stress
Geriatric Psychiatry:
A Review & Update
Newman et al., 2001, NEJM
Drug Interactions
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Anticholinergics: amitriptyline, atropine,
benztropine, scopolamine, hyoscyamine, oxybutynin,
diphenhydramine, chlorpheniramine, many antihistaminics
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May aggravate Alzheimer pathology
GABA agonists: benzodiazepines, barbiturates,
ethanol, anti-convulsants
Beta-blockers: propranolol
Dopaminergics: l-dopa, alpha-methyl-dopa
Narcotics: may contribute to dementia
Geriatric Psychiatry:
A Review & Update
Depression
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Onset: rapid
Precipitants: psycho-social (not organic)
Duration: less than 3 months to presentation
Mood: depressed, anxious
Behavior: decreased activity or agitation
Cognition: unimpaired or poor responses
Somatic symptoms: fatigue, lethargy, sleep, appetite
disruption
Course: rapid resolution with treatment,
but may precede Alzheimer’s disease
Geriatric Psychiatry:
A Review & Update
Delirium Definition

Disturbance of consciousness
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i.e., reduced clarity of awareness of the
environment with reduced ability to focus, sustain,
or shift attention
Change in cognition (memory, orientation,
language, perception)
Development over a short period (hours to
days), tends to fluctuate
Evidence of medical etiology
Geriatric Psychiatry:
A Review & Update
Ethanol
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Possibly Neuroprotective
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Accidents, Head Injury
Dietary Deficiency
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Thiamine – Wernicke-Korsakoff syndrome
Hepatic Encephalopathy
Withdrawal Damage (seizures) Delayed Alcohol
Withdrawal
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May not kill neurons directly
Watch for in hospitalized patients
Chronic Neurodegeneration
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Cerebellum, gray matter nuclei
Geriatric Psychiatry:
A Review & Update
Medical / Endocrine
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Thyroid dysfunction
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Hypothyoidism – elevated TSH
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Hyperthyroidism
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Compensated hypothyroidism may have normal T4, FTI
Apathetic, with anorexia, fatigue, weight loss, increased T4
Diabetes
Hypoglycemia (loss of recent memory since episode)
Hyperglycemia
Hypercalcemia
Nephropathy, Uremia
Hepatic dysfunction (Wilson’s disease)
Vitamin Deficiency (B12, thiamine, niacin)
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Pernicious anemia – B12 deficiency, ?homocysteine
Geriatric Psychiatry:
A Review & Update
Eyes, Ears, Environment
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Must consider sensory deficits might contribute to the
appearance of the patient being demented
Central Auditory Processing Deficits (CAPD)
Hearing problems are socially isolating
Visual problems are difficult to accommodate by a
demented patient, ?To do cataract op?
Environmental stress factors can predispose to a
variety of conditions
Nutritional deficiencies (tea & toast syndrome)
Geriatric Psychiatry:
A Review & Update
Neurological Conditions
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Primary Neurodegenerative Disease
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Focal cortical atrophy
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Primary progressive aphasia (many causes)
Unilateral atrophy, hypofunction on EEG, SPECT, PET
Normal pressure hydrocephalus
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Diffuse Lewy Body Dementia (? 7 - 50%)
Fronto-temporal dementia (tau gene)
Dementia with gait impairment, incontinence
Suggested on CT, MRI; need tap, ventriculography
Other Neurologic Conditions
Geriatric Psychiatry:
A Review & Update
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Tumor
Toxins
Trauma
Geriatric Psychiatry:
A Review & Update
Infectious Conditions
Affecting the Brain
HIV
 Neurosyphilis
 Viral encephalitis (herpes)
 Bacterial meningitis
 Fungal (cryptococcus)
 Prion (Creutzfeldt-Jakob disease); (mad cow disease)
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Geriatric Psychiatry:
A Review & Update
Amnesic Disorders
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Amnesia
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Dissociative: localized, selective, generalized
Organic - damage to CA1 of hippocampus
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Epileptic events
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thiamine deficiency (WKE), hypoglycemia, hypoxia
Partial complex seizures
Specific brain diseases
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Geriatric Psychiatry:
A Review & Update
Transient global amnesia
Multiple sclerosis
Age-Associated Memory Impairment
vs
Mild Cognitive Impairment
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Memory declines with age
Age - related memory decline corresponds with atrophy
of the hippocampus
Older individuals remember more complex items and
relationships
Older individuals are slower to respond
Memory problems predispose to development of
Alzheimer’s disease
Geriatric Psychiatry:
A Review & Update
Advances in Alzheimer’s
Disease
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Uncovering etiology
Understanding pathophysiology
Better screening tools
Improved diagnosis
Developing interventions
Etiology
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Age - therefore - design and stress
Genetics (amyloid related)
Relation to vascular factors, cholesterol, BP
Education (? design vs protection)
Environment - diet, exercise, smoking
Geriatric Psychiatry:
A Review & Update
Neuropathology of AD
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Senile plaques
Neurofibrillary tangles
Neurotransmitter losses
Inflammatory responses
New Neuropath Mechanisms
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Amyloid PreProtein (APP - ch21)
Tau phosphorylation (relation to dementia)
Geriatric Psychiatry:
A Review & Update
Biopsychosocial Systems
Affected by AD
(all related to neuroplasticity)
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Social Systems
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Psychological Systems
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Basic ADLs - Late
Primary Loss Of Memory
Later Loss Of Learned Skills
Neuronal Memory Systems
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Cortical Glutamatergic Storage
Subcortical (acetylcholine, norepi, serotonin)
Cellular Plastic Processes
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APP metabolism – early, broad cortical distribution
TAU hyperphosphorylation – late, focal effect, dementia related
Geriatric Psychiatry:
A Review & Update
Why Diagnose AD Early?
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Safety (driving, compliance, cooking, etc.)
Family stress and misunderstanding (blame, denial)
Early education of caregivers of how to handle
patient (choices, getting started)
Advance planning while patient is competent (will,
proxy, power of attorney, advance directives)
Patient’s and Family’s right to know
Specific treatments now available, may delay nursing
home placement longer if started earlier
Geriatric Psychiatry:
A Review & Update
Need for Better Screening
and Assessment Tools
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Genetic vulnerability testing
Early recognition (10 warning signs)
Screening tools (6th vital sign in elderly)
Positive diagnostic tests
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CSF – tau levels elevated, amyloid levels low
Brain scan – PET – DDNP, Congo-red derivatives
Dementia severity assessments
Tracking progression rate, prediction of change
Geriatric Psychiatry:
A Review & Update
Alzheimer Warning Signs
Top Ten
Alzheimer Association
1. Recent memory loss affecting job
2. Difficulty performing familiar tasks
3. Problems with language
4. Disorientation to time or place
5. Poor or decreased judgment
6. Problems with abstract thinking
7. Misplacing things
8. Changes in mood or behavior
9. Changes in personality
10. Loss of initiative
Geriatric Psychiatry:
A Review & Update
Assessment
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History Of The Development Of The
Dementia
Physical Examination
Neurological Examination
Geriatric Psychiatry:
A Review & Update
Neurological Exam
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Cranial Nerves
Sensory Deficits
Motor
Deep tendon
Pathological
Geriatric Psychiatry:
A Review & Update
SCORE
ALZHEIMER DETERIORATION ON
THE MINI-MENTAL STATE EXAM
OVER TIME
30
25
20
15
10
5
0
-5
0
5
10
AVERAGE TIME OF ILLNESS (years)
Geriatric Psychiatry:
A Review & Update
AD all (easiest to hardest at p=.5)
Mini-Mental State Exam items
PROBABILITY CORRECT
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
-4 -3 -2 -1
Geriatric Psychiatry:
A Review & Update
0
1
2
3
4
5
6
7
8
DISABILITY ("time-index" year units)
9 10
PENCIL
APPL-REP
WATC
LOCATION
PENY-REP
TABL-REP
CLOS-IS
RIT-HAND
CITY
FOLD-HLF
SENTENCE
COUNTY
NO-IFS
FLOOR
SEASON
YEAR
PUT-LAP
MONTH
ADDRESS
DRAW-PNT
DAY
SPEL_ALL
DATE
APPL-MEM
PENY-MEM
TABL-MEM
Laboratory Tests
ROUTINE
 Routine – Blood tests & Urinalysis
 EKG
 Chest X-Ray
 Anatomical Brain Scan – CT (cheapest), MRI
SPECIAL
 Functional Brain Imaging (SPECT, PET)
 EEG, Evoked Potentials (P300)
 Reaction Times
 CSF Analysis - Routine Studies
 Heavy Metal Screen (24 hr urine)
 Genotyping
Geriatric Psychiatry:
A Review & Update
Justification for Brain Scan in
Dementia Diagnosis
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Differential Diagnosis: Tumor, Stroke, Subdural
Hematoma, Normal Pressure Hydrocephalus,
Encephalomalacia
Confirmation of atrophy pattern
Estimation of severity of brain atrophy
MRI shows T2 white matter changes
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Periventricular, basal ganglia, focal vs confluent
These may indicate vascular pathology
SPECT, PET - estimation of regions of physiologic
dysfunction, areas of infarction
Helps family to visualize problem
Geriatric Psychiatry:
A Review & Update
Geriatric Psychiatry:
A Review & Update
Geriatric Psychiatry:
A Review & Update
Geriatric Psychiatry:
A Review & Update
Geriatric Psychiatry:
A Review & Update
Ashford et al,
2000
INTERVENTIONS
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Only successful intervention –
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Available Interventions –
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Cholinesterase Inhibition
(1st double blind study - Ashford et al., 1981)
Not yet proven or unconvincing effects
Promising Interventions
Geriatric Psychiatry:
A Review & Update
Other Medical Conditions
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Chronic pain syndrome
Medical consultation-liaison
Other Neurological Conditions
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Parkinson’s disease
Guillan Barre syndrome
Huntington’s disease
Seizure disorders – partial complex seizures
Geriatric Psychiatry:
A Review & Update
Parkinson’s Disease
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Increases steadily after 50 years of age
Pathophysiology
Concomitant conditions
Parkinson signs
Symptomatic treatment
Geriatric Psychiatry:
A Review & Update
Electroencephalography
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Seizure disorders
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Episodic behavior problems
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Primary neurodegeneration
Temporal slow waves may be “normal”
Focal slowing (stroke, focal cortical disease)
Specific neurologic syndromes
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Possible partial seizure disorder
Generalized slowing
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Sensitivity – 50% (90% after 3 recordings)
Creutzfeldt-Jakob disease
Sleep disorders
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In sleep studies: used to define stages
Geriatric Psychiatry:
A Review & Update
Behavioral Problems In
Dementia Patients
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Mood Disorders – depression – early in AD
Psychotic Disorders
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Particularly paranoia, e.g, people stealing things
Agitation
Meal Time Behaviors
Sleep Disorders
Geriatric Psychiatry:
A Review & Update
Neuropsychiatric Treatments
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First treat medical problems
Second environmental interventions
Third neuropsychiatric medications
Geriatric Psychiatry:
A Review & Update
Sleep Disorders
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Primary sleep problems
Breathing-related sleep disorders
 Narcolepsy / primary hypersomnia
 Circadian rhythm disorders
 Parasomnias
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Secondary sleep problems
Due to a psychiatric condition: depression, psychosis
 Due to a medical condition: arthritis, parkinson’s
 Substance induced disorders
 Fragmented circadian rhythms, sleep in AD
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Geriatric Psychiatry:
A Review & Update
Insomnia
15% of patients in sleep labs have sleep disturbance not
associated with extrinsic factors or other conditions
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Periodic limb movement, restless leg syndrome
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Sinemet or anti-convulsants
PTSD, nightmares (trazodone, prazosin)
Jet lag (? melatonin)
Drugs: caffeine, nicotine,
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Sleeping pill rebound
Geriatric Psychiatry:
A Review & Update