Transcript DIAGNOSIS OF AZLHEIMER’S DISEASE

NEUROPSYCHIATRY IN
THE NURSING HOME
J. Wesson Ashford, MD, PhD,
University of Kentucky
FAMILY MEDICINE REVIEW
www.medafile.com/neurnh1.ppt
2001 - 2002
NEUROPSYCHIATRIC
PROBLEMS IN THE
NURSING HOME
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Dementia
Delirium
Psychosis
Depression
Insomnia
Anorexia
Parkinson’s Disease
DEMENTIA DEFINITION
• Multiple Cognitive Deficits that include:
– Memory dysfunction (especially new learning)
• a prominent early symptom
– at least one additional cognitive deficit:
• (aphasia, apraxia, agnosia, or executive dysfunction)
• Cognitive disturbances must be sufficiently
severe to cause impairment of occupational
or social functioning and must represent a
decline from a previous level of functioning
Differential Diagnosis: Top Ten
1. Alzheimer Disease (pure ~40%, + mixed~70%)
2. Vascular Disease
5-20%
3. Drugs, Depression, Delirium
4. Ethanol
5-15%
5. Medical / Metabolic Systems
6. Endocrine (thyroid, diabetes), Ears, Eyes, Envir
7. Neurologic (Parkinson’s, etc.)
8. Tumor, Toxin, Trauma
9. Infection, Idiopathic, Immunologic
10. Autoimmune, Amnesia, Apnea
DIAGNOSTIC CRITERIA FOR DEMENTIA
OF THE ALZHEIMER TYPE
(DSM-IV, APA, 1994)
A. DEVELOPMENT OF MULTIPLE COGNITIVE DEFICITS
1. MEMORY IMPAIRMENT
2, OTHER COGNITIVE IMPAIRMENT
B. THESE IMPAIRMENTS CAUSE DYSFUNCTION IN
IN SOCIAL OR OCCUPATIONAL ACTIVITIES
C. COURSE SHOWS GRADUAL ONSET AND DECLINE
D. DEFICITS ARE NOT DUE TO:
1. OTHER CNS CONDITIONS
2. SUBSTANCE INDUCED CONDITIONS
F. DO NOT OCCUR EXCLUSIVELY DURING DELIRIUM
G. NOT DUE TO ANOTHER PSYCHIATRIC DISORDER
Vascular Dementia
(DSM-IV - APA, 1994)
A. MULTIPLE COGNTIVE IMPAIRMENTS
1) MEMORY IMPAIRMENT
2) OTHER COGNITIVE DISTURBANCES
B. DEFICITS IMPAIR SOCIAL/OCCUPATION
C. FOCAL NEUROLOGICAL SIGNS AND SYMPTOMS
OR LABORATORY EVIDENCE INDICATING
CEREBROVASCULAR DISEASE
ETIOLOGICALLY RELATED TO THE DEFICITS
D. NOT DUE TO DELIRIUM
(IN NURSING HOME – RECENT STROKE)
POST-CARDIAC SURGERY
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50% develop post-surgical confusion
40% develop dementia 5 years later
may be related to anoxic brain injury
may be related to narcotic/other medication
may occur in those patients who would have
developed dementia anyway
• cardio-vascular disease and stress may start
Alzheimer pathology
• other surgeries may have a similar effect related
to peri-op or post-op anoxia or vascular stress
DRUG INTERACTIONS
Anticholinergics: amitriptyline, atropine
benztropine, scopolamine, hyoscyamine,
oxybutynin, diphenhydramine,
chlorpheniramine, many anti-histaminics
(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
(NURSING HOME - MEDICATION
INDUCED ELECTROLYTE IMBALANCE)
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
Delirium Definition
A. Disturbance of consciousness (i.e.,
reduced clarity of awareness of the
environment) with reduced ability to
focus, sustain, or shift attention
B. Change in cognition (memory,
orientation, language, perception)
C. Development over a short period
(hours to days), tends to fluctuate
D. Evidence of medical etiology
ETHANOL
• POSSIBLY NEUROPROTECTIVE
– (may not kill neurons directly)
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ACCIDENTS, HEAD INJURY
DIETARY DEFICIENCY (thiamine)
HEPATIC ENCEPHALOPATHY
WITHDRAWAL DAMAGE (seizures)
CHRONIC NEURODEGENERATION
– (cerebellum, gray matter nuclei)
• DELAYED ALCOHOL WITHDRAWAL
NEUROLOGIC CONDITIONS
• PRIMARY NEURODEGENERATIVE DISEASE
– DIFFUSE LEWY BODY DEMENTIA (? 7 - 50%)
• (NOTE RELATION TO PARKINSON’S DISEASE)
– FRONTO-TEMPORAL DEMENTIA
• (PICK’S DISEASE, ARGYROPHILIC GRAIN DISEASE)
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FOCAL CORTICAL ATROPHY
NORMAL PRESSURE HYDROCEPHALUS
SUBDURAL HEMATOMA
HUNTINGTON’S DISEASE
MULTIPLE SCLEROSIS
CORTICOBASAL DEGENERATION
TRAUMA
• CONCUSSION, CONTUSION
– Occult head trauma if recent fall
• SUBDURAL HEMATOMA
• HYDROCEPHALUS:
– NORMAL PRESSURE (late effect of bleed)
• POSSIBLE CONTRIBUTOR TO
ALZHEIMER’S DISEASE INITIATION
AND PROGRESSION
OTHER NEUROPSYCHIATRIC
DISORDERS
• DELIRIUM
– medical conditions – infections, urinary, respiratory
– drug toxicity
– predisposing factors - age, infections, dementia
• AMNESIC DISORDERS
– dissociative: localized, selective, generalized
– organic - damage to CA1 of hippocampus
• thiamine deficiency, hypoglycemia, hypoxia
• EPILEPTIC PERSONALITY CHANGES
• SPECIFIC BRAIN DISEASES
LABORATORY TESTS (routine)
(less history usually found in NH setting)
• BLOOD TESTS
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electrolytes, liver, kidney function tests, glucose
thyroid function tests (T3, T4, FTI, TSH)
vitamin B12, folate
complete blood count, ESR
EKG
CHEST X-RAY
URINALYSIS
ANATOMICAL BRAIN SCAN – CT / MRI
BEHAVIORAL PROBLEMS
IN DEMENTIA PATIENTS
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MOOD DISORDERS
PSYCHOTIC DISORDERS
INAPPROPRIATE BEHAVIORS
AGGRESSION: verbal, physical
PURPOSELESS ACTIVITY: verbal, motor
MEAL TIME BEHAVIORS
SLEEP DISORDERS
NEUROPSYCHIATRIC
TREATMENTS
• First treat medical problems
• Second environmental interventions
• Third neuropsychiatric medications
– Cognitive impairment
– Psychotic symptoms
– Depressive symptoms
– Insomnia symptoms
– Anorexia symptoms
– Parkinsonian symptoms
Treatments for Cognitive
Impairment
• Avoidance of medications which impair
cognitive function
– Alprazolam, lorazepam (benzodiazepines),
diphenhydramine, oxybutynin, etc
• Cholinesterase inhibitors
– May help cognition, may not !!!!
– Effects may vary according to agent ????
– May improve behavior
– May extend life ?!?!
Treatment of psychotic
symptoms
• Most acute treatment
– Haloperidol intramuscularly
– Risperidone orally
• Long-term treatment
– Olanzapine
– Risperidone (for more paranoid, hallucinatory)
– Quetiapine (when parkinsonian symptoms)
Treatment of agitation,
aggression, insomnia
• Mild symptoms
– Trazodone (? Buspirone)
• Severe symptoms
– Higher doses of trazodone
– Risperidone (acute), olanzapine (chronic)
– Valproic acid, clonazepam, carbamazepine
– (lorazepam ?? Acute only)
Treatment of depression
• SSRI’s (low side-effect profile)
– Paroxetine vs sertraline vs citalopram
– Fluoxetine may be more potent
• Second generation TCA’s
– Nortriptyline, particularly for pain patients
• Bupropion – for appetite, parkinson sx
• Venlafaxine – for activation
• Numerous others for special circumstances
Treatment of Insomnia
• Melatonin
– Diagnostic test is trial of melatonin
– Time-release may be more helpful
– Watch for batch ineffectiveness
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Trazodone (12.5 mg – 500 mg, start 25 – 50)
Nortriptyline (especially if pain)
Mirtazapine (especially if depression)
Consider causes of insomnia
Avoid benzodiazepines
– May have to use if patients establish dependency
Treatment of anorexia
- poor oral intake, refusal
• No good treatment
• For more depressive symptoms
– bupropion
• For more psychotic symptoms
– olanzapine (major side-effect is weight gain)
• May try steroids – various
– Megestrol – may take weeks to work
• Marijuana
– not available
– marinol not potent
Parkinson symptoms
• Sinemet (many factors to establish level)
– Consider treatment before getting out of bed
– Consider treatment every 3 hours
– SA is less stable in its effect
– May avoid before bedtime or use at bedtime
• Dopamine agonists
• COMT antagonists
• Avoid anti-cholinergics if memory problems