Transcript The DSM-5: How we cured ‘dementia’, but Depression is Here

Overview of Dementia,
Depression and Schizophrenia
in the Elderly
Peter Betz, M.D.
Hierarchical Levels of Human
Mental Life
Components of
Psychological Life
Modes of
Mental Disorder
Treatment
Initiatives
Personal Chronicle
Disruptive Life Stories
Rescript
Constitutional
Dimensions
Problematic Dispositions
Guide
Motivational Rhythms
Behavior Disorders
Interrupt
Cerebral Faculties
Psychiatric Diseases
Remedy
McHugh and Slavney
Dementia is now
‘Neurocognitive Disorder’
(NCD)
Further Defined as ‘Major’ or ‘Minor’
What’s in a name?
Greater phenomenological correctness – especially with the
growing base of literature defining specific aetiologies
Broader term - can include syndromes with only one
cognitive domain affected (e.g. ‘amnestic d/o’)
NCD is often the preferred term in the literature and in
practice – such as in younger individuals or those with TBI
Dementia is ok to still use if it helps communicate the
nature of the illness
Neurocognitive Disorder
Major
Minor
Concern of the
individual, informant or
clinician
Concern of the
individual, informant or
clinician
‘significant’ cognitive
decline – needs IADL
assistance
‘modest’ cognitive decline
– preserved IADLs but
needs compensatory
strategies or
accommodation
Not due to delirium or
another mental disorder
Not due to delirium or
another mental disorder
Alzheimer Disease
Insidious onset and
gradual progression
without plateaus
Impairment in
Memory/Learning and
one other area
No mixed etiologies
Probable – all 3
331.0 +
294.10 or 294.11
Possible – not all 3
331.9
No coding +/behavioral disturbance
Vascular NCD
*Onset temporally related to
cerebrovascular event(s)
-orProminent impairment in
complex attention
(processing speed) or
executive function
(planning, organizing,
sequencing, abstraction)
Hx, PE &/or *Imaging
shows evidence of sufficient
vascular disease
Probable (290.4) if * is
present in your decision tree
Possible (331.9) if no *
No coding +/- behavioral
disturbance for either
possible or probable
NCD with Lewy Bodies
Core Features
Fluctuating cognition
Well defined VH
Parkinsonism onset
subsequent to cognitive
decline
Suggestive Features
REM sleep disorder
Severe neuroleptic
sensitivity
Probable
2+ bullets including at
least one core feature
331.82 + 294.10/294.11
Possible
1 bullet
331.82
No coding +/behavioral disturbance
Frontotemporal NCD
Behavioral Variant
3 or more bullets:
Behavioral disinhibition
Apathy or inertia
Loss of sympathy or empathy
Perseverative, stereotyped or
compulsive/ritualistic
behavior
Hyperorality and dietary
changes
Relative sparing of learning
/memory and perceptualmotor function
Language Variant
Prominent decline in one:
Form of speech
production
Word finding
Object naming
Grammar
Word comprehension
Relative sparing of learning
/memory and perceptualmotor function
Frontotemporal NCD
Probable
Evidence of
disproportionate frontal
&/or temporal
involvement
331.19 +
294.10/294.11
Possible
331.9
No coding +/- behavioral
disturbance
Common Complications of AD
Anosognosia (50%)
e.g. unawareness of illness, not “psychological” denial
Apathy (25-50%)
inanition, poor persistence
Psychosis
delusions (20%), hallucinations(15%)
Mood Disorders
depression (20%), anxiety (15%)
Agitation / Aggression (50-60%)
wandering, restlessness, verbal and physical attacking
Sundowning (25%)
Textbook of Alzheimer Disease and Other Dementias, Weiner & Lipton, 2009
Interventions - Medication
Cholinesterase Inhibitors
tacrine, donepezil, rivastigmine, galantamine
Memantine
Vitamin E
Monoamine Oxidase Inhibitor
selegeline
Ginko Biloba
Anti-Inflamatory Agents
Estrogen Replacement Therapy
Lipid Lowering Agents
‘Non-Medicinal’ Interventions
Education, support, counseling, community resources
for the patient AND the caregiver
Long-Term Planning
state and private resources
will
durable power of attorney
advance directive
‘Non-Medicinal’ Interventions
Environmental / Home Safety
remove dangerous objects
Medications, clutter
beware:
water temperature, stairs, sharp furniture, glassware,
windows, locks, kitchen equipment
assess activities of daily living
institutionalization
driving
FDA Approved Treatments for
Complications of AD
Behavioral Management
Environmental vs. Medication
meds are a last resort
The “4D Approach”
adapted from
Practical Dementia Care
by Rabins, Lyketsos, and Steele
Our Assumptions:
Behavioral dyscontrol can have multiple etiologies.
They can be distinguished from each other.
Identifying the cause can directly lead to treatment
strategies.
There is rarely “one-best” approach to address
these issues.
Directed “trial and error” is the rule, not the
exception.
The “4D Approach”
Define and Describe
Decode
Devise a treatment plan
Determine “does it work?”
Behavioral Management
Environmental vs. Medication
meds are a last resort
If you chose a medication… Which One?
antipsychotics
typical vs. atypical
benzodiazepine
other
e.g valproate
CATIE-AD
Lon S. Schneider et. Al.
Primary outcome – time to discontinuation for any reason
great “real world” approach to study design
Atypicals were no better “tolerated”
Big media spin after data released:
Known higher mortality per FDA.
Now evidence of “lack of efficacy.”
Therefore, doctors are abusing elderly patients.
Actually, study shows:
Placebo stopped more due the lack of benefit than S.E.
Atypicals stopped more due to S.E. than lack of benefit.
What you (and your patients) should
watch for:
EPS
Torsades de pointes
Dystonia
Postural hypotension
Akathisia
Weight gain
NMS
Agranulocytosis
TD
Glucose Dyscontrol
Cholesterol Dyscontrol
Delirium
Increased risk of all cause
death
What About Anticonvulsants?
Initial trials were promising, but…
Most recent studies show far less benefit if not more
behavioral discontrol
However, can be helpful in some augmenting
strategies or in catastrophic reactions.
What NOT To Use
Benzodiazepine Side Effects
Sedation
Deliriogenic
Behavioral disinhibition
Emotional lability
Cognitive impairment – particularly amnesia
Ataxia
Respiratory depression
Rebound insomnia and anxiety
Withdrawal / Physiologic dependence
Major Depression
DSM-5 – 5 of 9
*Depressed mood (reported or observed)
*Markedly diminished interest /pleasure
>5% weight loss or gain
Insomnia or hypersomnia
Psychomotor slowing or agitation (observable)
Fatigue or loss of energy
Worthlessness or inappropriate guilt (not of
being sick)
Poor concentration
Recurrent thoughts of death
Betz – 2 of 3
Dysphoric change in mood
sadness, irritability, no
‘yeah’
Impaired self-attitude
low self-esteem,
worthlessness, guilt, etc.
Neurovegitative symptom
impairment
eating, sleeping, energy,
conc., sex drive, etc.
Dysthymia (>2 years)
DSM – 5
Depression
2 of 6
Poor appetite or
overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or
difficulty making
decisions
Feelings of hopelessness
Betz – 2 of 3
Dysphoric change in mood
sadness, irritability, no
‘yeah’
Impaired self-attitude
low self-esteem,
worthlessness, guilt, etc.
Neurovegitative symptom
impairment
eating, sleeping, energy,
conc., sex drive, etc.
Premenstrual Dysphoric
Disorder
5 of 9 symptoms present
in week before menses
Improves within a few
days of onset of menses
Absent (or minimal) the
week post menses
At least one:
Affective liability
Depressed mood,
hopelessness
Anxiety, tension
At least one:
Apathy
Poor concentration
Anergia, lethargy
Sense of being
overwhelmed
Physical symptoms (e.g.
bloating, breast
tenderness, joint pain
etc.)
My Most Worrisome Issues
Hopelessness
Suicide
NIMH
18% of total in those ≥ 65yo (only 13% of pop)
6x higher risk if ≥ 80yo
suicidal thoughts in 7% of elderly
suicidal thoughts in 30% of elderly with MDD
20% saw physician within 24 hours
41% saw physician within 1 week
75% saw physician within 1 month
Acute Management:
Antidepressant + psychotherapy
Alternate:
Mild – meds alone or psychotherapy alone
Severe – meds alone or ECT
What Antidepressants?
SSRI
escitalopram, citalopram, sertraline
(avoid paroxetine, fluoxetine, fluvoxamine)
SNRI
venlafaxine, duloxetine
buproprion
mirtazapine
TCA
NTP, protriptyline, desipramine
(avoid others such as amytriptyline)
What NOT To Use
ECT
Psychosocial Interventions
Psychotherapy
supportive, cog-behav, problem solving, interpersonal
Education
Family Counseling
Visiting nurse to help with meds
Bereavement groups
Senior citizen center
Schizophrenia
1 Month: Two or More (has to include 1 of first 3):
Delusions
Hallucinations
Thought Disorder
Catatonia
Negative Symptoms
Ambivalence, Autism, Affect, Associations
Functional Impairment
Continued disturbance for 6 months
may be just negative symptoms
No longer has subtypes (except w or w/o catatonia)
Psychosocial Interventions
Psychotherapy
supportive, cog-behav, problem solving, interpersonal
Education
Family Counseling
Visiting nurse to help with meds
Bereavement groups
Senior citizen center
Lets Define the Atypicals
Atypical: “Deviating from what is usual or common or to be
expected” – Websters
So, what are Typical Antipsychotics?
Drugs that had high probability of inducing Extrapyramidal Side
Effects (EPS)
EPS ≡ Parkinsonism
via high D2 antagonism
High Potency vs. Low Potency
EPS generally mitigated by anticholinergic activity
exception is risperidone which uses 5HT2 antagonism
Examples:
high: haloperidol, fluphenazine, droperidol, pimozide
low: chlorpromazine, thioridazine,
Lets Define the Atypicals –
not a class created of equals
Clozapine (Clazaril)
Aripiprazole (Abilify)
Risperidone (Risperdal)
Paliperidone (Invega)
Olanzapine (Zyprexa)
Asenapine (Saphris)
Quetiapine (Seroquel)
Iloperidone (Fanapt)
Ziprasidone (Geodon)
Lurasidone (Latuda)
Clinical Recepterology
Receptor we antagonize:
What we watch for:
D2
EPS, (+) symptom relief,
hyperprolactinemia
5-HT2a
(-) symptom relief, mitigates
EPS
5-HT2c
Antidepression
α1
Postural hypotension
H1
Weight gain, sedation
M1
Weight gain, sedation, urinary
retention, confusion,
constipation, dry mouth etc…
Dissociation Constants
Drug
D1
D2
D3
D4
5-HT2a
5-HT2c
α1
H1
ACh
Haloperidol
210
1
2
3
45
>10,000
6
440
5,500
Clozapine
85
160
170
50
16
10
7
1
2
Olanzapine
31
44
50
50
5
11
19
3
2
Quetiapine
460
580
940
1,900
300
5,100
7
11
>1,000
Risperidone
430
2
10
10
0.5
25
1
20
>1,000
Ziprasidone
525
4
7
32
0.4
1
10
50
>1,000
Aripiprazole
410
0.52 7.2
260
20
15
57
61
>1,000
Asenapine
1.4
1.3
0.42 1.1
0.06
0.03
1.2
1.0
8128
Iloperidone
216
6.3
7.1
5.6
42.8
36
473
>1000
Lurasidone
262
0.99 15.7 29.2
0.47
262
>1000
>1000
25