geriatric psychiatry

GERIATRIC PSYCHIATRY

Prof. Nahathai Wongpakaran, MD, FRCPsychT

Geriatric Psychiatry Unit Department of Psychiatry, Faculty of Medicine

Chiang Mai University Psy 515

Objectives

• Learners will be able to list and describe

common mental illnesses in the elderly, and

the management of these conditions.

11/06/61 nahathai.wongpakaran@cmu.ac.th 2

Outline

• Introduction

• Late-life depression

• Late-life psychosis

• Late-life anxiety disorders

• Substance use disorders in the elderly

• Alcohol

• Sedative-hypnotics

• Neurocognitive disorders

• Behavioral and Psychological Symptoms of

Dementia (BPSD)

11 June 2018 nahathai.wongpakaran@cmu.ac.th 4

Social transition

Income level

Daily routine

Retirement

Lifestyle

Financial

planning Family

relationship

Social

relationship

Perceived

Old age transition

Physical frailty

Health condition

Loss of indipendence

Bereave

Placement

Functional assessment tasks • Activities of daily living (ADL)

• Bathing

• Ability to transfer

• Dressing

• Going to toilet

• Grooming

• Ability to feed self

• Instrumental activities of daily living (IADL)

• Able to use telephone

• Shopping

• Food preparation

• Laundry

• Motor transportation

• Responsibility for own medication

• Ability to handle finances

Prevalence of LLD among Thai elderly

11/06/61 nahathai.wongpakaran@cmu.ac.th

Studies Prevalence

Remarks

Siriwanarangsan P et al,

M 13.8, F

N = 9,632

Liang G et al, 2009 21.0 N = 200

TGDS, TMSE

Wongpoom T et al, 2011 5.9 MDD, PHQ-9

Wongpakaran N et al, 2012 23 N = 81, MDD by

MINI, LTC

Risk factors

• Older age

• Female gender

• Unmarried

• Low education

• Poverty

• Family history of

depression

• Poor social support

• Living in rural areas

•Loss and grief

•Loneliness

•Social isolation

•Care-taking

responsibility

•Dependency

•Role loss: mentor

•Life crisis

Barua A, et al. Indian J Psychol Med. 2010.; Büchtemann D. et al. J Affect Disord., 2012.;

Zhang L, et al. Int J Geriatr Psychiatry. 2012.

Health problems at risk for LLD & comorbid

• Cognitive impairment

• Chronic physical illness

Ischemic heart disease

• Poor function: ADL

A history of depression

Substance use: alcohol,

nicotine

Sensory deprivation

• Degenerative arthritis

• Hypertension

• Urinary incontinence

• Diabetes

Parkinson’s disease

Hypothyroidism

Neurologic disease

Stroke

Cancer

Barua A, et al. Indian J Psychol Med. 2010.

Co-occurring psychiatry diagnoses

Anxiety disorders of 10-20% (Lenze EJ et al 2000, Beekman AT et al 1998)

Personality disorders of 10-30%

Alcohol use disorders (Devanand DP et al 2002)

LOD: Association with cognitive disorders

• Late-life depression increases risk for

developing Alzheimer’s disease

(Alexopoulos G. 1993.; van Reekum, R. 1999.;

van Reekum R. 2005)

• Depressive symptoms are associated with

an increased risk for developing mild

cognitive impairment (MCI)

(van Reekum R. 2006)

Mechanisms that link depression to MCI

Adapted from Geda et al. Mild Cognitive Impairment. Textbook of Alzheimer’s Disease and Other dementias 2009.

Depression

Increased

corticosteroides Brain

damage MCI

Susceptibility

gene variant

or other risk

factors

Preclinical

Interaction

Depression

Depression MCI

Susceptibility

gene variant

or other risk

factors

Neurobiological theories

• Less genetic influence

• Less likely to have a family history of psychiatric illness

• Subtle structural brain damage

• Decrease neurogenesis

• Decrease in brain volume

• Prefrontal lobes, caudate, hippocampus

• White matter lesions and other abnormalities on imaging

• Neurotransmitter: 5-HT, NE, DA, Ach

• Declining health, inappropriate

medications, malnutrition

• Coexist with chronic disease and disability

• Regulation of homeostasis, organ system

reserve, immunologic responsiveness, and

body composition

• Cardiovascular pathology: Hypothesis of

‘vascular depression’

Psychodynamic theories

• Loss

• Premorbid personality

• Socially inhibited

• Helplessness

• Narcissistic injury

Cognitive and behavioral theories

• Learned helplessness

• Losses & schema

• Negative automatic thought

Social factors

• Loss of important social support and system due to death of spouse or siblings

• Death of adult child (Prince et al 1997)

• Retirement

• Relocation (NIH 1992)

• Negative life events

อาการส าคญ

values

Interest

81 (10.23) 8 (1.01) 6 (0.76) 141 (17.80) 70.97 < 0.001

Sadness

86 (10.86) 10 (1.26) 7 (0.88) 91 (11.49) 142.81 < 0.001

112 (14.14) 25 (3.16) 7 (0.88) 365 (46.09) 20.85 < 0.001

Appetite

67 (8.46) 5(0.63) 4 (0.51) 92 (11.62) 77.25 < 0.001

Energy

87 (10.99) 13 (1.64) 5 (0.63) 151 (19.07) 74.44 < 0.001

Cognition

78 (9.85) 26 (3.28) 9 (1.14) 402 (50.76) 5.73 0.126

Somatic

33 (4.16) 5 (0.63) 0.00 60 (7.58) 21.86 < 0.001

Chief complaints of elderly patients with depressive disorders

(n=792) Wongpakaran N, et al. DAS Prelim. 2015.

Did you know? • Depression without sadness

• Loss of interest and motivation

• Functional impairment is confused with

lower functional expectation

More frequent with delusions

• Still meet DSM-5 criteria

Assessment

• History

• Examination

• Cognitive screening

• Labs

• CBC, U/A, Meds plasma,

• Ca, Mg, PO4, e’,

• FBS, BUN/Cr,

• LFT, TFT

แบบวดความเศราในผสงอายไทย 15 ขอ (TGDS-15)

หวขอ ค ำตอบ

1.โดยทวไปแลวคณพงพอใจกบชวตตวเองหรอไม □ ใช □ ไมใช

2.คณลดกจกรรมหรอควำมสนใจในสงตำงๆ ลงหรอไม □ ใช □ ไมใช

3.คณรสกวำชวตคณวำงเปลำหรอไม □ ใช □ ไมใช

4.คณรสกเบอๆ อยบอยครงหรอไม □ ใช □ ไมใช

5.คณอำรมณดเปนสวนใหญหรอไม □ ใช □ ไมใช

6.คณกลววำอะไรรำยๆ จะเกดขนกบคณหรอไม □ ใช □ ไมใช

7.คณรสกมควำมสขเปนสวนใหญหรอไม □ ใช □ ไมใช

8.คณรสกหมดหนทำงอยบอยครงหรอไม □ ใช □ ไมใช

9.คณชอบอยกบบำนมำกกวำออกไปหำอะไรท ำนอกบำนหรอไม □ ใช □ ไมใช

10.คณรสกวำคณมปญหำควำมจ ำมำกกวำใครๆ หรอไม □ ใช □ ไมใช

11.คณคดวำกำรทมชวตอยมำไดจนถงทกวนนมนชำงแสนวเศษใช

หรอไม

□ ใช □ ไมใช

12.คณรสกหรอไมวำชวตทก ำลงเปนอยตอนนชำงไรคำเหลอเกน □ ใช □ ไมใช

13.คณรสกมก ำลงเตมทหรอไม □ ใช □ ไมใช

14.คณรสกหมดหวงกบสงทคณก ำลงเผชญอยหรอไม □ ใช □ ไมใช

15.คณคดวำคนอนๆ ดกวำคณหรอไม □ ใช □ ไมใช

คะแนนรวม _ _/15

Wongpakaran N, et al. J Clin Med Res, 2013.

ชมรมจตเวชศาสตรผสงอายและประสาทจตเวชศาสตรไทย. ค าแนะน าการรกษาโรคซมเศราในผสงอาย. 2559.

Depression management strategies in

primary care

• Detection

• Promoting treatment engagement and

adherence

• Stepped care

• Collaborative care

Park M. et al. Psychiatr Clin North Am. 2011

Aims of treatment

To reduce symptoms, remission

To prevent suicide, relapse, recurrence

To help with coping with patients’ disability

To decrease risk for developing cognitive disorders

To improve general health status

To improve cognitive and functional status

To improve quality of life

To reduce family or caregiver’s burden

ระยะของกำรรกษำโรคซมเศรำในผสงอำย

เฉยบพลน

ตงแตเรม

จนหำย

8-12 wks

ตอเนอง

เดอน

ไมลดยำ

รกษำสภำพ

1, 2, 3, …ป

ไมลดยำ

(Alexopoulos GS et al 2000), (Frank E. 1994)

Choices of medication • First-line agents

• SSRI’s (Esc, Ser, Par, Fluv, Fluo)

• SNRI’s (Venlafaxine/pristiq, duloxetine, +/- Milnacipran,

reboxetine (NaRI))

• Second-line agents

• Mirtazapine (NaSSA)

• Bupropion (NDRI)

• Third-line agents

• TCA’s (Nortriptyline)

• MAOI

• Psychostimulant

• Tianeptine (SSRE)

• Others: Quetiapine, Aripiprazole, Olanzapine, agomelatine Ravindran L, et al., 2005.; Shanmugham B. et al 2005.; Udomratn P & Wongpakaran N., 2012.

ชมรมจตเวชศาสตรผสงอายและประสาทจตเวชศาสตรไทย. ค าแนะน าการรกษาโรคซมเศราในผสงอาย. 2559.

ทางเลอกในการรกษา

ความรนแรง กลยทธการรกษา

Major depression

อาการโรคจต

Mild depression

ยาแกซมเศรา +/- จตบ าบด

ยาแกซมเศรา+ (ECT หรอยารกษาโรคจต)

ยาแกซมเศรา + จตบ าบด

ยาแกซมเศรา +/- จตบ าบด

Shanmugham B. et al 2005

Treatment options for other types of depression

• Adjustment disorder with depressed mood

• Pharmacologic intervention is not recommended [D]

• Minor depressive disorder

• Pharmacologic treatment should be considered if symptoms persist for more than 4 weeks

• Dysthymic disorder

• Antidepressant as first-line therapy

• Psychotherapy as an adjunct therapy unless there is clear improvement seen or a contraindication to medication

(Williams et al 2000, Alexopoulous et al 2001)

Suicide in the elderly

Risk factors • Age ≥ 75

• Male

• White

• Widowed or divorced

• Living alone, isolated, or recently moved

• Retired or unemployed

• Poor physical health, terminal illness, multiple or debilitating illnesses, or pain

• Depression, substance abuse or dependence, hopelessness

• History of suicide, depression, or other mental illness in close family members

Suicide: protective factors

• Able to learn from experience and accept help; sense of meaning in life; sense of humor and capacity for loving; able to reminisce about positive life experiences

• History of successful transitions and coping with life challenges

• Caring and available family member or supportive community network; accessible and caring health care provider

• Membership in a religious community

โรคจต (Late-life psychosis)

• โรคจตทเปนเอง (พบไดนอยกวา)

• โรคจตเภท

• โรคหลงผด

• อาการทางจตทมสาเหต (พบไดมากกวา)

• จากยาหรอสารเสพตด

• จากโรคสมองเสอมหรอสาเหตผดปกตทางสมองอนๆ

• จากโรคซมเศราหรอโรคทางอารมณอนๆ

• จากภาวะเพอคลง

Comparisons of characteristics of patients with late-onset versus earlier-onset schizophrenia

• Familial risk

• It is clear that the disorder has a genetic link

• Neurodevelopmental condition

• Minor physical anomalies

• A view of neurodevelopmental > neurodegenerative origin

• Some early, premorbid abnormalities are subtle or subclinical

• Acquired pathological change

• Normal structural MRI results, but larger ventricular and thalamic volumes

• No increased evidence of volume loss, strokes, tumors or white matter hyperintensities

• No evidence of cognitive decline

• Sensory deficits

• No etiological link

• Symptoms and treatment response

• Lower prevalence of disorganized subtype

• Higher prevalence of paranoid subtype

• Delusion > hallucination

• Less severe negative symptoms

• Responsive to antipsychotics (lower dosage)

• Gender differences

• Higher among women

• ‘Estrogen hypothesis’: estrogen, premenopausally, may modulate DA in a manner similar to antipsychotic

Decision tree to determining etiology of

psychosis in the elderly

Psychosis

Hx./Dx./s&s

Cognitive

decline

Primary

psychosis Dementia related

psychosis

Secondary

psychosis

Delirium

Medical

conditions

Substance-

psychosis

โรควตกกงวล

• แบงเปน 2 ประเภท ไดแก

• โรควตกกงวลทเปนเอง (Primary anxiety disorders)

• อาการวตกกงวลทพบในโรคอน (Secondary anxiety disorders)

•Depression

•Dementia

•Physical illness

•Medications

Primary anxiety disorders • Phobic disorders

• Agoraphobia, specific phobia, and social phobia

• The most or second most common

• Agoraphobia without panic attack

• Generalized anxiety disorders (GAD)

• Most common, or less common than phobia

• Comorbid with depression and other anxiety

disorders

• Rarely starts for the first time in late life

• Panic disorders

• Prevalence < 0.5%

• Fewer/less severe symptoms, less

avoidant

• Comorbid with depression/medical

condition (cardiovascular, GI, pulmo.)

Pharmacologic treatment

• Antidepressants

•SSRI’s are considered first line

•SNRI’s, NaSSA, and other newer can

be selected

• Benzodiazepines

• Please avoid

• Short-term therapy for only severe

symptoms

• Lorazepam is preferred

6/11/2018 nkuntawo@med.cmu.ac.th 44

Psychosocial treatment

• Cognitive and behavioral therapy

• Little information

• Little evidence of exposure therapy in

OCD and phobia

• Exposure therapy is TOC in late-onset

agoraphobia

• Cognitive therapy in panic disorder

โรคของการใชแอลกอฮอล (Alcohol use disorder)

•30-60% ของคนทดมสราเรมดมหลงอาย 60 ป

•การดมสราในผสงอายเปนปญหานอยกวาและคอนขางเฉพาะเจาะจงกวาคนทเรมมาตงแตอายนอยกวาน

•สาเหตการดม

•ปญหาโรคซมเศรา สถานการณทสรางความเครยดเปนสาเหตของการดมสราทพบไดบอยในผสงอาย

•หรอปญหาความจ า เชน เรมมอาการสมองเสอมขนเรมตน

Alcohol related disorders

• Prevalence of alcohol abuse and

dependence in community 2-4% , 8-50% in

nursing home

• Men > women

• Associated psychiatric conditions

• Cognitive impairment

• Depression

แบบคดกรองมชแกนอลกอฮอลสซม ฉบบสน ส าหรบผสงอาย • เวลาทคยกบคนอน คณคดวาคณดมนอยกวาความเปนจรง

• หลงจากทดมไปสกพก คณมกจะไมกนอาหารเพราะไมรสกหว

• การดมชวยลดอาการสนหรอมอสนของคณไดได

• บางครงอลกอฮอลกท าใหคณหลงวนหลงคน

• คณมกจะดมเพอใหรสกผอนคลายหรอสงบ

• คณดมเพอใหลมเรองไมสบายใจ

• คณดมมากขนหลงการสญเสย

• หมอหรอพยาบาลเคยแสดงความเปนหวงเกยวกบการดมของคณ

• คณเคยตงกฎส าหรบการดมของตวเอง

• เวลาทรสกเหงา การดมชวยคณได

ตอบถก 3 ขอหมายถงการดมมปญหา ดดแปลงจาก Blow 1991

Treatment

• Pharmacology

• Disulfiram: Lack study

• Naltrexone: 50% relapse

• Topiramate: Lack study

• SSRI’s for anti-craving and/or for depression

• Psychosocial treatment

• Counselling

• Supportive psychotherapy

• Brief intervention: Motivational enhancement therapy

• Other specific treatment for comorbidity: CBT for

depression, dynamic psychotherapy, etc.

• Individual or group approach

Benzodiazepines

• Physical dependence and chronic toxicity

• 20-50% have withdraw symptoms after discontinuation

• Risk factors for BZD dependence:

• duration, higher dose, shorter half-life, higher

potency, a history of alcohol related

disorder/sedative drug dependence, chronic

insomnia, chronic pain, personality disorder

• Drug discontinuation in the dependent

patients

• Gradual discontinuation

• Period: many months to a couple of years

by reduction q 1-4 months

• Reduction to a very low dose in some

patients

• Often overlooked

• MI, hypertensive crisis, infection, delirium

Prevalence of NCD’s

• Prevalence of dementia in Thai elderly 5.5% 1

• Prevalence of dementia in CM people > 45 y/o was 2.35%, with 75% with Alzheimer’s disease (AD) 2

• Dementia was found in 41.6% of residents in a long-term care home in CM3

1.Jitapunkul S, et al. Geriatr Gerontol Int. 2009.;

2. Wangtongkum S, et al. J Med Assoc Thai. 2008.;

Wongpakaran N, et al. Psychogeriatrics. 2012.

Pattern of cognitive decline

Golomb J, et al. Dialogues Clin Neurosci. 2004.

Elements of cognition

Elements

• Consciousness & Alertness

• Attention

• Orientation

• Memory

• Calculation

• Thinking & Concept formation

• Intelligence

• Language

• Abstraction

• Judgment

Domains

• Complex attention

• Executive function

• Learning and

memory

• Language

• Perceptual-motor

• Social cognition

APA DSM-5, 2013.

Brain and cognitive function

DSM-5 Diagnosis of major NCD (APA, 2013)

One cognitive decline

Pt, informant or

clinician

No delirium or other

psychiatric illness

Impairment by testings

Substantial: Major

Modest: Mild

Interfered: Major

Not interfered: Mild

Alzheimer’s disease

Frontotemporal lobar degeneration

Lewy body disease Vascular disease

Traumatic brain injury

Substance/medication use

HIV infection Prion disease

Parkinson’s disease

Huntington’s disease Another medical condition

Multiple etiologies

Unspecified

ปจจยเสยงของการเกดอลไซเมอร

อาย

ประวตครอบครว

ปจจยทางพนธกรรมเกยวกบ apolipoprotein E-

4 (APOE 4)

โรคพทธปญญาบกพรองระยะเรมแรก (Mild Cognitive Impairment)

ปจจยเสยงส าหรบโรคหวใจและหลอดเลอด

การบาดเจบทศรษะและการบาดเจบตอเนอสมอง

11/06/61

nahathai.wongpakaran@cmu.ac.th 62

NCD due to Alzheimer’s disease

◦Mild or major NCD

◦Gradual onset

◦Progressive

◦Memory + another cognitive domain

impairment

◦No other cause

11-Jun-18 63

Alzheimer’s dementia, amyloid

plaques, and neurofibrillary tangles

• BAP: abnormal processing amyloid proteins

• Amyloid casecade hypothesis

• NFT: abnormal phosphorylation of tau proteins

https://www.youtube.com/watch?v=cqmZFoGvzfU

Cortex Sulci & gyri

11-Jun-18 nahathai.wongpakaran@cmu.ac.th 65

Normal brain vs Alzheimer brain

Cortical neurochemistry-MRS

Kantarci et al, 2004

MRS of Normal vs. AD • Hippocampal neurobiological abnormailities

• Reduced in N-acetylaspartate (NAA), creatinine (Cr) and

choline (Cho)

• Increased mioinositol (MI)

• Reduced in NAA/Cr, NAA/Cho and NAA/MI

11/06/61 67

Kantarci et al, 2004

nahathai.wongpakaran@cmu.ac.th

Algorithm for evaluation of cognitive complaint Hildreth K, et al. Med Clin North Am. 2015.

Management

• History taking

• Physical & neurologic examination

• MSE

• Cognitive screening

• Neuropsychological testing

History taking

Hildreth K, et al. Med Clin North Am. 2015.

Physical examination

Parkinson’s disease • May be normal

• Delirious stages:

psychomotor activity,

inattention, disorganized

thinking, etc.

• Behavioral and

Psychological Symptoms of

Dementia-BPSD

• Depression: poor

hygiene, self-neglect

• Focal neurological deficits

• Parkinsonian signs

• Frontal lobe signs

• Etc.

Kayser-Fleischer ring

Wilson disease

• MMSE-Thai 2002, TMSE, 3MS, etc.

• Mini-Cog

• Clock Drawing Tests

• Standardized MMSE (SMMSE)

• Informant Questionnaire on Cognitive

decline in the elderly (IQCODE)

• Frontal Assessment Batteries (FAB)

• Etc.

Screening tools

11/06/61 75

11/06/61 76

Investigation-1

• CBC, FBC, ESR, CRP - anemia,

vasculitis

• U/A - delirium

• Glucose

• e’, Ca++, Mg+, PO43- – hypercalcium/

hypocalcaemia

• BUN/Cr - renal failure

• LFT-clotting and albumin

• T4 and TSH – hypothyroidism

Investigation-2

• B12 and folate - vitamin deficiency

dementia

• Syphilis serology, HIV

• Caeruloplasmin - Wilson's disease

• Chest X-ray, electrocardiogram (ECG)

(as determined by clinical presentation)

• Cerebrospinal fluid examination (if

Creutzfeldt-Jakob disease (CJD) or

other forms of rapidly progressive

dementia are suspected)

Investigation-3

• Electroencephalography (EEG) - not routinely

indicated

• Imaging • Use structural imaging to exclude other cerebral pathologies

and help establish the subtype of dementia

• To identify treatable causes

• Prefer MRI to assist with early diagnosis and detect subcortical

vascular changes

• Single-photon emission computed tomography (SPECT) to

help differentiate Alzheimer's disease, vascular dementia and

frontotemporal dementia

• Use dopaminergic iodine-123-radiolabelled 2b-

carbomethoxy-3b-(4-iodophenyl)-N-(3-fluoropropyl)

nortropane (FP-CIT) SPECT to confirm suspected dementia

with Lewy bodies (DLB)

Management plan

• What are presenting problems?

• Current functional ability

• Global deriorating scale

• ADL/IADL

• Dependency need

• Risk assessment

• Self or others

• Disturbed/negative behavior

• Concurrent physical/psychological

illness

• Carer assessment

Treatment targets in AD

• Neurotransmitter-based treatments

• Protein-focused treatments

• Intracellular-focused treatments

• Regeneration agents

11/06/61 82 nahathai.wongpakaran@cmu.ac.th

Available cognitive enhancers

• Cholinesterase inhibitors

• Donepezil

• Rivastigmine

• Galantamine

• NMDA antagonist

• Memantine

การจดการปญหาดานความจ า

R – Reminders (เครองเตอนความจ า) 1. ค าใบหรอค าชวย

2. เขยนเปนตวหนงสอหรอแทนดวยภาพ

E – Environment (สภาพแวดลอม) 1. วางของใหเปนทเปนทางถาวร

2. อยาเปลยนแปลงสภาพแวดลอม

C – Consistent Routines (กจวตรประจ า) 1. คงกจกรรมงายๆ และประจ าไว

2. กจกรรมใหมท าใหเปนประจ า

A – Attention (ความใสใจ) 1. หลกเลยงสงรบกวน

2. ฝกความใสใจ

P – Practice (ฝกฝน) 1. สรางทกษะดวยการปฏบต

2. ปฏบตสงใหมเพอสรางทกษะใหม

S – Simple Steps (ท าในสงงาย) 1. ท าทกอยางใหเปนขนตอนงายๆ

2. ใหเวลาแกผปวย 11/06/61 nahathai.wongpakaran@cmu.ac.th

Vernooij-Dassen, M. Int Psychogeriatr. 2010.

การแกปญหาการสอสาร M- MAXIMIZE attention (เพมความใสใจ) 1. ดงความสนใจ

2. หลกเลยงสงรบกวน

3. ทละอยาง

E- Watch your EXPRESSION and body language (ระวง

การแสดงออกและภาษากายของเรา)

1. ผอนคลายและสงบ

2. แสดงความสนใจ

S- Keep it SIMPLE (ท าใหงาย) 1. สน ๆ งาย ๆ และถนด

2. ตวเลอกชดเจน

S- SUPPORT their conversation (ชวยการสนทนาของเขา) 1. ใหเวลา

2. ชวยนกค า

3. พดซ าและใหพดตาม

4. เตอนเกยวกบเรองทพด

A- ASSIST with visual AIDS (ชวยเพมการมองเหน) 1. ใชทาทางประกอบ

2. ใชวตถและภาพ

G- GET their message (เขาใจความหมาย) 1. ฟง ด และตอบสนอง

2. พฤตกรรมและภาษากาย

E- ENCOURAGE and ENGAGE in communication (สงเสรม

และมสวนรวมในการสอสาร)

1. หวขอนาสนใจและถนด

2. ครอบครวและเพอน 11/06/61

Vernooij-Dassen, M. Int Psychogeriatr. 2010.

Mild Cognitive

Impairment

11-Jun-18 87

Petersen’s criteria

Memory complaint (self/informant) Impaired on a standardized memory (0.5

on Clinical Dementia Rating (CDR) and/or 1.5 SD below norm on different NP test

Normal general cognitive function (MMSE > 24)

No or minimal impairment on ADL’s or IADL’s

Do not meet NINCDS-ADRDA criteria for AD

Petersen RC et al 2001, Petersen RC et al 2004

MCI—Criteria for the clinical and

cognitive syndrome

1. Concern regarding a change in cognition

2. Impairment in one or more cognitive domains

3. Preservation of independence in functional abilities

4. Not demented

Albert MS, et al. 2011.

What is the prevalence of MCI in the general population? • Prevalence (95% CI 28.1%–48.0%, I2 24.8).

• Higher prevalence with

• Age

• Lower education

Age (Years) Prevalence (%)

60–64 6.7

65–69 8.4

70–74 10.17

75–79 14.8

80–84 25.2

85 and older 37.6

Decision making for MCI subtypes

Geda YE. Curr Psychiatry Rep. 2012. 11 June 2018 nahathai.wongpakaran@cmu.ac.th 92

Montreal Cognitive Assessment- MoCA

Montreal Cognitive Assessment (MoCA)

Clinician rated, well-trained

11 cognitive domains

Can be completed in 10 min

Thai version Hemrungroj S. 2011.

Score 30, Cut-off 24/25

Cronbach's alpha 0.744, Pearson’s 0.91, sensitivity 0.70 & specificity 0.95

(Tangwongchai S. et al. 2009.)

Nasreddine Z. et al. J Am Geriatr Soc. 2005.

11/06/61 95

Neuroimaging

• Importance: Clarifying diagnosis

• i.e. MRI is helpful in predicting progression to dementia

• The entorhinal cortex in a normal control (A) and a person with

mild cognitive impairment (B) Masdeu JC, 2005.

PET scan of MCI

PET images obtained with the amyloid-imaging agent Pittsburgh Compound-B ([11C]PIB) in a normal

control (left); three different patients with mild cognitive impairment (MCI, center); and a mild AD patient (right). Some MCI patients have control-like levels of amyloid, some have AD-like levels of amyloid, and some have intermediate levels. PET, positron emission tomography; MCI, mild cognitive impairment; AD, Alzheimer's disease.

Course of MCI

Improved/recovered 14.4%-55.6%

Stay impaired

Progress to dementia 14.9%

(in 2 years)

Treatment-MCI

No standard treatment

Aim delay onset of dementia

Non-pharmacologic approaches

What pharmacologic treatments are effective for patients diagnosed with MCI? • AChEI’s are ineffective

• Insufficient/uncertain evidence

• High-dose flavonoids (990 mg)

• Homocysteine-lowering therapies

• Piribedil

• V0191/procholinergic drug

• Vitamin E 2,000 IU

• Oral vitamin E 300 mg/d + vitamin C 400 mg/d over 12 months

• Possible improvement

• transdermal nicotine (15 mg/d)

• Tesamorelin/Growth hormone–releasing hormone injections

over 20 weeks

• Increase risk of AD progression

• Rofecoxib

Brain activation 16-wk concord grape juice consumption

Krikorian R. et al. J Agri Food Chem. 2012.

Folate

Magnesium

11/06/61 nahathai.wongpakaran@cmu.ac.th

อาหารหลากส

11/06/61

What nonpharmacologic treatments are effective for patients diagnosed with MCI?

◦ Improve cognition

◦exercise training for 6 months

◦Controversial/inconclusive

◦Cognitive interventions

Exercise

Aerobic exercise increases hippocampal volume

ten Brinke LF, et al. Br J Sports Med. 2015.

Exercise: Tai Chi

oPhysical, cognitive, social, and meditative components

Wayne PM, et al. J Am Geriatr Soc. 2014.

Effect of exercise on dementia: theoretical model

Kirk-Sanchez NJ, et al. Clin Interv Aging. 2014.

Pet-assisted living intervention

◦Mild to moderate cognitive impairment

◦22 on Pet dog vs. 18 on reminiscence

◦Evaluation

◦Physical: energy expenditure, ADL’s

◦Emotional: depression, apathy

◦Behavioral: agitation, function

◦60-90 minute, 2/wk x 12 wks.

◦Pet group: improved physical activity and

depression Friedmann E. et al. Am J Alzheimers Dis Other Demen. 2015.

Peppers

Lavender & Vanilla

Ginseng

Humors

Chocolate

Social activities

จดการกบความเครยด

◦คมการหายใจ

◦จดตารางส าหรบกจกรรมคลายเครยด

◦ กจกรรมทางศาสนา

เรองเครยดมผลกระทบกบคนทมพนธกรรมผดปกต (5-HT transporter gene promoter polymorphism)

18 January 2016 121

การนงสมาธเพมเนอสมองได

Leung MK, et al. 2013.

Holzel BK, et al. 2012.

พฒนาจต ท าใหสมองพฒนา

Drumond Marra HL, et al. Behav Neurol. 2015.

BPSD: Definition

BPSD: Behavioral and Psychological

Symptoms of Dementia

“Symptoms of disturbed perception, thought

content, mood or behavior that frequently

occur in patients with dementia”

(Finkel and Burns, 1999)

Aggressivity

Screaming

Restlessness

/Agitation

Anger/

Irritability

Cursing

Wandering

Common specific symptoms

Delusion

Hallucination

Depression

Sexual

disinhibition Culturally

inappropriate

behavior

Shadowing

Hoarding BPSD

Apathy

5 Most common BPSD’s among Thais

Studies/It

Senanarong V,

et al. 2005

Charernboon T,

et al. 2014.

Taemeeyapradit U,

et al. 2014.

N 73 62 158

Types AD AD Mixed

BPSD’s

Irritability

Apathy

Irritability

Apathy

Aberrant motor

behavior

Sleep problems

Anxiety &

Aberrant motor

behavior

Sleep problems

Depression

Night time beh

Eating problems

Anxiety

Agitation

Agitation/aggressio

n 45.2%

Agitation/aggressio

44.9% nahathai.wongpakaran@cmu.ac.th

Multiple Etiologies Model

Genetics (receptor

polymorphism)

Neurobiological aspects

(neurochemical,

neuropathology)

Psychological aspects

(e.g., premorbid

personality, response to

stress)

Social aspects (e.g.,

environmental

change and

caregiver factors)

Treated if burdensome

Cause(s)?

Non-pharmacological

treatment

Pharmacological

treatment

Psychosocial intervention

• Activity and recreation

• Carer education

• Exercise, movement, relaxation & massage

• Simulated family presence

• Music, sensory enrichment & aromatherapy

• Reminiscence and validation therapy O’Connor DW et al, International psychogeriatrics 2009

IPA’s Guide to BPSD Management, 2012.

Recreational therapy

Massage Therapy

• Aromatherapy1,2

• Agitated behaviors

• Family tape-recordings3

• Agitated behaviors

• Physical activity4

• Active exercise program

• Has a calming effect and lifts mood

1.Holmes et al., 2002.; 2.Ballard et al., 2002.;

3.Garland et al., 2007.; 4.Williams and Tappen, 2007.

Snoezelen: Multi-sensory stimulation (MSS)

Reminiscence Therapy

Medications

• Cholinesterase inhibitors

• N-methyl-D-aspartate receptor modulators

• Antipsychotics

• Antidepressants

geriatric psychiatry - wongpakaran.com · geriatric psychiatry prof. nahathai wongpakaran, md,...

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