Transcript Dr. Clifford Singer, MD

The Neuropsychiatry of
Aging
Clifford Singer, MD
Medical Director of Geriatric Mental Health and Neuropsychiatry
The Acadia Hospital and Eastern Maine Medical Center
Bangor, Maine
Overview
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Introduction
Dementia/Depression/Delirium
Clinical Assessment
Treatment
Summary
Introduction
• Normal neurological and psychological aging:
– Challenging to define
– Increased variability in old age
– Effect of “preclinical” disease hard to detect
• Of neuropsychiatric variables, memory, mood
and motor functions are the most sensitive to
aging and pathology: “The 3 D’s”
Clinical Syndromes in Old
Age: The Four D’s
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Dementia: Cognitive disorder
Depression: Mood disorder
Delirium: Attention/arousal disorder
Delusions: Disorder of perception and
beliefs
• All share a “Fifth D”: disability
• And a “sixth D”: dyskinesia
The Overlapping Syndromes
Cognition
Depression
Mood
Delusions
Attention
Delirium
Dementia
Perception
Motor
Dementia
• Decline in cognitive function from a
previous adult level
• Recent memory impairment
• Impaired executive function is the real
disability
• Many underlying causes; detection of
dementia should prompt effort to
diagnosis underlying cause
Mood in Dementia
• Changes in mood and behavior can be seen
before changes in cognition are noticeable
• Apathy (loss of: initiative, motivation, drive,
emotional responsiveness, engagement) is
disabling
• Depression, irritability and anxiety are very
common in dementia
• Affect dysregulation can be severe in later
stages leading to “catastrophic reactions”
Major Depressive Disorder
• Disorder of mood with cognitive and motor
features
• MDD increases with disability in old age
• Mood is affected by other common
conditions: 3 I’s: isolation, immobility,
impairment
• Brain diseases of aging increase prevalence
rates: especially vascular and parkinsonian
diseases
Depression and Dementia
• Complex relationship of cause and
affect
• Old concept of “pseudodementia” no
longer valid
• Depression “accelerates” brain aging:
cortisol, decreased neurotrophic factors
• MDD and AD co-existing bring on
dementia sooner than either alone
Delirium
• Disorder of cortical arousal and confusion
– Alert-delirious-stuporous-comatose
• AKA: Transient confusional episode,
encephalopathy, altered mental status
• Hallmark: impaired sustained attention
• Other features: disorientation, hallucinations,
delusions, agitation, anxiety, fluctuating
congition and awareness, sleep-wake cycle
disturbances
Causes of Delirium
• Predisposing factors: Immature brain
development or brain damage or dysfunction
• Precipitating factors: infection, metabolic
derangements, vascular events, toxic
substances (including meds), seizures,
stress, surgery (multifactorial)
• Good prognosis for index episode, less
favorable for long term
Delusional Disorders
• Late life psychosis may occur in context
of mood disorder (MDD, Bipolar),
dementia, delirium, long standing
mental illness (schizophrenia) or late life
onset (delusional disorder)
• Psychosis without delusions: visual
hallucinations (Charles Bonnet), musical
hallucinations
Key Elements of Clinical
Assessment
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History
Geriatric ROS and functional status
Exam
Labs
Imaging
History
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What has changed?
When did it change?
What did you notice first?
Gradual or progressive?
Personality change?
Memory
• The impaired ability to learn new
information is the core of dementia
– Affected by normal aging, beginning in
early adulthood: annoying, not disabling
– Aging affects episodic and working
memory not implicit memory
• Severe memory impairment without
dementia is known as “MCI” or mild
cognitive impairment
Executive Functions
• Reasoning, decision-making, judgment,
impulse control, initiation, abstraction,
planning, task execution
• Served by the frontal cortex: not
affected by normal aging
• The real disability of dementia
• Impaired by depression
Attention
• Essential for survival
• Must be selectively focused or organism
becomes overwhelmed
• Brain stem, reticular activating system
and frontal cortex all necessary
• Diffuse processes affect system at all
levels and produce delirium
Motor Functions
• Diseases that affect central motor
functions usually cause cognitive and
mood changes
– Stroke, Parkinsonian diseases, ALS,
Huntington’s
• Dementia, depression and delirium also
associated with motor changes
Geriatric Review of Systems
for Neuropsychiatry
• MOMS: mobility, output, memory, sleep
• AND: aches, neurological, depression
• DADS: delusions, appetite, dermis,
sensory
Functional Status
• ADLs
• IADLs (instrumental or cognitive ADLs)
• Descriptive instruments
– Clinical Dementia Rating Scale
• Morris JC, 1993, Neurology 43:2412-4
• Rate five domains (memory, orientation,
problem solving, community affairs, home and
hobbies, self-care) on 0-3 scale to score no
dementia, questionable, mild, moderate, severe
Cognitive Exam
• Select instrument or assessment based
on your objective:
– Screening (high sensitivity, fast, easy)
– Differential diagnosis (high selectivity)
– Detecting change over time (high testretest reliability)
Executive Function
• Key concept in assessment: the true
disability of dementia
• Refers to frontal lobe cognition:
abstraction, reasoning, decisionmaking, impulse control, initiation,
cognitive flexibility, attention and
concentration, planning and sequencing
in task execution, verbal skills
Looking for AD
• Abnormal tests of memory and
orientation, verbal fluency, copy of
geometric design, praxis in context of
normal gait, balance, mood and affect
• Screening: Mini-Cog, Mini-Cog + verbal
fluency task
• Global tests recommended: MMSE,
MoCA (mocatest.org), SLUMS
Quick Screen: Mini-Cog
Borson S et al. 2003 JAGS 51(10):1451-1454
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3-word recall
Clock draw test
Sensitivity and specificity rivals MMSE
Validated cross cultures
Can be augmented with other quick
tests of attention and verbal fluency to
create an impromptu screening tool
Common Global Tests
• Mini-Mental State Exam
• Modified MMSE (3MSE)
• Montreal Cognitive Assessment
– Public domain
– Excellent website with instructions and validation
data
– Validated in numerous languages
– More sensitive than MMSE
• St. Louis University Mental Status
www.mocatest.org
Differential Diagnosis
• Nature and severity of impairment give
critical clues to diagnosis.
• Sample broad spectrum of cognitive
functions, but take a “deeper biopsy”
where you think the lesion is based on
history.
Alzheimer’s Disease
• Medial temporal/hippocampal phase:
– AD begins with a long phase of recent
memory impairment
• Dementia phase:
– As the disease spreads to frontal and
parietal cotex, it becomes disabling with
task, verbal, executive and perceptual
dysfunction
Vascular Dementia
• Small vessel disease presents as a
subcortical process with gradual erosion
of executive function associated with
parkinsonism
• Large vessel disease highly variable,
“step-wise” progression in cognition and
neurological findings
Dementia with Lewy Bodies
• A diffuse cortical-subcortical process
characterized by a progressive, chronic
delirium with parkinsonism without
tremor and REM Sleep Behavior
Disorder
• Less memory impairment than AD
• Fluctuating alertness, attention,
executive function
Frontal Lobe Dementia
• Diagnosis based on age, history of
personality changes as much as
cognitive changes.
• Verbal fluency often impaired early on
• Imaging (especially PET, SPECT)
especially helpful
Verbal Fluency
• A sensitive measure of prefrontal cortex
function
• Impaired in many types of dementia as
well as mental illness
• Number of words generated in one
minute in either letter or semantic
categories (FAS or animals)
– >15 is good performance, <10 is impaired
Depression
• Complex relationship to dementia as
both a risk factor and cause
• General memory impairment
• General executive impairment
• Highly variable and fluctuating
• Not a “pseudo-dementia”
• Depression with dementia has a poor
prognosis
Delirium
• Primarily a disorder of cortical activation
with fluctuating alertness, attention and
concentration
• Diffuse problems with orientation,
memory and executive function
• Often associated with ataxia, praxis and
problems with gait and balance
Attention and Concentration
• Attention:
– Digit Span (7 forward and 5 reverse)
• Concentration: Sustained mental tasks
– Reverse spelling
– Reverse sequences (months)
– Serial subtractions
– Story recall
Assessing Mood and Behavior
• Instruments:
– Geriatric Depression Scale
– Cornell Scale for Depression in Dementia
– Neuropsychiatric Inventory
Lab Tests
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CBC, complete metabolic profile
Thyroid function tests
UA, HIV?, RPR/FTA?
B12, folate, vitamin D
EEG?
Polysomnography?
Imaging
• Non-contrast CT in most
• MRI in vascular dementia is considered
or better documentation of AD is
needed (hippocampal atrophy)
• SPECT or PET when FTD is considered
or better documentation of AD is
needed
Key Clinical Features
AD
VaD
DLB
FTD
MDD
Delirium
memory
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executive
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attention
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motor
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behavior
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Summary
• Changes in mood, behavior, thinking
and cognition are pathological in old
age and require a differential diagnosis
• Assessment skills should suit the
occasion
• Clinicians should think about specific
functions and pathology in assessment