NEUROPSYCHIATRY IN THE NURSING HOME J Wesson Ashford

NEUROPSYCHIATRY IN THE NURSING HOME J. Wesson Ashford, MD, Ph. D, University of Kentucky FAMILY MEDICINE REVIEW www. medafile. com/neurnh 1. ppt 2001 - 2002

NEUROPSYCHIATRIC PROBLEMS IN THE NURSING HOME • • 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 • • • 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 • • 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) • • • 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) • • • 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 CA 1 of hippocampus • thiamine deficiency, hypoglycemia, hypoxia • EPILEPTIC PERSONALITY CHANGES • SPECIFIC BRAIN DISEASES

LABORATORY TESTS (routine) (less history usually found in NH setting) • BLOOD TESTS – – • • electrolytes, liver, kidney function tests, glucose thyroid function tests (T 3, T 4, FTI, TSH) vitamin B 12, folate complete blood count, ESR EKG CHEST X-RAY URINALYSIS ANATOMICAL BRAIN SCAN – CT / MRI

BEHAVIORAL PROBLEMS IN DEMENTIA PATIENTS • • 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 • (not FDA controlled) • • • 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