(1)
Uniformed Services University of Health Sciences, Honolulu, HI, USA
(2)
University of Hawaii, 2756 L Pali Highway, Honolulu, HI 96817, USA
(3)
Tripler Army Medical Center, Honolulu, HI, USA
(4)
University of Hawaii, 2861 Kalawao Street, Honolulu, HI 96822, USA
33.1 Vignette
33.2 Introduction
33.5.2 Delirium
33.5.3 Mood Disorders
33.5.4 Psychosis
33.5.5 Anxiety disorders
33.6.2 Capacity
33.6.5 Discussion of vignette
33.1 Vignette
An 85-year-old woman, with a history of moderate dementia (with an MMSE of eighteen 6 months ago), hypertension, hyperlipidemia, coronary artery disease was admitted to the hospital because of altered mental status. History reveals worsening agitation after a fall about a week ago. Her current medications include oxybutynin for urinary incontinence, cimetidine for acid reflux, and citalopram 40 mg daily for depression, in addition to her antihypertensive and cardiovascular medications. Because she was agitated she had also been started on haloperidol (5 mg total daily) and 1 mg lorazepam every 6 h as needed a week ago with no improvement in behavior, but with further decrease in her eating and self-care. On physical exam she was noted to have cogwheeling, restlessness, and bruises on her arms and her left hip area. When palpating and performing range of motion of her left lower extremity, it was noted that she pulled back and got more agitated. Mini-Mental Status Exam was 12/30 with difficulties with orientation, spelling “WORLD” backwards, and recall. During the interview she stated that she wants to go home and dislikes medications. Staff reported that she has been refusing some of her medications. Labs were performed which indicated sodium 120, urinalysis positive for leukocyte esterase and nitrites, an EKG with QTc 490, and X-ray indicating ankle fracture. The patient was started on ciprofloxacin for urinary tract infection. A psychiatric consultation is requested for management of altered mental status and agitation, as well as for assessment of capacity to refuse treatment.
33.2 Introduction
The elderly or geriatric population—comprising people over the age of 65 years—is rapidly growing in the USA and throughout the world. According to the United Nations World Prospects (2012), the global population of people over age 60 years in 2013 was estimated to be 841 million or 12 % of the population. They are expected to reach two billion, or 21 % of the population, by 2050. In 2010, the US Census Bureau estimated that the elderly population over age 65 years was 40.3 million, or 13 % of the total US population. Of this group, those over the age of 90 nearly tripled in the past 30 years to 1.9 million.
This growing elderly population correlates with the increasing utilization of health services by the elderly. The 2006 National Hospital Discharge Survey conducted by the US Department of Health and Human Services (DeFrances et al. 2006) found that 38 % of inpatient beds were occupied by patients ages 65 and older compared to 20 % in 1970. A prospective study (Fulop et al. 1998) found that 44.5 % of geriatric inpatients met criteria for a psychiatric comorbidity. Studies have shown that treatment of these psychiatric comorbidities can actually impact health care spending because of the correlation between psychiatric comorbidities and length of stay in the hospital (Fulop et al. 1998). Levitan and Kornfeld (1981) also found that elderly patients receiving psychiatric consultations after being admitted for hip fractures spent 12 fewer days in the hospital and were also more likely to be discharged home rather than to a nursing home.
33.3 Principles of Geriatric Assessment and Treatment
The geriatric population on the Consultation-Liaison service is a distinct and challenging group because high rates of medical comorbidity and biological changes associated with aging can impact treatment. Most elderly patients have at least one or more chronic medical conditions (Table 33.1). In addition, the psychiatric problems and stressors elderly patients deal with are vastly different from their younger counterparts (Table 33.2) with higher rates of dementia, delirium, and depression (Downing et al. 2013). They are also unique because of issues related to death, dying, and palliative care.
Table 33.1
Most frequently occurring conditions of the elderly in 2009–2011 (US Department of Health and Human Services, Administration on Aging 2012)
Arthritis (51 %) |
Cardiac disease (31 %) |
Cancer (24 %) |
Diagnosed diabetes (20 %) |
Hypertension (72 %) |
Dementiaa |
Deliriuma |
Mood disorders (particularly depressiona) |
Psychosis |
Personality disorder |
Adjustment disorder |
Anxiety disorder |
Many of the unique developmental issues facing geriatric patients can be understood from a biopsychosocial perspective (Table 33.3, Ahmed and Takeshita 1997). From a biological perspective, understanding normal age-related changes is important to distinguish them from pathological ones. For example, there are age-related cognitive changes such as reduced mental processing speed, perceptual-motor tasks, memory, and the performance of novel tasks. Vocabulary, comprehension, knowledge, reasoning, and judgment, however, should remain the same (Albert and Moss 1988; Christensen 2001). Also, understanding the concept of young-old (65–75) versus old-old (85+) helps emphasize that elderly patients cannot all be categorized as one homogenous group. The old-old tend to have more comorbidities, functional problems, and poor prognostic conditions. From a psychological and social perspective, there are changes in self-concept and roles, particularly increasing dependency issues. Age-related biopsychosocial issues make elderly patients more vulnerable to psychiatric disorders.
Table 33.3
Issues facing the geriatric population
Biological aging issues | Psychological aging issues | Sociological aging issues |
|---|---|---|
Age-related changes of the body and organ systems. | Changing roles and relationships: family, friends, society, occupational. | Societal and cultural attitudes towards aging. |
Changes in the brain: Gross structural changes. Loss of neurons which can affect mood, behavior, and cognition. Decreased adaptive capacity. Neurotransmitter and receptor changes. | Issues and fears of dependency. Coping with physical and cognitive limitations. | Changes in socioeconomic status, marital status, occupation. |
Sensory changes (vision, hearing). | Coping with loss and end of life issues. Preparing for death. | Changing and decreasing sources of support. Increasing emphasis on the extended family. |
Higher rates of medical comorbidities. | Erik Erikson’s developmental stage of Ego Integrity versus Despair. | Intergenerational issues including role reversals. |
Changes in pharmacokinetics and pharmacodynamics. Brain having increased vulnerability to side effects of medications. | Institutionalization. |
The assessment of the geriatric patient should also pay attention to their medical co-morbidities as well as their level of cognition and functioning. Geriatric patients more likely have medical illnesses that coexist with or cause psychiatric symptoms. Therefore understanding patterns of onset, associated medical/psychiatric symptoms, recent changes to health status, and medications can help differentiate medical versus psychiatric causes. The presentation of psychiatric disorders may also be different than that seen in the younger population. They often present with more somatic and cognitive symptoms and may report psychiatric symptoms less often (Jeste et al. 2005).
Compared to their younger counterparts, there also may be barriers to communication due to their sensory loss (vision, hearing), slower processing time, and varying degrees of cognitive decline (Stubbe 2013). In addition, because there may be capacity issues, assessment often includes speaking with family members or caregivers. Allowing extra time for these assessments and limiting the distractions in the room can be helpful. Speaking slowly, simply, using visual/hearing devices if necessary, and having caregivers involved can also improve communication.
33.4 Pharmacological issues in the Elderly
Pharmacokinetic changes occur with both normal aging and with the diseases that increase with aging such as cardiac, renal and liver diseases (Table 33.4). In addition, age-related changes in the various organ systems render them more susceptible to the adverse effects of the medications. The changes in the brain with aging are particularly significant (Table 33.5) and have an impact on both the therapeutic and adverse effects of the drugs.
Physiologic change | Pharmacokinetic effect |
|---|---|
Increased body fat | Slower elimination of fat soluble drugs |
Decreased total body water | Increased concentration of water soluble drugs |
Decreased serum albumin | Higher percent of unbound active drug |
Decreased hepatic blood flow | Delayed clearance of drugs through the liver |
Decreased phase I metabolism | Decreased effectiveness of metabolism of most psychotropic drugs |
Decreased renal excretion | Increased concentration of renally excreted drugs |
Table 33.5
Biological changes in aging brain
Brain size decreases 10–15 %, with the most dramatic changes occurring in frontal lobes and hippocampus |
Increased blood–brain barrier permeability |
Decrease in horizontal dendritic components |
Formation of neurofibrillary tangles and amyloid plaques |
Decrease in neurons and neurotransmitters, particularly dopamine, and acetylcholine |
Altered receptor sensitivity |
Adhering to the principles of pharmacotherapy outlined in Table 33.6 should help ensure the optimal therapeutic benefit of medications in the elderly while avoiding the risks of adverse reactions. Specific considerations in choice of agents should include caution in the use of drugs with anticholinergic effects and those with cardiovascular effects. Because of increased medical comorbidities, the elderly are at increased risk for adverse outcomes with medications. In addition, with the increased use of both prescribed and over-the-counter medications, there is a greater risk of drug–drug interactions. The choice of agents used should factor in the associated medical/neurologic comorbidity. For example, in patients with specific disorders such as Parkinson’s disease, agents with minimal extrapyramidal effects such as quetiapine may be preferred.
1. Rule out medical etiologies for psychiatric symptoms. |
2. Review the patient’s medication list (both before admission and during admission) and ask about over-the-counter or herbal medications. |
(a) Avoid polypharmacy |
(b) Watch for drug–drug interactions |
3. Consider removing psychiatric/psychoactive medications that may be causing symptoms. |
4. Use behavioral interventions first and minimize use of medications. |
5. If medications are used, determine what symptoms are to be targeted. |
6. Ensure adequate hepatic or kidney function depending on the medication used. |
7. Start low and go slow (half the usual dose and rate). Use the lowest effective dose. |
8. Change one medication at a time. Utilize blood levels if possible. |
9. Monitor for side effects, particularly anticholinergic/cardiovascular/hyponatremic effects, orthostasis, falls, and confusion. |
10. Laboratory monitoring for adverse effects from psychotropics that could include complete blood count, electrolytes, lipid profile, fasting glucose, and EKG. |
In a prospective study conducted by Hamilton et al. (2011) of hospitalized patients 65 years or older, 26 % had adverse drug reactions. 66.6 % of the total adverse drug reactions either contributed to or were the cause of the admission. The Beers criteria was developed and updated (American Geriatrics Society 2012 Beers Criteria Updated Expert Panel 2012) to evaluate for potentially inappropriate medication use in the older adults. Examples of potentially inappropriate medications (PIMs) in the elderly include: tertiary tricyclic antidepressants (such as amitriptyline, doxepin) and first generation antipsychotics such as thioridazine and mesoridazine because of their high anticholinergic effects. Other PIMs include benzodiazepines and nonbenzodiazepines, which can increase fall risk, produce prolonged sedation, and diminished cognition. It is also recommended that first and second generation antipsychotics be avoided for behavioral disturbances of dementia, unless non-pharmacological treatment has failed, due to its increased stroke and mortality risk. Medications that can cause or worsen SIADH and are thus to be used with caution are antipsychotics, carbamazepine, mirtazapine, SSRIs, SNRIs, and tricyclic antidepressants.
33.5 Specific Disorders in the Elderly
33.5.1 Dementia/Major Neurocognitive Disorders (NCD)
With the rapidly growing elderly population, dementia (renamed major NCD in DSM5) is a commonly encountered issue in the medical unit. (See Chap. 13 for further details regarding change in criteria from Dementia to Major NCD.) According to Alzheimer’s Association Report (2013), 11 % of those age 65 and older have Alzheimer’s Disease, and the prevalence reaches 32 % by age 85 years or older.
The presence of dementia can directly affect the care of an elderly patient in the hospital setting. A study conducted by Erkinjuntti et al. (1986) reported that patients suffering from dementia had increased lengths of stay and required more daily nursing care upon discharge than those without it. The distinction between delirium and dementia is a frequent subject of inpatient consults. Taking a proper history of patients’ cognitive symptoms from a reliable caregiver and recognizing the fluctuating level of consciousness that characterizes delirium may help distinguish between the two conditions. Using a cognitive screening instrument such as the Saint Louis University Mental Status (SLUMS), Montreal Cognitive Assessment (MOCA), Mini-Mental State Examination (MMSE, although now copyrighted), or Mini-Cog may be helpful in both the diagnosis of cognitive impairment and in determining if cognition is fluctuating with serial examinations (Feliciano et al. 2013; Ismail et al. 2010) (see Chaps. 12 and 13 for additional discussion of delirium and dementia).
Additionally, assisting the treatment team with problematic behaviors that arise with dementia is also a common role for CL psychiatrists. Some of these behavioral problems are included in Table 33.7.
Depression, anxiety, irritability, mood lability |
Apathy, social disengagement |
Psychosis: hallucinations, delusions, paranoia |
Physically nonaggressive behaviors: |
Restlessness, pacing, wandering |
Repetitive behaviors, hoarding, hiding things |
Inappropriate/disinhibited social interactions and regressive behavior (neediness) |
Physically agitated/aggressive behaviors: |
Resistance to care |
Biting, hitting, kicking |
Verbally nonaggressive behaviors: |
Repetitive vocalizations/questions |
Verbally agitated/aggressive behaviors: |
Yelling, swearing, calling out |
33.5.1.1 Treatment of Dementia
When approaching treatment of behavioral problems, it is important to first investigate the following (American Psychiatric Association 1997):
1.
New medical problems
2.
Medication side effects, recently added medications
3.
Pain issues
4.
Sleep deprivation
5.
Recent environmental changes (e.g., transition to hospital, changes in caregivers)_
6.
“ABC’s” (antecedent → behavior → consequence)
Considering these factors can aid in not only determining the etiologies for these problematic behaviors, but can also give clues to what interventions can help in the future.
Before considering pharmacologic treatment of behavioral problems, non-pharmacologic interventions must first be attempted. Some general recommendations in dealing with agitated dementia patients are listed in Table 33.8 (American Psychiatric Association 1997; Cohen-Mansfield 2001; Wyszynski and Wyszynski 2005).
Table 33.8
Recommendations in dealing with agitated dementia patients
Sensory interventions: |
Use relaxation techniques, massage, or music during nursing activities to promote ease of care |
Use glasses, dentures, and hearing aids |
Provide adequate lighting |
Adequate pain assessment |
Light exercise |
Environmental interventions: |
Minimize noise in the environment |
Provide adequate personal space |
Limit interventions during most agitated times of the day (often times after late afternoon/early evening) |
Allow safe places for patients to wander |
Behavioral interventions: |
Calm and soothing tones |
Use simple sentence directions |
Use distraction and redirection. |
Minimize arguing, scolding. Understand that insight into their illness may be limited-Praise for positive behavior |
Limit use of restraints for problematic behaviors |
Caregiver support: |
Providing caregiver support |
Monitoring for caregiver burnout |
Side effects and drug interactions must be considered when administering medications for elderly patients with medical comorbidities. Acetylcholinesterase inhibitors such as donepezil, rivastigmine, or galantamine are routinely used for those with mild to moderate dementia, with donepezil labeled for the severe stage as well (Patel and Holland 2011). These medications frequently have gastrointestinal side effects such as nausea, vomiting, diarrhea, and anorexia therefore slow titration and administering with food can be helpful. Although less common, other side effects to consider include gastrointestinal bleeding, urinary incontinence, fatigue, muscle cramps/weakness, insomnia, abnormal dreams, tremors, seizures, dizziness, bradycardia, orthostatic hypotension, and syncope. Thus they should be used with caution in those with a history of bradycardia, heart block, sick sinus syndrome, syncope, seizure disorder, peptic ulcer disease, low body weight, or severe asthma/chronic obstructive pulmonary disease.
Memantine, an NMDA receptor antagonist can also be used to treat moderate to severe dementia. Often used in combination with cholinesterase inhibitors in the past (Tariot et al. 2004), a recent study by Howard et al. (2012) indicated no significant advantage of using combination treatment compared to donepezil alone.
The decision whether to discontinue these medications in the inpatient setting may be considered when the patient has reached the end-stage of dementia or when other medical comorbidities make continued treatment burdensome or futile. It is the role of the clinician with input from the caregiver and family members to make that assessment.
For the treatment of agitation and psychosis in dementia patients when non-pharmacologic approaches fail, medications such as SSRIs or antipsychotics may need to be used (Keenmon and Sultzer 2013; Barak et al. 2011, and Pollock et al. 2007). A greater number of studies indicate atypicals, particularly risperidone as having the best evidence of efficacy for agitation (Corbett et al. 2012). However, in the studies by Pollock (2007) and subsequently Barak (2011), there was no statistically significant difference in efficacy of citalopram or escitalopram respectively compared to risperidone.
The FDA has, however, recently issued warnings about antipsychotic use in dementia patients. In 2003 a safety alert was issued when patients participating in risperidone trials were found to have increased incidence of cerebrovascular accidents (FDA 2003). Other sources, however, indicate this is probably a class effect (Corbett et al. 2012; FDA 2003). Later in 2005, the FDA issued an advisory declaring an increase in overall mortality in elderly patients with dementia being treated with any atypical antipsychotic medication (FDA 2005). The advisory then expanded to include typical antipsychotics in 2008 with typicals likely having a greater mortality risk (FDA 2008; Wang et al. 2005). Of note, none of these agents are approved by the FDA for treating psychotic and behavioral symptoms associated with dementia.
33.5.2 Delirium
Delays in recognizing and treating delirium can have significant complications from both a medical and economic standpoint. Nearly 12.5 million elderly patients are admitted to US hospitals each year (Inouye 2006). The development of delirium complicates at least 20 % of these hospitalizations, contributing to over 49 % of all hospital days and increasing hospital costs by as much as $2,500 per patient. These effects in the elderly are further magnified in the postoperative setting (15–53 %), in the intensive care setting (70–87 %) and in the end of life setting where the incidence is estimated at nearly 83 %. A meta-analysis by Witlox et al. (2010) found that there are long term consequences to delirium post-discharge. Those with delirium were at higher risk for mortality (38 % compared to 27.5 % for controls), institutionalization (33.4 % vs. 10.7 %), and dementia (62.5 % vs. 8.1 %).
Elderly patients are more prone to delirium because of the increased prevalence of risk factors such as chronic medical illness, dementia/cognitive impairment, sensory impairment (visual and hearing), structural brain disease, age-related central nervous system changes, and changes in pharmacokinetics and pharmacodynamics (Inouye 2006; Goy and Ganzini 2003). The presentation of delirium in the elderly shares many of the same characteristics as in the younger population (see Chap. 12 for DSM-5 diagnostic criteria for delirium).
Although priority should always be placed on non-pharmacological treatment and on treating the underlying etiology, a meta-analysis by Meagher et al. (2013) found 75 % clinical response rate in those with delirium that received short-term, low dosage antipsychotics. Historically treatment guidelines have generally recommended haloperidol when an antipsychotic is considered for agitation or psychosis due to its minimal anticholinergic effects, its wide therapeutic window, and its multiple routes of delivery. This meta-analysis, however, found no difference in response rates between atypicals (such as risperidone, olanzapine, and quetiapine) versus haloperidol except for the later having higher extrapyramidal rates.
If haloperidol is used in elderly patients, haloperidol can be administered at 0.25–1.0 by mouth (po) twice to three times daily with 0.25–1.0 mg po or intramuscularly (IM), repeated every 30–60 min if needed (Mittal et al. 2011). Similarly, dosing schedules were also reported for the atypicals as well. It should be noted that for delirium attributed to seizures or alcohol/sedative withdrawal, benzodiazepines are the first line agents for therapy. Lorazepam may have advantages for the elderly because of its rapid onset, shorter ½ life, more predictable bioavailability, lack of active metabolites, and decreased risk of accumulation (see Chap. 20 for a discussion of the controversy over lorazepam versus long acting benzodiazepines for alcohol withdrawal).
There have also been studies that have looked into whether prophylactic antipsychotic use would be beneficial for those at high risk for delirium. A meta-analysis by Teslyar et al. (2013) found that prophylactic antipsychotics had a 50 % reduction in relative risk for delirium compared to placebo.
33.5.3 Mood Disorders
33.5.3.1 Depression
The prevalence of major depression is higher in disabled, medically ill elderly patients at 10–12 % compared to their community-dwelling counterparts with an even larger number having less severe forms of depression (Alexopoulos and Kelly 2009). Elderly patients that have depression combined with chronic medical issues have higher disability rates, cost of inpatient services, and rates of readmission, nursing home placements, and mortality (Ellison et al. 2012; Shanmugham et al. 2005). Geriatric patients have unique risk factors for depression that are discussed in Table 33.9. Their clinical presentation of depression can also be different as they may complain of more somatic symptoms and sometimes deny feeling depressed. Table 33.10 describes some of the differences in characteristics of geriatric depression.
Death of a spouse or loved one (increased risk by 24.3 over 1 year) |
Medical illness/injury (increased risk by 3.0 over 1 year)including: Parkinson’s disease Cardiovascular disease Alzheimer’s disease Cerebrovascular disease (including stroke and white matter infarcts) |
Disability and functional decline (increased risk by 4.2 over 1 year) |
Limited social support |
Table 33.10
The Why and How of Psychiatric Consultation
Interviewing in Consultation-Liaison Psychiatry
Systems and Ethical Issues in CL Psychiatry: Hospital as a Social System, Sick Role and Doctor Role, Ethical and Legal Issues
Somatic Symptom and Related Disorders
Chronic Conditions, Lung Disease, Cancer, the Palliative Care Settings, and the Dying Patient
The Renal Dialysis and Kidney Transplant Patient
Differences in depressive characteristics in the elderly compared to younger populations: (Alexopoulos et al. 2002; Alexopoulos et al. 2005; Burke and Wengel 2003; Wise and Rundell 1996; Shanmugham et al. 2005)
Related posts:
The Why and How of Psychiatric Consultation
Interviewing in Consultation-Liaison Psychiatry
Systems and Ethical Issues in CL Psychiatry: Hospital as a Social System, Sick Role and Doctor Role, Ethical and Legal Issues
Somatic Symptom and Related Disorders
Chronic Conditions, Lung Disease, Cancer, the Palliative Care Settings, and the Dying Patient
The Renal Dialysis and Kidney Transplant Patient
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