old age psychiatry

Old age psychiatry
د.وليد عزيز العميدي
Normal aging :
Brain :
- There is reduction in the weight and volume of brain by 5% between age 30 and 70 y. , by 10%by the age of 80 , and by 20% by the age of 90.
- Ventricular enlargement .
- There is loss of nerve cells in the cortex , hippocampus , substantia nigra and purkinje cells of cerebellum of approximately 50000 per day.
- Appearance of senile plaques in the neocortex and amydala ; neurofibrillary tangles are usually confined to the cells of the hippocampal and entorhinal cortex.
Intellectual function :
- IQ peaks at 25y. , plateau until 60 – 70 y. and then declines.
- Working memory shows a gradual decline in capacity and it is worse with increased complexity of tasks and increases memory load.
- Long term memory declines. However remote events of personal significance may be recalled with great clarity.
Bodily functions :
- Decrease in cardiac output and stroke volume.
- Decrease in glomular filtration rate .
- Reduction in cerebral blood flow and oxygenation.
- Decreased vital capacity in the lungs.
- Decrease in melatonin.
- Impaired T-cell response to Ag and an increase in the formation of autoimmune Ab , which increase the susceptibility to infection and even to neoplastic diseases in old age.
- Thickening of the optic lens in association with an inability to accommodate (presbyopia).
- Progressive hearing loss .
Endocrine changes :
- Reduction in post menopausal oestrogen levels leading to vaginal epithelial atrophy and breast tissue involution.
- Gradual decline in the testosterone levels from 6th decade.
- Increase in levels of FSH and LH.
Sleep changes:
- Reduction in slow wave sleep (particularly stage 4 sleep ) and REM sleep.
- Increased night time wakefulness and reductions in total night time sleep.
- Increased fragmentation of sleep by periods of wakefulness.
- Increase in sensitivity to environmental stimuli that disrupt sleep.
- More day time fatigue , more day time napping .
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The social problems faced by the elderly :
- Social isolation.
- Stigmatization.
- Limited income and unemployment .
- Increase in medical problems.
- Loss of status .
- Loss of independence.
- Loss of spouse.

Delirium :
Is characterized by global impairment of consciousness (clouding of consciousness ) , resulting in reduced level of alertness ,attention and perception of environment .A number of other terms such as confusional state and acute organic syndrome have also been used. Delirium occurs in 15-30% of patients in general medical or surgical wards , and a higher proportion of patients in ICU. It is more common in the elderly .
Clinical features : the cardinal feature is disturbed consciousness . it is manifested as drowsiness , decreased awareness of surroundings , disorientation in time and place and distractability.
The onset is rapid with fluctuation in severity over min. and hr. Disturbance of sleep/wake cycle with nocturnal worsening of symptoms. Psychomotor agitation and emotional lability. Perceptual distortions , illusions and hallucinations-characteristically visual. Speech may rambling , incoherent and thought disordered.
Two distinct clinical subtypes are recognized :
1- Hyperactive delirium: characterized by increased motor activity with agitation , hallucinations and inappropriate behavior.
2- Hypoactive delirium : characterized by reduced motor activity and lethargy and has a poorer prognosis.

Aetiology :old age and prior medical and neurological disorders lower the threshold for developing delirium.The major pathway implicated is dorsal tegmental pathway , the major neurotransmitter hypothesized to be involved is Ach.EEG characteristically shows a generalized slowing of activity, which may be helpful in differentiating delirium from depression and psychosis.
1- Drug intoxication.
2- Alcohol withdrawal.
3- Metabolic failure : cardiac , respiratory , renal ,hepatic and hypo- or hyper-glycemia.
4- Fever : systemic infection.
5- Neurological causes : encephalitis , space occupying lesion , raised intracranial pressure ,following epileptic seizure and head injury
6- Others : constipation , dehydration , pain and sensory deprivation.


Management of delirium :
- Delirium is a medical emergency , it is essential to identify and treat the underlying cause.
- Provide environmental and supportive measures (education , reorientation ,reassurance , adequate lighting ,reduce unnecessary noise , consistent staffing ).
- Avoid sedation unless severely agitated or necessary to minimize risk to patients or to facilitate investigation/treatment.
- Correct sensory impairment (hearing aids , glasses).
- Optimize patient`s condition and attention to hydration , nutrition elimination and pain control.
- Make environment safe (remove objects with which patient could harm self or others).
- Use of drugs : low dose haloperidol is effective in alleviating a range of delirious symptoms in both hyperactive and hypoactive states , but haloperidol should be avoided in some causes of delirium as in the case of alcohol withdrawal (delirium tremens) in which benzodiazepines are usually used .

Dementia :
Is an acquired global impairment of intellect , memory and personality but without impairment of consciousness . it is usually but not always progressive . the syndrome of dementia is caused by a range of diseases , of which Alzheimer`s disease (accounting for 50 – 60 % of cases ), vascular dementia ( 20 – 25% ) , and dementia with Lewy bodies (15 – 20% ) are commonest. Both DSM- IV and ICD 10 definitions require impairment in two or more of cognitive domains (memory , language , abstract thinking and judgment , praxis , visuospatial skills , personality and social conduct ) , sufficient to interfere with social or occupational functioning. Dementia may be classified in terms of primary site of pathology :
1- Cortical : Alzheimer`s disease , fronto-temporal dementia , Creutzfeldt-Jacob disease.
2- Subcortical : normal pressure hydrocephalus , Huntington`s disease , Parkinson`s disease , multiple sclerosis.
3- Mixed : vascular dementia , dementia with Lewy bodies , neurosyhilis.

Causes of dementia :
1- Primary neurodegenerative disorders : Alzheimer`s disease , dementia with Lewy bodies and other frontotemporal dementia.
2- Vascular : vascular dementia , multiple sclerosis , subdural hematoma.
3- Inflammatory and autoimmune : SLE.
4- Infections : HIV.
5- Traumatic : severe head injury or repeated head injury in boxes (dementia pugilistica).
6- Metabolic and endocrine : sustained uraemia . hypothyroidism , hyperthyroidism , Cushing`s syndrome , hypoglycemia.
7- Vitamins and other nutritional deficiency : sustained lack of B12 and folate.
8- Other : normal pressure hydrocephalus.

Clinical features of dementia : the presenting complaint is usually of poor memory .
Other features include disturbance of behavior , language , personality , mood or perception .
The clinical picture is much determined by the patient`s premorbid personality. People with good social skills may continue to function adequately despite severe intellectual deterioration .
Forgetfulness is usually early and prominent, but may sometimes be difficult to detect in the early stages . impaired attention and concentration are common and nonspecific features.
Memory loss is more evident for recent than for more remote material. Disturbed episodic memory manifests as forgetfulness for recent day –to- day events , with relative preservation of procedural memory.Loss of adaptability and flexibility in new situations, with the appearance of rigid and stereotyped routines ( organic orderliness ) , and , when taxed beyond restricted abilities , sudden explosions of rage or grief are frequent ( catastrophic reaction).As dementia worsens , patients are less able to care for themselves and they neglect social conventions . disorientation for time ,and later for place and person is common.Behavior becomes aimless , and stereotypies and mannerisms may appear. Thinking slows and becomes impoverished in content and perseverative .In the later stages , thinking becomes grossly fragmented and incoherent , eventually the patient becomes mute . mortality increased , with death often following bronchopneumonia and a terminal coma.Behavioral , affective and psychotic features often accompany the cognitive deficit during dementia.
Baseline investigations in dementia : - in all patients : full blood count , ESR , urea and electrolytes , LFT , Ca and phosphates , TFT , syphilis serology , urinalysis , B12 and folate.
- With considering : HIV status , ECG , EEG , CT , MRI , CXR and neuropsychological assessment.
Screening test for dementia : e.g. MMSE , cut-off 24/30 , takes 5-10min. , most widely used test and has been validated , it is good for screening global cognitive dysfunction as opposed to focal cognitive dysfunctions , it covers the following area of cognitive functions: memory , orientation , attention and concentration , language , praxis , and gnosis .however , it is important to note that it is subject to variation with age , socio-economic status and educational achievement , moreover it is heavily weighted on verbal performance , which means that the performance of dysphasic patients is particularly poor.

Alzheimer`s disease : it is the commonest cause of senile dementia , prevalence rates for population over 65y . range from 2 – 7% , rising at age of 80y. to 8-10% .
Key features of Alzheimer`s disease :
- Memory impairment.
- Gradual onset and continuing decline.
- One or more of : aphasia , apraxia , agnosia , disturbance of executive function ( planning , reasoning).
- Exclusion of other disorders causing dementia.
Behavioral disturbances would include wandering , aggression , anger outburst , sexual disinhibition , incontinence , excessive eating and searching behavior.
Psychiatric symptoms : delusion , auditory and visual hallucination and depression.
The average survival expectation for patients with dementia of the Alzheimer`s disease is 8y.
Risk factors : age , Down`s syndrome , APL e4 allele , female sex , head injury , postmenoposal estrogen decline .
Protective factors : use of NSAIDS , hormonal replacement therapy , use of statins , cognitive and physical activity in mid-life.
The genetics of Alzheimer`s disease :- presenlin 2 gene (chromosome 1)---early onset.
- Presenlin 1 gene (chrom.14)-----early onset.
- Beta amyloid precursor protein gene (chrom.21) -----early onset.
- APL e4(chrom.19)-----late onset of Alzh.type.

Neuropathology : the classic gross neuroanatomical observation of a brain from a patient with A -lzheimer`s disease is diffuse atrophy with flattened cortical sulci and enlarged cerebral ventricles.
The classic and pathognomic findings are senile plaque , neurofibrillary tangles , neuronal loss (particularly in cortex and hippocampus ) , synaptic loss and granulovascular degeneration of neurons.
The Neurotransmitters that are most implicated in the pathophysiology of Alzh. Disease are Ach and norepinephrine , both of which are hypothesized to be hypoactive.
Neuroimaging : CT is mainly used to exclude other treatable causes . other indications include seizures , features suggestive of NPH.
CT: cortical atrophy over parietal and temporal lobes , dilatation of third ventricle which correlates with cognitive impairment .
MRI: reduced grey matter , hippocampus , amygdale , and temporal lobe volumes.

Other dementias:
Vascular dementia : it is the second most common cause of dementia after Alzh. Type ,
Risk factors include : old age , HT , IHD , smoking , hyperlipidemia , alcohol ,family hist. and AF.
Prominent symptoms and signs : personality change , labile mood , preserved insight.
Stepwise progression , signs of cerebrovascular disease , hist. of HT , commoner in men , smokers.
Most studies show somewhat shorter survival in than Alzheimer`s disease.

Dementia with Lewy bodies : it is the third most common cause of dementia , as the name suggests the cardinal feature neuropathologically is Lewy bodies in the cerebral cortex . also associated with more widespread reduction in cholineacetyltransferase in the neocortex (more than Alz. Disease ) and there is loss of dopamenergic markers . brain atrophy is less marked than in Alz. Disease especially in hippocampus
Key features :
- Progressive cognitive decline , especially in attention and visuospatial ability.
- Pronounced fluctuations in cognition and attention.
- Recurrent visual hallucinations , usually well formed and detailed.
- Motor features of parkinsonism.
Suggestive features :
- Repeated falls.
- Syncope.
- Transient loss of consciousness.
- Sensitivity to antipsychotics.
- Systematized delusion.
- Non-visual hallucination.

Frontotemporal dementias : are the second most common form of presenile dementia , presentation is usually between 45 and 70y.
Clinical picture : prominent behavioral change , expressive dysphasia , perseveration, echolalia, early loss of insight , early primitive reflexes, depression , apathy and late parkinsonism.
Pick`s disease : sometime used as synonymous with frontotemporal dementia ,the key clinical features are aphasia with dementia , the striking pathological findings were focal knife-blade atrophy of frontal temporal poleswith ballooned neurons(pick cells) containing inclusions called pick bodies , features of Alzh.disease are absent.

Prion diseases : unique groups of disease , can be inherited , acquired infectiously or iatrogenically , whilst other cases are sporadic . they are grouped together because the central role of a protein called prion protein as well as by common neuropathological features : diffuse spongiosis , neuronal loss , gliosis and amyloid plaque.
Creutzfeldt-Jacob disease : is the main prion disease , with an approximate annual incidence of one case per million. Few cases are inherited as an autosomal dominant disorder , other cases have been transmitted iatrognically by contaminated neuro surgical instruments or graft material , and possibly blood transfusion.
Sporadic CJD : affects both sexes equally . onset is typically between 50 and 65y. , it is usually heralded by memory impairment which may be accompanied by prominent behavioral abnormalities or personality change , cerebellar signs and other motor features . seizure occur later in the course.there is rapid progression to death often within 6 months.
Variant CJD : has an earlier onset , slower course and usually presents with psychiatric symptoms , including depression and personality change , caused by eating contaminated bovine products
Pulvinar sign on MRI (hyperintensity over the posterior thalamus) is useful and non-invasive diagnostic sign.

Potentially reversible causes of dementia :
- Intracranial causes :
* Normal pressure hydrocephalus.
* Subdural hematoma.
* Cerebral tumors.
* General paralysis of insane ( neurosyphylis).

- Systemic disorders :
* Alcoholism.
* Anoxia.
*Myxoedema.
*Vit.deficiency.
* Pseudodementia.
* Renal and hepatic disease.

Antidementia drugs : donepezil(Aricept) , rivastigmine(exelon) , galantamine(reminyl) are cholinesterase inhibitors used to treat mild to moderate cognitive impairment in Alzh.disease . these drugs can be used in patients with MMSE score between 10 and 20 , they reduce the inactivation of the neurotransmitter Ach and thus potentiate the cholinergic neurotransmitter.
Tacrine is rarely used because of its potential for hepatotoxicity.
Memantine (ebixa) protects neuron from excessive amounts of glutamate , which may be neurotoxic , memantine acts as antagonist NMDA receptors , an action that may be neuroprotective and thus disease modifying drug.

Delirium VS delirium
features dementia delirium
onset slow rapid
duration Months to years Hours to weeks
attention preserved fluctuates
memory Impaired remote memory Impaired recent and immediate memory
speech Word finding difficulty incoherant
Sleep-wake cycle Fragmented sleep Frequent disruption
thoughts impoverished disorganized
awareness Usually normal reduced