NEUROPSYCHIATRY IN THE NURSING HOME

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NEUROPSYCHIATRY IN THE NURSING HOME

• J. Wesson Ashford, MD, PhD,
• University of Kentucky
• FAMILY MEDICINE REVIEW
• www.medafile.com/neurnh1.ppt
• 2001 - 2002

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NEUROPSYCHIATRIC PROBLEMS IN THE NURSING HOME

• Dementia
• Delirium
• Psychosis
• Depression
• Insomnia
• Anorexia
• Parkinsons Disease

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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

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Differential Diagnosis Top Ten

• 1. Alzheimer Disease (pure 40,
  mixed70)
• 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 (Parkinsons, etc.)
• 8. Tumor, Toxin, Trauma
• 9. Infection, Idiopathic, Immunologic
• 10. Autoimmune, Amnesia, Apnea

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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

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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
• NOT DUE TO DELIRIUM
• (IN NURSING HOME RECENT STROKE)

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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

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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)

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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 Alzheimers disease

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Delirium Definition

• Disturbance of consciousness (i.e., reduced
  clarity of awareness of the environment) with
  reduced ability to focus, sustain, or shift
  attention
• Change in cognition (memory, orientation,
  language, perception)
• Development over a short period (hours to days),
  tends to fluctuate
• Evidence of medical etiology

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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

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NEUROLOGIC CONDITIONS

• PRIMARY NEURODEGENERATIVE DISEASE
• DIFFUSE LEWY BODY DEMENTIA (? 7 - 50)
• (NOTE RELATION TO PARKINSONS DISEASE)
• FRONTO-TEMPORAL DEMENTIA
• (PICKS DISEASE, ARGYROPHILIC GRAIN DISEASE)
• FOCAL CORTICAL ATROPHY
• NORMAL PRESSURE HYDROCEPHALUS
• SUBDURAL HEMATOMA
• HUNTINGTONS DISEASE
• MULTIPLE SCLEROSIS
• CORTICOBASAL DEGENERATION

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TRAUMA

• CONCUSSION, CONTUSION
• Occult head trauma if recent fall
• SUBDURAL HEMATOMA
• HYDROCEPHALUS
• NORMAL PRESSURE (late effect of bleed)
• POSSIBLE CONTRIBUTOR TO ALZHEIMERS DISEASE
  INITIATION AND PROGRESSION

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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 CA1 of hippocampus
• thiamine deficiency, hypoglycemia, hypoxia
• EPILEPTIC PERSONALITY CHANGES
• SPECIFIC BRAIN DISEASES

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LABORATORY TESTS (routine)(less history usually
found in NH setting)

• BLOOD TESTS
• electrolytes, liver, kidney function tests,
  glucose
• thyroid function tests (T3, T4, FTI, TSH)
• vitamin B12, folate
• complete blood count, ESR
• EKG
• CHEST X-RAY
• URINALYSIS
• ANATOMICAL BRAIN SCAN CT / MRI

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BEHAVIORAL PROBLEMS IN DEMENTIA PATIENTS

• MOOD DISORDERS
• PSYCHOTIC DISORDERS
• INAPPROPRIATE BEHAVIORS
• AGGRESSION verbal, physical
• PURPOSELESS ACTIVITY verbal, motor
• MEAL TIME BEHAVIORS
• SLEEP DISORDERS

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NEUROPSYCHIATRIC TREATMENTS

• First treat medical problems
• Second environmental interventions
• Third neuropsychiatric medications
• Cognitive impairment
• Psychotic symptoms
• Depressive symptoms
• Insomnia symptoms
• Anorexia symptoms
• Parkinsonian symptoms

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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 ?!?!

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Treatment of psychotic symptoms

• Most acute treatment
• Haloperidol intramuscularly
• Risperidone orally
• Long-term treatment
• Olanzapine
• Risperidone (for more paranoid, hallucinatory)
• Quetiapine (when parkinsonian symptoms)

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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)

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Treatment of depression

• SSRIs (low side-effect profile)
• Paroxetine vs sertraline vs citalopram
• Fluoxetine may be more potent
• Second generation TCAs
• Nortriptyline, particularly for pain patients
• Bupropion for appetite, parkinson sx
• Venlafaxine for activation
• Numerous others for special circumstances

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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

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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

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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