MENTAL HEALTH
the age of 80 or 85 with complex mixtures of cognitive loss, mood
symptoms, medical illness, polypharmacy, declining mobility and
functional status. Geriatric psychiatrists are often presented with
conditions which cannot be “cured” but which are managed to
improve function and minimize suffering, both for the patient as
well as for their families and care communities. Polypharmacy is a
frequent issue that requires the attention of the geriatric psychiatrist.
Working with the patient, family, pharmacist and other physicians
to reduce medication burden is an important component of this
work. Necessary activities of daily living such as cooking, driving,
paying bills and managing medications are often at issue in these
patients and require the psychiatrist’s input. Decisions about these
factors, as well as decisions about placement in a care facility, are
among the more controversial aspects of the work.
Geriatric psychiatrists manage the entire spectrum of mental
disorders, most of which may occur in older adult patients. The
most common disorders encountered include mood disorders
such as depression, bipolar disorder and dementia, especially the
behavioral syndromes which often accompany dementing illnesses.
Geriatric psychiatrists may also occasionally be called upon to treat
younger patients who develop early onset dementia.
Depression in older adults may be a chronic condition or a
recurrence of illness first suffered earlier in life. Another group of
patients may develop depression for the first time late in life. For
this group, loss and grief, as well as medical illness such as cardio-
vascular or neurological conditions may be especially important in
the mood disorder. Suicide is more common among older adults,
especially Caucasian men, than in many other segments of society.
Addressing this concern is an important aspect of treatment. In
severe cases, late life depression may involve a sense of negativity,
anxiety and profound disturbances in function, sleep, appetite and
activity level. Successful treatment may make an enormous difference
in the patient’s function as well as mood. Geriatric psychiatrists use
many of the same medications and psychotherapeutic approaches
as with younger patients, but with a strong emphasis on exploring
social, medical, and pharmacologic determinants. In extreme cases,
electroconvulsive therapy (ECT) may be a very useful treatment. At
one time, depression in old age was considered almost inevitable.
However, modern research has revealed that as a group, older adults
are not more depressed than other groups.
The term dementia refers to a general syndrome of cognitive
loss. In order to be described as having dementia, a patient must
have declined from a baseline of normal cognitive development
and have symptoms sufficient to affect normal functioning or ac-
tivities of living, typically occurring during the aging process. Most
cases of dementia in the developed world involve brain disorders
which cannot be cured with current methods. The most common
dementias in the United States includes Alzheimer’s Disease (AD),
which accounts for about 2/3rds of cases, Lewy Body dementia, and
vascular dementia. Less common causes include frontotemporal
dementia, Parkinson’s disease dementia, normal pressure hydro-
cephalus, and a long list of rarer conditions. Dementia has become
more prevalent in our society as life expectancy and the number of
elders has increased. In addition to brain diseases, general medical
conditions including infectious diseases (particularly HIV/AIDS
and syphilis), hypothyroidism, nutritional deficiencies (such as low
B12) and others can cause or contribute to dementia. In much of the
developing world, infectious and nutritional causes are the major
contributors to dementia. In recent years, it has become apparent
that some cases of dementia have multiple contributory factors,
often Alzheimer’s plus vascular or medical factors. Evaluation of
dementia includes a history and physical examination, neurological
assessment, mental status exam (sometimes including neuropsy-
chological testing), laboratory testing, and usually neuroimaging.
MRI is the typical imaging technology used today. In most cases
neuroimaging serves to rule out specific neurological conditions.
Atrophy and hippocampal volume loss may suggest AD but most
experts believe it is not possible to conclusively diagnose AD with
such scans.
PET scanning may serve to distinguish AD from frontotemporal
dementia. There are also several labeling compounds which allow
visualization of amyloid in the brain, although amyloid may also be
present in some patients who do not show the signs of AD. There is
currently no available lab test which can conclusively diagnose AD,
although numerous candidate tests of blood and CSF have been pro-
posed. Identifying the typical course of AD is an important part of
diagnosis, including an insidious onset and very gradual progression
from short term memory deficit to global deficits over a period of
time. Dementias, including AD, are also marked by loss of function
and behavioral changes. Geriatric psychiatrists may be involved
in all areas of dementia care but typically focus on management
of behavior, using both pharmacologic and non-pharmacologic
means, including support and education for caregivers. There are
several FDA approved drugs for AD, including the cholinesterase
inhibitors and memantine. These medications are supportive rather
than curative or disease-modifying, and benefits are usually modest.
There is no psychiatric drug specifically approved for dementia, so
psychiatrists treat the psychiatric symptoms with the best available
medication, attempting to avoid polypharmacy and anticholinergic
drugs. A variety of different medications may be used including
atypical antipsychotics, SSRI, SNRI and mood stabilizers. The po-
tential for side effects is high in dementia patients and these drugs
must be carefully monitored, especially antipsychotics, which have
been singled out by the FDA for special caution. Benzodiazepines
are also prescribed occasionally for anxiety or agitation but are
used less frequently in modern gero-psychiatric practice because of
concerns over sedation, falling and cognitive clouding. Medication
requirements and side effects may rapidly evolve over the course of
illness and must be reevaluated frequently.
Dr. Casey is a practicing UofL psychiatrist specializing in geriatric
psychiatry.
DECEMBER 2018
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