Case-based learning is emerging as a promising teaching method for trainees in all medical fields, including geriatric psychiatry. The cases relate well to the American Association for Geriatric Psychiatry and the Canadian Academy of Geriatric Psychiatry and other international postgraduate curricula in geriatric psychiatry.
III Special Topics
Contributors
Edwin Smith, MD, FRCPC Department of Psychiatry
Zahida Meghji, MD, MSc, BSc Department of Psychiatry and Behavioral Neuroscience McMaster University Hamilton, ON, Canada [email protected]. Sachin Sarin, MSc, MD Department of Psychiatry and Behavioral Neuroscience McMaster University Hamilton, ON, Canada [email protected].
Basic Principles in the Assessment and
Treatment of Late-Life Neuropsychiatric
Syndromes
Contents
Physiology and Pathology of Aging – 3 Calvin H. Hirsch and Ana Hategan
Pharmacotherapy: Safe Prescribing and Adverse Drug Events – 109
Somatic Therapies: Repetitive Transcranial Magnetic Stimulation (rTMS) and Deep Brain Stimulation
Ethics, Mental Health Law, and Aging – 201
Physiology and
Pathology of Aging
Background – 4
Test and Answers – 22 References – 23
- Normal Versus Normative Aging
- Loss of Resilience
- Construct of Frailty
- Multimorbidity
- Telomere Length, Inflammation, and Multimorbidity
- Aging in Individual Organ Systems and Implications
- Age-Related Changes in the Heart Ventricular Function
- The Aging Lung
- The Aging Endocrine System Thyroid Disorders
- Clinically Relevant Age-Associated Changes in Kidney and Liver Function
- Sarcopenia of Aging
- Case Studies
- Case 1 Case 1 History
- Questions and Answers Questions
- Answers
- Case 2 Case 2 History
- Questions and Answers Questions
- Answers
- Continued)
- Key Points: Physiology and Pathology of Aging
- Comprehension Multiple Choice Question (MCQ) Test and Answers
Age-related changes in the peripheral nervous system affect balance, coordination, and motor responses, increasing vulnerability to falls. Age-related changes in the conduction system include prolongation of inter-PR, QRS and QTc.
Resnick SM, Matsumoto AM, Stephens-Shields AJ, Ellenberg SS, Gill TM, Shumaker SA, et al. Shores MM, Arnold AM, Biggs ML, Longstreth WT Jr, Smith NL, Kizer JR, etj.
Comprehensive Geriatric Assessment
Background – 28 .1 Overview – 28
Key Points: Comprehensive Geriatric Assessment – 44 2.4 Comprehension Multiple Choice Question (MCQ) Test
Background
- Overview
- Cognition and Mood
- Functional Ability
- Physical Health
- Medication Review
- Social Supports
- Focused Geriatric Physical Examination
- Special Challenges with Geriatric Patients
Computed tomography (CT) of the brain is therefore recommended—and should be obtained if the patient is taking an anticoagulant. Testing for tone in the upper extremities can be performed by rapid supination of the relaxed forearm.
Case Studies
- Case 1 Case 1 History
Orthostatic hypotension may worsen if heart rate fails to increase cardiac output due to conduction system disease or autonomic dysfunction. Bell's palsy results from idiopathic inflammation of the peripheral part of CN VII, so the entire side of the face is affected.
Continued)
- Case 2 Case 2 History
- Key Points: Comprehensive Geriatric Assessment
- Comprehension Multiple Choice Question (MCQ) Test and Answers
The results of the lab tests came back to the psychiatrist's office 36 hours later. 5 Comprehensive geriatric assessment consists of the systematic evaluation of an elderly patient's functional and psychosocial status as well as their medical conditions.
Neuroimaging in Clinical Geriatric Psychiatry
Answers – 86 References – 87
Background
- Introduction
- Brain Structure and Networks Neuroanatomical Landmarks
- Age-Related Changes in Brain Structure and Brain Networks
- Overview of Brain Imaging Modalities
Therefore, brain imaging is often a significant part of the diagnostic work-up in geriatric psychiatry. 3.1 (continued) c Close-up view of the cingulate gyrus with some Brodmann areas added for demonstration, and d transverse section (top) and coronal section (bottom) approximately at the level of the anterior commissure. The sensitivity (the amount of photons detected) and spatial resolution (the full width-half-maximum (FWHM) of the line spread function) are greatly influenced by the shape, width and length of the collimator.
Case Studies
- Case 1 Case 1 History
- Functional Imaging Brief Cases Case 1
This is a likely clinical diagnosis in this case and should be explored given the patient's change in social behavior relatively early in the course (manifested as disinhibition), early apathy/inertia, decreased social interest, and some neuropsychological evidence of reduced attention with relatively preserved episodic memory of cognitive screening tools [72]. In this case, alcohol abuse should have been investigated, although there was nothing in the patient history or family reports to indicate this. They show evidence of bilateral lesions involving the basal ganglia near the globus pallidus.
Case 2
There was no significant left/right asymmetry, the ratio of cortical to cortical activity was clearly above 1 (more on this later in the chapter), and the activity of polymodal associative regions was higher. as primary motor and somatic (but not visual) cortices. Posterior parts of the cingulate gyrus showed greater uptake than other cortical regions (more on this later), again with the exception of the primary visual cortex (calcarine cortex). A part of the DMN that is often not clearly seen as abnormal in Alzheimer's disease is the hippocampal formation.
Case 3
In fact, it should be noted that this area is difficult to image quantitatively with PET, unless analysis of the MRI-defined region of interest is performed, and that most studies may only comment on activity in "mesial temporal structures. " Moreover, there are indications (from fMRI and ASL measurements) that the hippocampal formation is actually subject to upregulation of its activity in Alzheimer's disease, further explaining why 18F-FDG signaling can appear normal. Nevertheless, data from studies in patients with rare, predominantly inherited forms of Alzheimer's disease, as well as from sporadic cases, agree on a significant delay between the initial observation of a typical PET 18F-FDG pattern and the onset of symptoms. Given those observations, and the clinical status of the patient, this study is highly subjective of a logopenic variant of Alzheimer's disease, one of its not rare clinical variants.
Case 4
Case 5
3.8 (continued) a–c Transaxial, coronal and sagittal slices after registration to the MNI_305 Neuroimaging in Clinical Geriatric Psychiatry template. Most cases (again not all, as predicting pathology in such cases remains notoriously difficult, although their neurodegenerative nature is clear) are associated with pathology of the frontotemporal neurodegenerative type, as this case is probably due to the absence of anomalies in the posterior nervous system. parts of the cingulate gyri. This case shows that there is generally a good correlation between clinical cases of primary progressive aphasia and their PET pattern, although it is not uncommon to see PET patterns that do not correspond to the more typical patterns for primary progressive aphasia, despite the typical clinical picture.
Case 6
- Sampler CT Scan Cases
- Key Points: Neuroimaging in Clinical Geriatric Psychiatry
- Comprehension Multiple Choice Question (MCQ) Test and Answers
Dosenbach NU, Fair DA, Miezin FM, Cohen AL, Wenger KK, Dosenbach RA, et al. Recommendations of the 4th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD4). Silverman DH, Small GW, Chang CY, Lu CS, Kung De Aburto MA, Chen W, et al.
Neuropsychology in Late Life
Test and Answers – 106 References – 108
- Background
- Rationale
- Neuropsychology of Normal Aging
- Neurocognitive Disorder
- Neuropsychological Assessment Procedures
- Case Studies
- Case 1 Case 1 History
- Case 2 Case 2 History
- Key Points: Neuropsychology in Late Life
- Comprehension Multiple Choice Question (MCQ) Test and Answers
This is particularly important with patients who premorbidly fell at the upper or lower ends of the normal distribution. Establishing rapport and engaging the patient in the assessment process early in the interview is essential to ensure the collection of valid and reliable assessment data. What might account for impaired visual recognition in the face of strong free recall.
Pharmacotherapy: Safe
Prescribing and Adverse Drug Events
Background – 110
Key Points: Pharmacotherapy, Safe Prescribing and Adverse Drug Events – 128
Comprehension Multiple Choice Question (MCQ) Test and Answers – 131
Background
- General Principles of Pharmacotherapy in Old Age
- Epidemiology of Polypharmacy and Adverse Drug Events
- Prescription Complexity
- Drug-Food/Nutrient Interactions
- Dietary Supplements and Drug- Supplement Interactions
- Potentially Inappropriate Medications (PIMs)
- Medications of Special Concern for Older Adults
- Adverse Reactions Meriting Special Consideration
Certain types of medication are associated with a high risk of side effects in the geriatric population. In a meta-analysis of outcomes associated with use of the STOP/START criteria, Hill-Taylor et al. In severe rhabdomyolysis, alkalinization of the urine can reduce the binding of myoglobin to renal tubules and reduce the risk of renal failure.
Case Studies
- Case 1 Case 1 History
- Case 2 Case 2 History
SSRIs have been associated with an increased risk of gastrointestinal bleeding [74] and increase the risk associated with the concomitant use of aspirin and NSAIDs. Her internal temperature was within normal limits, but she was out in the cold rain and could be expected to be relatively hypothermic. Cyproheptadine should probably be given, although her motor stiffness and rhabdomyolysis improved without it.
Key Points: Pharmacotherapy, Safe Prescribing and Adverse Drug Events
SSRIs, SNRIs SIADH History of hyponatremia Concomitant use of sodium-lowering medications (eg diuretics) or drugs also associated with SIADH (eg opioids). Fatigue History of falls Use with caution with other drugs that may lower serum sodium (eg, SSRIs, diuretics). Valproic acid Hepatotoxicity Liver disease Cumulative effect with other CNS depressants Hyperammonemia Urea cycle enzyme.
Comprehension Multiple Choice Question (MCQ) Test and Answers
Opioids and other central nervous system active polypharmacy in older adults in the United States. Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review. Antipsychotic drugs and the risk of hyperglycemia in older adults without diabetes: a population-based observational study.
Somatic Therapies
Electroconvulsive Therapy
Key Points: Electroconvulsive Therapy – 153
Comprehension Multiple Choice Question (MCQ) Test and Answers – 154
Background
- Introduction
- History of ECT
- The Electrical Stimulus
- Electrode Placement
- Stimulus Dosing
- Seizure Monitoring
- Mechanism of Action
- Cardiovascular Response to ECT
- Pre-ECT Evaluation
- Informed Consent
- Management of Medications
- Use of ECT in Geriatric Psychiatry
- Diagnostic Indications and Efficacy Major Depressive Disorder
- Side Effects in Geriatric Patients
- Continuation ECT and Maintenance ECT
- Electroconvulsive Therapy Versus Repetitive Transcranial Magnetic
When the risk of ECT associated with the existing systemic medical illness is unclear, further testing and/or consultation should be considered. An evaluation of the risk of cognitive impairment should be considered in all cases before ECT. ECT is effective in elderly patients with depressive disorders regardless of age of onset.
Case Studies
- Case 1 Case 1 History
The study found that patients who received either rTMS or ECT had statistically significant reductions in their depressive symptoms, as measured by the Ham-D. When the degree of improvement between rTMS and ECT participants was analyzed, patients who received ECT showed significantly lower Ham-D scores compared to patients with rTMS. It also suggests the therapeutic validity of rTMS as a treatment option for treatment-resistant depressed patients [73].
Answer 1 ( Question 1—Name two alternative treat- ment approaches and the rationale for your preferred treat-
She did hit her head, but CT of the brain showed no evidence of subdural or cerebral hemorrhage post-trauma, which would greatly increase the risk of ECT. The old lacunar infarcts in the left frontal region will not affect the efficacy of ECT or its safety. However, they may offer an explanation of the etiology of her first depressive episode at age 88.).
Answer 4 ( Question 4—How would you manage her nonpsychiatric medications in the peri-ECT context?)
This is partly due to evidence suggesting a 15% improvement in remission rates when a noradrenergic antidepressant is combined with ECT [19]. This strategy also allows an adequate antidepressant dose to be established when the acute course of ECT is complete, allowing a smooth transition to maintenance pharmacotherapy. Although muscles throughout the body are temporarily paralyzed via the depolarizing muscle relaxant succinylcholine, direct electrical stimulation of the masseter muscles cannot be avoided, and this produces a strong sting that can worsen temporomandibular joint pain.
Answer 5 ( Question 5—What electrode placement and pulse width would you choose?)
Answer 6 ( Question 6—If she responds to ECT, what would you choose as a maintenance strategy?)
- Case 2 Case 2 History
- Key Points: Electroconvulsive Therapy
- Comprehension Multiple Choice Question (MCQ) Test and Answers
Speed of response and remission in major depressive disorder with acute electroconvulsive therapy (ECT): a consortium for research in ECT (CORE) report. Cognitive effects of bilateral versus right unilateral electroconvulsive therapy in the treatment of major depression in elderly patients: a randomized, controlled trial. Comparison of the effects of repetitive transcranial magnetic stimulation and electroconvulsive therapy in the treatment of depression: a systematic review and meta-analysis.
Somatic Therapies: Repetitive Transcranial Magnetic
Stimulation (rTMS) and Deep Brain Stimulation (DBS)
Background
- Somatic Therapies
- Repetitive Transcranial Magnetic Stimulation (rTMS)
- Deep Brain Stimulation (DBS)
With this development, there have been more consistent demonstrations of the efficacy of rTMS in generating response and remission in depressive disorders in the adult population [13]. Depressive disorder in association with major or mild neurocognitive disorder (former dementia) with behavioral disturbances. Future directions for rTMS in older adults rTMS is now an accepted treatment for depressive disorders in the general adult population [40].
Case Studies
- Case 1 Case 1 History
Regardless of the age of onset of the depressive disorder, current evidence suggests that with appropriate intensity and duration of treatment, older patients can respond as well as younger patients to rTMS [31]. However, at least one study found that white matter hyperintensities had no demonstrable effect on response to rTMS treatment [42]. Even with the onset of a depressive disorder in late life and the presence of white matter changes, elderly patients may respond to rTMS.
Answer 5 ( Question 5—How does the presence of sig- nificant alcohol use affect the proposed rTMS treatment?)
- Case 2 Case 2 History
- Key Points: Somatic Therapies (rTMS and DBS)
- Comprehension Multiple Choice Question (MCQ) Test and Answers
Repetitive transcranial magnetic stimulation versus electroconvulsive therapy for major depression: a systematic review and meta-analysis. Repetitive transcranial magnetic stimulation (rTMS) for the treatment of depression in Parkinson's disease: a meta-analysis of randomized controlled clinical trials. Cost-effectiveness decision analysis of repetitive transcranial magnetic stimulation versus electroconvulsive therapy for the treatment of major nonpsychotic depression.
Psychotherapy in Late Life
Test and Answers – 197 Appendix – 199
Background
- Generalities
- Procedural Adaptations
- Types of Psychotherapies
- Experiential Psychotherapies
- Corporal Mediation Therapies
- Systemic Family Therapy
Kabat-Zinn's operational working definition of mindfulness is “the awareness that arises from paying attention intentionally, in the present moment, and non-judgmentally to things as they are” [ 23 ]. In The Mindful Brain, Daniel Siegel admirably describes mindful awareness as follows: “The role of mindful awareness is to enable the mind to “discern” the nature of the mind itself, awakening the person to the insight that preconceived ideas and emotional responses are. embedded in thinking and reflexive responses that create inner distress. Anxiety: "The doctor didn't get back to me with the results, it must mean I'm going to die soon and he's afraid to tell me."
