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3	ABC’s of the 4D’s In conjunction with The Changing Face of Aging Equinox Hotel Manchester, Vermont May 14, 2003
4	Identification High index of suspicion Screening Tools Drug testing Corroborating information Who and when to screen? Specific triggers Every adult >60 Annual physical exam Senior centers Adult Day Other
5	The 4D’s Sponsored by Southern Vermont AHEC Presenter: Susan Wehry, M.D. Associate Professor, Department of Psychiatry, College of Medicine, University of Vermont
6	Goals Recognize the 4D’s Appreciate the consequences Prevent delirium
7	Objectives Describe clinical presentation Describe morbidity and mortality Describe how to intervene
8	Why the 4D’s?
9	Why missed? Dismissed Depression is “reasonable” Confusion, memory loss are “normal” Stigma Therapeutic nihilism
10	Meet George 79, married, retired, WWII veteran, HS education “He won’t do anything” “Not himself ”, “Cranky” “There’s not much to do” “I don’t want to go out” “I’m not as sharp as I used to be” ‘Absentminded’, forgetful “Can’t remember news”
11	George Fatigue ¯ Sleep ¯ Appetite ¯ Libido Poor concentration Forgetful Pessimistic Hopelessness Purposelessness
12	George Flat à annoyed affect Argumentative “Would rather be dead than losing my mind”
13	George Physically healthy No psychiatric history Mother died, 84, ? dementia Father died, 60, MI MMSE: below normal
14	Initial Hypotheses “Normal” aging? Dementia? Adverse drug reaction ? Alcohol or other drug use? Depressed?
15	Normal aging? (+) life satisfaction, development 90% not depressed Cognitive slowing, not loss of learning risk Alzheimer’s, other dementia
16	Dementia? Syndrome Acquired Persistent decline impaired memory disturbed language visuospatioal abnormalities
17	Dementia? Persistent decline abstraction problem-solving arithmetic recognition executive function
18	The 6 A’s Amnesia Aphasia Agnosia Apraxia Anomia Abulia
19	"DEMENTIA" DEMENTIA
20	About AD/RD Progressive Slow onset Multiple, variable realms Interferes with function
21	About AD/RD Common behaviors Wandering Rummaging, Pillaging, Hoarding Agitation Aggression Isolation Psychosis
22	Alzheimer’s Disease EARLY DETECTION is VERY Important EARLY TREATMENT SLOWS disease
23	Treatment Symptom management Slow progression Cognitive enhancement Behavior, mood symptoms Neuroprotection Caregiver Support
24	WORK-UP Separate interviews Accurate medical and psychiatric history Instrumental ADL’s Medication review Substance use history
25	WORK-UP Physical exam Mental status exam 7 - minute screen MMSE (Folstein): Mini Mental Status Exam GDS: Geriatric Depression Screen Electrocardiogram Laboratory assessment Imaging studies
26	Drugs? Use, misuse, abuse Prescription drugs Over the Counter drugs Alcohol
27	Drugs? Drug-drug interaction Mixing with alcohol CNS-toxic side effect* Intoxication Withdrawal
28	Significance Physiological changes ¯ in body water ¯ metabolism ¯ # receptors sensitivity Drug-drug interactions
29	Drugs? risk for falls Hip fracture Head trauma risk illness Infections Ulcers Diabetes Others
30	Drugs? Intentional misuse, abuse Significant impairment or distress Failure to fulfill roles Persistent use in hazardous situations Continued use despite problems
31	Identification Medical System largest single point of contact uniquely qualified screen manage life-threatening crises treat medical problems largest prescribers of anxiolytics Home health workers Human service workers Family and friends “Gatekeepers”
32	Screening Triggers Irritability Sleep complaints Eating habits Restlessness, agitation Bruising Muscle wasting Seizures Frequent falls ¯ Cognition
33	Screening Link to successful aging Tools HSS AUDIT MAST-G CAGE
34	Back to George Not normal aging No case for drugs No alcohol Not medication Dementia Reversible due to Depression? Irreversible? Depression?
35	Why not delirium? Acute change in baseline mental status Consciousness usually impaired Course fluctuates rapidly
36	RECOGNITION ACUTE ONSET FLUCTUATING COURSE AND INATTENTION DISORGANIZED THINKING OR ALTERED CONSCIOUSNESS
37	DELIRIUM Predisposing factors Dementia Age Sensory deficits Severe Illness Fractures Polypharmacy
38	DELIRIUM Precipitating factors Malnutrition > 3 medications Bladder catheter Physical restraints
39	Delirium a medical emergency can lead to death or worsening dementia
40	Causes
41	MULTIFACTORIAL More than one cause Improvement may not be sustained Underlying medical condition requires urgent identification and treatment
42	Treatment Treat agitation when threatens the patient’s safety interferes with medical treatment causes significant subjective distress
43	Treatment For delirium caused by common medical disorders Conventional high potency antipsychotics Risperidone and olanzapine BRIEF TAPER when medical condition improved
44	Course of Delirium Typically resolve within 10-12 days Symptoms < 1 week to > 2 months Majority recover fully May à stupor, coma, seizures, death
45	Course of Delirium Elderly more likely à prolonged course symptom duration > 1 month Full recovery is less likely Persistent cognitive deficits are quite common
46	Mrs. S Mrs. S. is 78 years old Lives independently Diabetes, arthritis, and cataracts Falls, breaks wrist, emergency department, surgery
47	Mrs. S Day 2 Post surgery à Agitated, confused à restraints and Haldol Day 4 UTI, fever, confusion à Catheter discontinued Incontinence, skin breakdown
48	Mrs. S Day 9 Incontinent Large sacral decubitus ulcer Unable to walk or care for herself Social Work consult for nursing home placement
49	DEPRESSION: Clinical Characteristics YOUNG OLD Sad mood or affect Sleep Appetite Pessimism Hopelessness Thoughts of death or suicide OLD OLD Irritability Multiple somatic complaints headache, gastrointestinal disturbances Sleep disturbance Fatigue Anxiety Loss of interest in ADLs
50	Depression General medical illness Migraine Ulcers Mass lesions Metabolic, electrolyte disturbances Thyroid dysfunction Adverse Drug Reaction Temporal relationship Common offenders Cardiovascular drugs Antihypertensives Antineoplastics Neuroleptics Steroids Hormones
51	Clues to DEPRESSION Risk Factors Female Prior History Family History Isolation Illness Financial Strain Loss Precipitants Recent bereavement Retirement Move Illness
52	Failure to treat morbidity from medical illness utilization of medical services likelihood of institutionalization Longer hospitalization Slower recovery
53	Failure to treat physical disability depression> diabetes, arthritis and hypertension pain mortality cardiac disease suicide
54	Depression May resemble dementia flat affect loss of interest poverty of speech inability to remember or concentrate withdraw socially fear is of Alzheimer’s Disease
55	Depression and Dementia symptoms may fluctuate may not meet criteria hard to separate apathy and anhedonia George: treat and re-evaluate
56
57	Take Home: Dementia Reversible and Irreversible Types Risk for Delirium
58	Take Home: DELIRIUM Recognize Think about it Know CAM Refer Medical attention Communicate clearly Reassure Be patient Avoid rush to judgment regarding guardianship! Prevent Monitor risk factors
59	Prevention Assess cognition daily Avoid psychoactive medications Avoid bed rest Adequate hydration Glasses, hearing aids, dentures Sleep enhancement Inform patients of schedule Keep them involved
60	Take Home: Depression Common Most common reversible dementia Commonly co-occurs with dementia Treatable
61	Take Home: Drugs Safe use of prescription drug High index of suspicion Routine screening