GERIATRIC PSYCHIATRY
Prof. Nahathai Wongpakaran, MD, FRCPsychT
Geriatric Psychiatry Unit Department of Psychiatry, Faculty of Medicine
Chiang Mai University Psy 515
Objectives
• Learners will be able to list and describe
common mental illnesses in the elderly, and
the management of these conditions.
11/06/61 [email protected] 2
Outline
• Introduction
• Late-life depression
• Late-life psychosis
• Late-life anxiety disorders
• Substance use disorders in the elderly
• Alcohol
• Sedative-hypnotics
• Neurocognitive disorders
• Behavioral and Psychological Symptoms of
Dementia (BPSD)
11/06/61 [email protected] 3
11 June 2018 [email protected] 4
Social transition
Income level
Daily routine
Retirement
Lifestyle
Financial
planning Family
relationship
Social
relationship
Perceived
role
Old age transition
Physical frailty
Health condition
Loss of indipendence
Bereave
ment
Placement
Functional assessment tasks • Activities of daily living (ADL)
• Bathing
• Ability to transfer
• Dressing
• Going to toilet
• Grooming
• Ability to feed self
• Instrumental activities of daily living (IADL)
• Able to use telephone
• Shopping
• Food preparation
• Laundry
• Motor transportation
• Responsibility for own medication
• Ability to handle finances
11/06/61 [email protected] 5
11/06/61 [email protected] 6
Prevalence of LLD among Thai elderly
11/06/61 [email protected]
7
Studies Prevalence
(%)
Remarks
Siriwanarangsan P et al,
2005
17.5
M 13.8, F
20.9
N = 9,632
Liang G et al, 2009 21.0 N = 200
TGDS, TMSE
Wongpoom T et al, 2011 5.9 MDD, PHQ-9
Wongpakaran N et al, 2012 23 N = 81, MDD by
MINI, LTC
Risk factors
• Older age
• Female gender
• Unmarried
• Low education
• Poverty
• Family history of
depression
• Poor social support
• Living in rural areas
•Loss and grief
•Loneliness
•Social isolation
•Care-taking
responsibility
•Dependency
•Role loss: mentor
•Life crisis
11 June 2018 [email protected] 8
Barua A, et al. Indian J Psychol Med. 2010.; Büchtemann D. et al. J Affect Disord., 2012.;
Zhang L, et al. Int J Geriatr Psychiatry. 2012.
Health problems at risk for LLD & comorbid
• Cognitive impairment
• Chronic physical illness
Ischemic heart disease
• Poor function: ADL
A history of depression
Substance use: alcohol,
nicotine
Sensory deprivation
Pain
• Degenerative arthritis
• Hypertension
• Urinary incontinence
• Diabetes
Parkinson’s disease
Hypothyroidism
Neurologic disease
Stroke
Cancer
11 June 2018 [email protected] 9
Barua A, et al. Indian J Psychol Med. 2010.
Co-occurring psychiatry diagnoses
Anxiety disorders of 10-20% (Lenze EJ et al 2000, Beekman AT et al 1998)
Personality disorders of 10-30%
Alcohol use disorders (Devanand DP et al 2002)
11/06/61 [email protected] 10
LOD: Association with cognitive disorders
• Late-life depression increases risk for
developing Alzheimer’s disease
(Alexopoulos G. 1993.; van Reekum, R. 1999.;
van Reekum R. 2005)
• Depressive symptoms are associated with
an increased risk for developing mild
cognitive impairment (MCI)
(van Reekum R. 2006)
11/06/61 [email protected] 11
Mechanisms that link depression to MCI
1.
2.
3.
4.
Adapted from Geda et al. Mild Cognitive Impairment. Textbook of Alzheimer’s Disease and Other dementias 2009.
11/06/61 [email protected] 12
Depression
Increased
corticosteroides Brain
damage MCI
Susceptibility
gene variant
or other risk
factors
Preclinical
MCI
Interaction
Depression
MCI
Depression
MCI
Depression MCI
Susceptibility
gene variant
or other risk
factors
11/06/61 [email protected] 13
Neurobiological theories
• Less genetic influence
• Less likely to have a family history of psychiatric illness
• Subtle structural brain damage
• Decrease neurogenesis
• Decrease in brain volume
• Prefrontal lobes, caudate, hippocampus
• White matter lesions and other abnormalities on imaging
11/06/61 [email protected] 14
• Neurotransmitter: 5-HT, NE, DA, Ach
• Declining health, inappropriate
medications, malnutrition
• Coexist with chronic disease and disability
• Regulation of homeostasis, organ system
reserve, immunologic responsiveness, and
body composition
• Cardiovascular pathology: Hypothesis of
‘vascular depression’
11/06/61 [email protected] 15
Psychodynamic theories
• Loss
• Premorbid personality
• Socially inhibited
• Helplessness
• Narcissistic injury
11/06/61 [email protected] 16
Cognitive and behavioral theories
• Learned helplessness
• Losses & schema
• Negative automatic thought
11/06/61 [email protected] 17
Social factors
• Loss of important social support and system due to death of spouse or siblings
• Death of adult child (Prince et al 1997)
• Retirement
• Relocation (NIH 1992)
• Negative life events
11/06/61 [email protected] 18
11/06/61 [email protected] 19
อาการส าคญ
MDD
Dys
DD
No
2
P
values
Interest
81 (10.23) 8 (1.01) 6 (0.76) 141 (17.80) 70.97 < 0.001
Sadness
86 (10.86) 10 (1.26) 7 (0.88) 91 (11.49) 142.81 < 0.001
Sleep
112 (14.14) 25 (3.16) 7 (0.88) 365 (46.09) 20.85 < 0.001
Appetite
67 (8.46) 5(0.63) 4 (0.51) 92 (11.62) 77.25 < 0.001
Energy
87 (10.99) 13 (1.64) 5 (0.63) 151 (19.07) 74.44 < 0.001
Cognition
78 (9.85) 26 (3.28) 9 (1.14) 402 (50.76) 5.73 0.126
Somatic
33 (4.16) 5 (0.63) 0.00 60 (7.58) 21.86 < 0.001
11 June 2018 [email protected] 20
Chief complaints of elderly patients with depressive disorders
(n=792) Wongpakaran N, et al. DAS Prelim. 2015.
Did you know? • Depression without sadness
• Loss of interest and motivation
• Functional impairment is confused with
lower functional expectation
More frequent with delusions
• Still meet DSM-5 criteria
11/06/61 [email protected] 21
Assessment
• History
• Examination
• Cognitive screening
• Labs
• CBC, U/A, Meds plasma,
• Ca, Mg, PO4, e’,
• FBS, BUN/Cr,
• LFT, TFT
11/06/61 [email protected] 22
แบบวดความเศราในผสงอายไทย 15 ขอ (TGDS-15)
หวขอ ค ำตอบ
1.โดยทวไปแลวคณพงพอใจกบชวตตวเองหรอไม □ ใช □ ไมใช
2.คณลดกจกรรมหรอควำมสนใจในสงตำงๆ ลงหรอไม □ ใช □ ไมใช
3.คณรสกวำชวตคณวำงเปลำหรอไม □ ใช □ ไมใช
4.คณรสกเบอๆ อยบอยครงหรอไม □ ใช □ ไมใช
5.คณอำรมณดเปนสวนใหญหรอไม □ ใช □ ไมใช
6.คณกลววำอะไรรำยๆ จะเกดขนกบคณหรอไม □ ใช □ ไมใช
7.คณรสกมควำมสขเปนสวนใหญหรอไม □ ใช □ ไมใช
8.คณรสกหมดหนทำงอยบอยครงหรอไม □ ใช □ ไมใช
9.คณชอบอยกบบำนมำกกวำออกไปหำอะไรท ำนอกบำนหรอไม □ ใช □ ไมใช
10.คณรสกวำคณมปญหำควำมจ ำมำกกวำใครๆ หรอไม □ ใช □ ไมใช
11.คณคดวำกำรทมชวตอยมำไดจนถงทกวนนมนชำงแสนวเศษใช
หรอไม
□ ใช □ ไมใช
12.คณรสกหรอไมวำชวตทก ำลงเปนอยตอนนชำงไรคำเหลอเกน □ ใช □ ไมใช
13.คณรสกมก ำลงเตมทหรอไม □ ใช □ ไมใช
14.คณรสกหมดหวงกบสงทคณก ำลงเผชญอยหรอไม □ ใช □ ไมใช
15.คณคดวำคนอนๆ ดกวำคณหรอไม □ ใช □ ไมใช
คะแนนรวม _ _/15
11/06/61 [email protected] 23
Wongpakaran N, et al. J Clin Med Res, 2013.
ชมรมจตเวชศาสตรผสงอายและประสาทจตเวชศาสตรไทย. ค าแนะน าการรกษาโรคซมเศราในผสงอาย. 2559.
11 June 2018 [email protected] 24
Depression management strategies in
primary care
• Detection
• Promoting treatment engagement and
adherence
• Stepped care
• Collaborative care
Park M. et al. Psychiatr Clin North Am. 2011
11 June 2018 [email protected] 25
Aims of treatment
To reduce symptoms, remission
To prevent suicide, relapse, recurrence
To help with coping with patients’ disability
To decrease risk for developing cognitive disorders
To improve general health status
To improve cognitive and functional status
To improve quality of life
To reduce family or caregiver’s burden
11/06/61 [email protected] 26
ระยะของกำรรกษำโรคซมเศรำในผสงอำย
11/06/61 [email protected] 27
เฉยบพลน
ตงแตเรม
จนหำย
8-12 wks
ตอเนอง
6-12
เดอน
ไมลดยำ
รกษำสภำพ
1, 2, 3, …ป
ไมลดยำ
(Alexopoulos GS et al 2000), (Frank E. 1994)
Choices of medication • First-line agents
• SSRI’s (Esc, Ser, Par, Fluv, Fluo)
• SNRI’s (Venlafaxine/pristiq, duloxetine, +/- Milnacipran,
reboxetine (NaRI))
• Second-line agents
• Mirtazapine (NaSSA)
• Bupropion (NDRI)
• Third-line agents
• TCA’s (Nortriptyline)
• MAOI
• Psychostimulant
• Tianeptine (SSRE)
• Others: Quetiapine, Aripiprazole, Olanzapine, agomelatine Ravindran L, et al., 2005.; Shanmugham B. et al 2005.; Udomratn P & Wongpakaran N., 2012.
28
ชมรมจตเวชศาสตรผสงอายและประสาทจตเวชศาสตรไทย. ค าแนะน าการรกษาโรคซมเศราในผสงอาย. 2559.
11 June 2018 [email protected] 29
11/06/61 [email protected] 30
ทางเลอกในการรกษา
ความรนแรง กลยทธการรกษา
Major depression
อาการโรคจต
Mild depression
ยาแกซมเศรา +/- จตบ าบด
ยาแกซมเศรา+ (ECT หรอยารกษาโรคจต)
ยาแกซมเศรา + จตบ าบด
ยาแกซมเศรา +/- จตบ าบด
11/06/61 [email protected] 31
Shanmugham B. et al 2005
Treatment options for other types of depression
• Adjustment disorder with depressed mood
• Pharmacologic intervention is not recommended [D]
• Minor depressive disorder
• Pharmacologic treatment should be considered if symptoms persist for more than 4 weeks
• Dysthymic disorder
• Antidepressant as first-line therapy
• Psychotherapy as an adjunct therapy unless there is clear improvement seen or a contraindication to medication
(Williams et al 2000, Alexopoulous et al 2001)
11/06/61 [email protected] 32
Suicide in the elderly
Risk factors • Age ≥ 75
• Male
• White
• Widowed or divorced
• Living alone, isolated, or recently moved
• Retired or unemployed
• Poor physical health, terminal illness, multiple or debilitating illnesses, or pain
• Depression, substance abuse or dependence, hopelessness
• History of suicide, depression, or other mental illness in close family members
11/06/61 [email protected] 33
Suicide: protective factors
• Able to learn from experience and accept help; sense of meaning in life; sense of humor and capacity for loving; able to reminisce about positive life experiences
• History of successful transitions and coping with life challenges
• Caring and available family member or supportive community network; accessible and caring health care provider
• Membership in a religious community
11/06/61 [email protected] 34
11/06/61 [email protected] 35
โรคจต (Late-life psychosis)
• โรคจตทเปนเอง (พบไดนอยกวา)
• โรคจตเภท
• โรคหลงผด
• อาการทางจตทมสาเหต (พบไดมากกวา)
• จากยาหรอสารเสพตด
• จากโรคสมองเสอมหรอสาเหตผดปกตทางสมองอนๆ
• จากโรคซมเศราหรอโรคทางอารมณอนๆ
• จากภาวะเพอคลง
11/06/61 [email protected] 36
Comparisons of characteristics of patients with late-onset versus earlier-onset schizophrenia
• Familial risk
• It is clear that the disorder has a genetic link
• Neurodevelopmental condition
• Minor physical anomalies
• A view of neurodevelopmental > neurodegenerative origin
• Some early, premorbid abnormalities are subtle or subclinical
• Acquired pathological change
• Normal structural MRI results, but larger ventricular and thalamic volumes
• No increased evidence of volume loss, strokes, tumors or white matter hyperintensities
• No evidence of cognitive decline
11/06/61 [email protected] 37
• Sensory deficits
• No etiological link
• Symptoms and treatment response
• Lower prevalence of disorganized subtype
• Higher prevalence of paranoid subtype
• Delusion > hallucination
• Less severe negative symptoms
• Responsive to antipsychotics (lower dosage)
• Gender differences
• Higher among women
• ‘Estrogen hypothesis’: estrogen, premenopausally, may modulate DA in a manner similar to antipsychotic
11/06/61 [email protected] 38
Decision tree to determining etiology of
psychosis in the elderly
11/06/61 [email protected] 39
Psychosis
Prior
Hx./Dx./s&s
Cognitive
decline
Primary
psychosis Dementia related
psychosis
Secondary
psychosis
Delirium
Medical
conditions
Substance-
related
Primary
psychosis
N
Y N
N
N
N Y N
11/06/61 [email protected] 40
โรควตกกงวล
• แบงเปน 2 ประเภท ไดแก
• โรควตกกงวลทเปนเอง (Primary anxiety disorders)
• อาการวตกกงวลทพบในโรคอน (Secondary anxiety disorders)
•Depression
•Dementia
•Physical illness
•Medications
11/06/61 [email protected] 41
Primary anxiety disorders • Phobic disorders
• Agoraphobia, specific phobia, and social phobia
• The most or second most common
• Agoraphobia without panic attack
• Generalized anxiety disorders (GAD)
• Most common, or less common than phobia
• Comorbid with depression and other anxiety
disorders
• Rarely starts for the first time in late life
11/06/61 [email protected] 42
• Panic disorders
• Prevalence < 0.5%
• Fewer/less severe symptoms, less
avoidant
• Comorbid with depression/medical
condition (cardiovascular, GI, pulmo.)
11/06/61 [email protected] 43
Pharmacologic treatment
• Antidepressants
•SSRI’s are considered first line
•SNRI’s, NaSSA, and other newer can
be selected
• Benzodiazepines
• Please avoid
• Short-term therapy for only severe
symptoms
• Lorazepam is preferred
6/11/2018 [email protected] 44
Psychosocial treatment
• Cognitive and behavioral therapy
• Little information
• Little evidence of exposure therapy in
OCD and phobia
• Exposure therapy is TOC in late-onset
agoraphobia
• Cognitive therapy in panic disorder
11/06/61 [email protected] 45
11/06/61 [email protected] 46
โรคของการใชแอลกอฮอล (Alcohol use disorder)
•30-60% ของคนทดมสราเรมดมหลงอาย 60 ป
•การดมสราในผสงอายเปนปญหานอยกวาและคอนขางเฉพาะเจาะจงกวาคนทเรมมาตงแตอายนอยกวาน
•สาเหตการดม
•ปญหาโรคซมเศรา สถานการณทสรางความเครยดเปนสาเหตของการดมสราทพบไดบอยในผสงอาย
•หรอปญหาความจ า เชน เรมมอาการสมองเสอมขนเรมตน
11/06/61 [email protected] 47
Alcohol related disorders
• Prevalence of alcohol abuse and
dependence in community 2-4% , 8-50% in
nursing home
• Men > women
• Associated psychiatric conditions
• Cognitive impairment
• Depression
11/06/61 [email protected] 48
แบบคดกรองมชแกนอลกอฮอลสซม ฉบบสน ส าหรบผสงอาย • เวลาทคยกบคนอน คณคดวาคณดมนอยกวาความเปนจรง
• หลงจากทดมไปสกพก คณมกจะไมกนอาหารเพราะไมรสกหว
• การดมชวยลดอาการสนหรอมอสนของคณไดได
• บางครงอลกอฮอลกท าใหคณหลงวนหลงคน
• คณมกจะดมเพอใหรสกผอนคลายหรอสงบ
• คณดมเพอใหลมเรองไมสบายใจ
• คณดมมากขนหลงการสญเสย
• หมอหรอพยาบาลเคยแสดงความเปนหวงเกยวกบการดมของคณ
• คณเคยตงกฎส าหรบการดมของตวเอง
• เวลาทรสกเหงา การดมชวยคณได
ตอบถก 3 ขอหมายถงการดมมปญหา ดดแปลงจาก Blow 1991
11/06/61 [email protected] 49
Treatment
• Pharmacology
• Disulfiram: Lack study
• Naltrexone: 50% relapse
• Topiramate: Lack study
• SSRI’s for anti-craving and/or for depression
• Psychosocial treatment
• Counselling
• Supportive psychotherapy
• Brief intervention: Motivational enhancement therapy
• Other specific treatment for comorbidity: CBT for
depression, dynamic psychotherapy, etc.
• Individual or group approach
11/06/61 [email protected] 50
11/06/61 [email protected] 51
Benzodiazepines
• Physical dependence and chronic toxicity
• 20-50% have withdraw symptoms after discontinuation
• Risk factors for BZD dependence:
• duration, higher dose, shorter half-life, higher
potency, a history of alcohol related
disorder/sedative drug dependence, chronic
insomnia, chronic pain, personality disorder
11/06/61 [email protected] 52
• Drug discontinuation in the dependent
patients
• Gradual discontinuation
• Period: many months to a couple of years
by reduction q 1-4 months
• Reduction to a very low dose in some
patients
• Often overlooked
• MI, hypertensive crisis, infection, delirium
11/06/61 [email protected] 53
11 June 2018 [email protected] 54
11/06/61 [email protected] 55
Prevalence of NCD’s
• Prevalence of dementia in Thai elderly 5.5% 1
• Prevalence of dementia in CM people > 45 y/o was 2.35%, with 75% with Alzheimer’s disease (AD) 2
• Dementia was found in 41.6% of residents in a long-term care home in CM3
1.Jitapunkul S, et al. Geriatr Gerontol Int. 2009.;
2. Wangtongkum S, et al. J Med Assoc Thai. 2008.;
Wongpakaran N, et al. Psychogeriatrics. 2012.
6/11/2018 [email protected] 56
Pattern of cognitive decline
11 June 2018 [email protected] 57
Golomb J, et al. Dialogues Clin Neurosci. 2004.
Elements of cognition
Elements
• Consciousness & Alertness
• Attention
• Orientation
• Memory
• Calculation
• Thinking & Concept formation
• Intelligence
• Language
• Abstraction
• Judgment
Domains
• Complex attention
• Executive function
• Learning and
memory
• Language
• Perceptual-motor
• Social cognition
APA DSM-5, 2013.
11 June 2018 [email protected] 58
59
Brain and cognitive function
11 June 2018 [email protected] 60
DSM-5 Diagnosis of major NCD (APA, 2013)
One cognitive decline
Pt, informant or
clinician
No delirium or other
psychiatric illness
Impairment by testings
Substantial: Major
Modest: Mild
ADL
Interfered: Major
Not interfered: Mild
Alzheimer’s disease
Frontotemporal lobar degeneration
Lewy body disease Vascular disease
Traumatic brain injury
Substance/medication use
HIV infection Prion disease
Parkinson’s disease
Huntington’s disease Another medical condition
Multiple etiologies
Unspecified
ปจจยเสยงของการเกดอลไซเมอร
อาย
ประวตครอบครว
ปจจยทางพนธกรรมเกยวกบ apolipoprotein E-
4 (APOE 4)
โรคพทธปญญาบกพรองระยะเรมแรก (Mild Cognitive Impairment)
ปจจยเสยงส าหรบโรคหวใจและหลอดเลอด
การบาดเจบทศรษะและการบาดเจบตอเนอสมอง
11/06/61
NCD due to Alzheimer’s disease
◦Mild or major NCD
◦Gradual onset
◦Progressive
◦Memory + another cognitive domain
impairment
◦No other cause
11-Jun-18 63
Alzheimer’s dementia, amyloid
plaques, and neurofibrillary tangles
• BAP: abnormal processing amyloid proteins
• Amyloid casecade hypothesis
• NFT: abnormal phosphorylation of tau proteins
11/06/61 [email protected] 64
https://www.youtube.com/watch?v=cqmZFoGvzfU
Cortex Sulci & gyri
11-Jun-18 [email protected] 65
Normal brain vs Alzheimer brain
MRS of Normal vs. AD • Hippocampal neurobiological abnormailities
• Reduced in N-acetylaspartate (NAA), creatinine (Cr) and
choline (Cho)
• Increased mioinositol (MI)
• Reduced in NAA/Cr, NAA/Cho and NAA/MI
11/06/61 67
Kantarci et al, 2004
Algorithm for evaluation of cognitive complaint Hildreth K, et al. Med Clin North Am. 2015.
Management
• History taking
• Physical & neurologic examination
• MSE
• Cognitive screening
• Neuropsychological testing
11/06/61 [email protected] 70
History taking
Hildreth K, et al. Med Clin North Am. 2015.
Physical examination
Parkinson’s disease • May be normal
• Delirious stages:
psychomotor activity,
inattention, disorganized
thinking, etc.
• Behavioral and
Psychological Symptoms of
Dementia-BPSD
• Depression: poor
hygiene, self-neglect
• Focal neurological deficits
• Parkinsonian signs
• Frontal lobe signs
• Etc.
Kayser-Fleischer ring
Wilson disease
• MMSE-Thai 2002, TMSE, 3MS, etc.
• Mini-Cog
• Clock Drawing Tests
• Standardized MMSE (SMMSE)
• Informant Questionnaire on Cognitive
decline in the elderly (IQCODE)
• Frontal Assessment Batteries (FAB)
• Etc.
11/06/61 [email protected] 74
Screening tools
11/06/61 75
11/06/61 76
11/06/61 [email protected] 77
Investigation-1
• CBC, FBC, ESR, CRP - anemia,
vasculitis
• U/A - delirium
• Glucose
• e’, Ca++, Mg+, PO43- – hypercalcium/
hypocalcaemia
• BUN/Cr - renal failure
• LFT-clotting and albumin
• T4 and TSH – hypothyroidism
11-Jun-18 [email protected] 78
Investigation-2
• B12 and folate - vitamin deficiency
dementia
• Syphilis serology, HIV
• Caeruloplasmin - Wilson's disease
• Chest X-ray, electrocardiogram (ECG)
(as determined by clinical presentation)
• Cerebrospinal fluid examination (if
Creutzfeldt-Jakob disease (CJD) or
other forms of rapidly progressive
dementia are suspected)
11-Jun-18 [email protected] 79
Investigation-3
• Electroencephalography (EEG) - not routinely
indicated
• Imaging • Use structural imaging to exclude other cerebral pathologies
and help establish the subtype of dementia
• To identify treatable causes
• Prefer MRI to assist with early diagnosis and detect subcortical
vascular changes
• Single-photon emission computed tomography (SPECT) to
help differentiate Alzheimer's disease, vascular dementia and
frontotemporal dementia
• Use dopaminergic iodine-123-radiolabelled 2b-
carbomethoxy-3b-(4-iodophenyl)-N-(3-fluoropropyl)
nortropane (FP-CIT) SPECT to confirm suspected dementia
with Lewy bodies (DLB)
11-Jun-18 [email protected] 80
Management plan
• What are presenting problems?
• Current functional ability
• Global deriorating scale
• ADL/IADL
• Dependency need
• Risk assessment
• Self or others
• Disturbed/negative behavior
• Concurrent physical/psychological
illness
• Carer assessment
11/06/61 [email protected] 81
Treatment targets in AD
• Neurotransmitter-based treatments
• Protein-focused treatments
• Intracellular-focused treatments
• Regeneration agents
11/06/61 82 [email protected]
Available cognitive enhancers
• Cholinesterase inhibitors
• Donepezil
• Rivastigmine
• Galantamine
• NMDA antagonist
• Memantine
11/06/61 [email protected] 83
การจดการปญหาดานความจ า
R – Reminders (เครองเตอนความจ า) 1. ค าใบหรอค าชวย
2. เขยนเปนตวหนงสอหรอแทนดวยภาพ
E – Environment (สภาพแวดลอม) 1. วางของใหเปนทเปนทางถาวร
2. อยาเปลยนแปลงสภาพแวดลอม
C – Consistent Routines (กจวตรประจ า) 1. คงกจกรรมงายๆ และประจ าไว
2. กจกรรมใหมท าใหเปนประจ า
A – Attention (ความใสใจ) 1. หลกเลยงสงรบกวน
2. ฝกความใสใจ
P – Practice (ฝกฝน) 1. สรางทกษะดวยการปฏบต
2. ปฏบตสงใหมเพอสรางทกษะใหม
S – Simple Steps (ท าในสงงาย) 1. ท าทกอยางใหเปนขนตอนงายๆ
2. ใหเวลาแกผปวย 11/06/61 [email protected]
84
Vernooij-Dassen, M. Int Psychogeriatr. 2010.
การแกปญหาการสอสาร M- MAXIMIZE attention (เพมความใสใจ) 1. ดงความสนใจ
2. หลกเลยงสงรบกวน
3. ทละอยาง
E- Watch your EXPRESSION and body language (ระวง
การแสดงออกและภาษากายของเรา)
1. ผอนคลายและสงบ
2. แสดงความสนใจ
S- Keep it SIMPLE (ท าใหงาย) 1. สน ๆ งาย ๆ และถนด
2. ตวเลอกชดเจน
S- SUPPORT their conversation (ชวยการสนทนาของเขา) 1. ใหเวลา
2. ชวยนกค า
3. พดซ าและใหพดตาม
4. เตอนเกยวกบเรองทพด
A- ASSIST with visual AIDS (ชวยเพมการมองเหน) 1. ใชทาทางประกอบ
2. ใชวตถและภาพ
G- GET their message (เขาใจความหมาย) 1. ฟง ด และตอบสนอง
2. พฤตกรรมและภาษากาย
E- ENCOURAGE and ENGAGE in communication (สงเสรม
และมสวนรวมในการสอสาร)
1. หวขอนาสนใจและถนด
2. ครอบครวและเพอน 11/06/61
85
Vernooij-Dassen, M. Int Psychogeriatr. 2010.
Mild Cognitive
Impairment
11-Jun-18 87
Petersen’s criteria
Memory complaint (self/informant) Impaired on a standardized memory (0.5
on Clinical Dementia Rating (CDR) and/or 1.5 SD below norm on different NP test
Normal general cognitive function (MMSE > 24)
No or minimal impairment on ADL’s or IADL’s
Do not meet NINCDS-ADRDA criteria for AD
Petersen RC et al 2001, Petersen RC et al 2004
11 June 2018 [email protected] 89
MCI—Criteria for the clinical and
cognitive syndrome
1. Concern regarding a change in cognition
2. Impairment in one or more cognitive domains
3. Preservation of independence in functional abilities
4. Not demented
Albert MS, et al. 2011.
11 June 2018 [email protected] 90
What is the prevalence of MCI in the general population? • Prevalence (95% CI 28.1%–48.0%, I2 24.8).
• Higher prevalence with
• Age
• Lower education
11/06/61 [email protected] 91
Age (Years) Prevalence (%)
60–64 6.7
65–69 8.4
70–74 10.17
75–79 14.8
80–84 25.2
85 and older 37.6
Decision making for MCI subtypes
Geda YE. Curr Psychiatry Rep. 2012. 11 June 2018 [email protected] 92
Montreal Cognitive Assessment- MoCA
11/06/61 [email protected] 93
Montreal Cognitive Assessment (MoCA)
Clinician rated, well-trained
11 cognitive domains
Can be completed in 10 min
Thai version Hemrungroj S. 2011.
Score 30, Cut-off 24/25
Cronbach's alpha 0.744, Pearson’s 0.91, sensitivity 0.70 & specificity 0.95
(Tangwongchai S. et al. 2009.)
Nasreddine Z. et al. J Am Geriatr Soc. 2005.
11/06/61 95
Neuroimaging
• Importance: Clarifying diagnosis
• i.e. MRI is helpful in predicting progression to dementia
• The entorhinal cortex in a normal control (A) and a person with
mild cognitive impairment (B) Masdeu JC, 2005.
11/06/61 [email protected] 96
PET scan of MCI
97
PET images obtained with the amyloid-imaging agent Pittsburgh Compound-B ([11C]PIB) in a normal
control (left); three different patients with mild cognitive impairment (MCI, center); and a mild AD patient (right). Some MCI patients have control-like levels of amyloid, some have AD-like levels of amyloid, and some have intermediate levels. PET, positron emission tomography; MCI, mild cognitive impairment; AD, Alzheimer's disease.
11/06/61 [email protected] 98
Course of MCI
Improved/recovered 14.4%-55.6%
Stay impaired
Progress to dementia 14.9%
(in 2 years)
11/06/61 [email protected] 99
Treatment-MCI
No standard treatment
Aim delay onset of dementia
Non-pharmacologic approaches
11/06/61 [email protected] 100
What pharmacologic treatments are effective for patients diagnosed with MCI? • AChEI’s are ineffective
• Insufficient/uncertain evidence
• High-dose flavonoids (990 mg)
• Homocysteine-lowering therapies
• Piribedil
• V0191/procholinergic drug
• Vitamin E 2,000 IU
• Oral vitamin E 300 mg/d + vitamin C 400 mg/d over 12 months
• Possible improvement
• transdermal nicotine (15 mg/d)
• Tesamorelin/Growth hormone–releasing hormone injections
over 20 weeks
• Increase risk of AD progression
• Rofecoxib
11/06/61 [email protected] 101
11-Jun-18 [email protected] 102
11-Jun-18 [email protected] 103
Brain activation 16-wk concord grape juice consumption
11-Jun-18 [email protected] 104
Krikorian R. et al. J Agri Food Chem. 2012.
Folate
105
What nonpharmacologic treatments are effective for patients diagnosed with MCI?
◦ Improve cognition
◦exercise training for 6 months
◦Controversial/inconclusive
◦Cognitive interventions
11-Jun-18 [email protected] 108
109
Exercise
11/06/61 [email protected] 110
Aerobic exercise increases hippocampal volume
11-Jun-18 [email protected] 111
ten Brinke LF, et al. Br J Sports Med. 2015.
Exercise: Tai Chi
oPhysical, cognitive, social, and meditative components
11-Jun-18 [email protected] 112
Wayne PM, et al. J Am Geriatr Soc. 2014.
11-Jun-18 [email protected] 113
Effect of exercise on dementia: theoretical model
Kirk-Sanchez NJ, et al. Clin Interv Aging. 2014.
11-Jun-18 [email protected] 114
Pet-assisted living intervention
◦Mild to moderate cognitive impairment
◦22 on Pet dog vs. 18 on reminiscence
◦Evaluation
◦Physical: energy expenditure, ADL’s
◦Emotional: depression, apathy
◦Behavioral: agitation, function
◦60-90 minute, 2/wk x 12 wks.
◦Pet group: improved physical activity and
depression Friedmann E. et al. Am J Alzheimers Dis Other Demen. 2015.
11-Jun-18 [email protected] 115
116
117
Peppers
Lavender & Vanilla
Ginseng
118
Humors
Sex
Music
119
Chocolate
Social activities
จดการกบความเครยด
◦คมการหายใจ
◦จดตารางส าหรบกจกรรมคลายเครยด
◦ กจกรรมทางศาสนา
6/11/2018 [email protected] 120
เรองเครยดมผลกระทบกบคนทมพนธกรรมผดปกต (5-HT transporter gene promoter polymorphism)
18 January 2016 121
การนงสมาธเพมเนอสมองได
Leung MK, et al. 2013.
Holzel BK, et al. 2012.
พฒนาจต ท าใหสมองพฒนา
11/06/61 [email protected] 123
BPSD: Definition
BPSD: Behavioral and Psychological
Symptoms of Dementia
“Symptoms of disturbed perception, thought
content, mood or behavior that frequently
occur in patients with dementia”
(Finkel and Burns, 1999)
11/06/61 [email protected] 124
Aggressivity
Screaming
Restlessness
/Agitation
Anger/
Irritability
Cursing
Wandering
Common specific symptoms
11/06/61 [email protected] 125
Delusion
Hallucination
Depression
Sexual
disinhibition Culturally
inappropriate
behavior
Shadowing
Hoarding BPSD
Apathy
5 Most common BPSD’s among Thais
Studies/It
ems
Senanarong V,
et al. 2005
Charernboon T,
et al. 2014.
Taemeeyapradit U,
et al. 2014.
N 73 62 158
Types AD AD Mixed
BPSD’s
Irritability
47.9%
Apathy
71%
Irritability
60.8%
Apathy
45.2%
Aberrant motor
behavior
61.3%
Sleep problems
57%
Anxiety &
Aberrant motor
behavior
42.5%
Sleep problems
56.5%
Depression
54.5%
Night time beh
38.4%
Eating problems
51.6%
Anxiety
52%
Agitation
35.6%
Agitation/aggressio
n 45.2%
Agitation/aggressio
n
44.9% [email protected]
11/06/61 126 [email protected]
Multiple Etiologies Model
11/06/61 [email protected] 127
Genetics (receptor
polymorphism)
Neurobiological aspects
(neurochemical,
neuropathology)
Psychological aspects
(e.g., premorbid
personality, response to
stress)
Social aspects (e.g.,
environmental
change and
caregiver factors)
Treated if burdensome
Cause(s)?
Non-pharmacological
treatment
Pharmacological
treatment
128
11/06/61 128 [email protected]
Psychosocial intervention
• Activity and recreation
• Carer education
• Exercise, movement, relaxation & massage
• Simulated family presence
• Music, sensory enrichment & aromatherapy
• Reminiscence and validation therapy O’Connor DW et al, International psychogeriatrics 2009
IPA’s Guide to BPSD Management, 2012.
11/06/61 [email protected] 129
Recreational therapy
11/06/61 [email protected] 130
Massage Therapy
11/06/61 [email protected] 131
• Aromatherapy1,2
• Agitated behaviors
• Family tape-recordings3
• Agitated behaviors
• Physical activity4
• Active exercise program
• Has a calming effect and lifts mood
1.Holmes et al., 2002.; 2.Ballard et al., 2002.;
3.Garland et al., 2007.; 4.Williams and Tappen, 2007.
11/06/61 [email protected] 132
Snoezelen: Multi-sensory stimulation (MSS)
11/06/61 [email protected] 133
Reminiscence Therapy
11/06/61 [email protected] 134
Medications
• Cholinesterase inhibitors
• N-methyl-D-aspartate receptor modulators
• Antipsychotics
• Antidepressants
11/06/61 [email protected] 135
11/06/61 [email protected] 136