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DIAGNOSING AND TREATING DISORDERS OF AFFECT, BEHAVIOR, AND COGNITION IN DEMENTIA
Abstracts TREATING THE “OLDEST OLD” WITH DEPRESSION. Carl Salzman, M.D.
C
ombined research data and clinical experience using antidepressants in very old people (⬎age 75) suggest that 1) diagnostic criteria for very-late-life depression may differ from criteria for those ⬍ age 75 as well as from young and middle-age adults, 2) the two most reliable indicators of depression in very late life, especially in nursing homes, are irritability and withdrawal of interests, 3) very old depressed outpatients, as well as nursing home residents, respond to a variety of therapeutic interventions; in research studies, placebo response rates are very high, 4) plasma levels of tricyclic antidepressants need to be in the same therapeutic range as young and middle-age adults; side effects are more likely and more serious, 5) limited research data on selective seratonin (5-HT) reuptake inhibitors suggest that the response rate of very old depressed patients is variable and sometimes difficult to distinguish from placebo response, and 6) data are presented from studies indicating useful and non-useful outcome criteria, as well as the relationship of cognition to outcome in treatment.
DIAGNOSING AND TREATING DISORDERS OF AFFECT, BEHAVIOR, AND COGNITION IN DEMENTIA. Vinod Kumar, M.D.; George S. Alexopoulos, M.D.; George T. Grossberg, M.D.; Theresa Rummans, M.D., Pierre Tariot, M.D.
D
isorders of mood (depression), of behavior (agitation), and of cognition (dementia) are among the three most frequently encountered psychiatric challenges in elderly patients, and increasingly more attention is being focused on the accurate diagnosis and treatment of these problems. This symposium reviews in detail the methodology for the diagnosis and treatment of these disorders. The diagnosis of dementia is no longer thought of as exclusionary but, rather, is based on specific criteria that enable rapid and accurate evaluations. Similarly, the diagnosis of depression in elderly patients can be made effectively if one looks for the particular elements unique to this special population. New research is revealing that a diagnosis of late-onset depression may be predictive of yet to emerge dementia, and appropriate diagnosis and treatment may help ameliorate the effect of the illness later on. Disorders of behavior, including agitation, may be comorbid to either dementia or depression or both, significantly complicating the process of diagnosis. The treatment of the cognitive disorder in dementia patients, with the advent of the new cognitive enhancers, has brought with it exciting possibilities for patients, families, and caregivers. Similarly, the newer antidepressants have replaced the older tricyclics in most situations, giving the clinician a wider range of pos-
Am J Geriatr Psychiatry Supplement, Fall 1999
sibilities to treat depressed elderly patients with similar efficacy and without significant adverse side effects. Likewise, treatment of behavioral disorders associated with dementia and depression is now possible with alternatives to benzodiazepines and older antipsychotics, with the use of nonbenzodiazepine anxiolytics, antidepressants, and the novel antipsychotics. There will be adequate time made available at the conclusion of the presentations for in-depth discussion by those attending with the presenters of these important topics.
DIAGNOSIS OF DEMENTIA. George T. Grossberg, M.D.
I
ncreasingly, the diagnosis of dementia is one of inclusion. This presentation will review clinical, laboratory, and neuroimaging components of dementia diagnosis. A variety of screening tools including the MMSE, EXIT, Drawa-Clock, and the “7 minute AD Screen” will be analyzed. Risk factors and protective factors will be surveyed. The role of APO-E screening and cerebrospinal fluid testing will be discussed.
DIAGNOSIS OF AFFECTIVE DISORDERS AND BEHAVIORAL PROBLEMS IN THE COGNITIVELY IMPAIRED OLDER PERSON. Theresa Rummans, M.D.
A
ffective disorders and behavioral problems have a tremendous impact on the quality of life of the older person and his/her caregiver(s). The symptoms of depression may be similar and easily obtained in the noncognitively impaired person; however, depression in the person with dementia frequently is hard to recognize. Common symptoms of depression, including sadness, withdrawal, and feelings of worthlessness, observed in the noncognitively impaired person may present in atypical or unusual ways, such as irritability and aggression, in the cognitively impaired individual. Likewise, determining the etiology of behavioral problems in the cognitively impaired older person is difficult. Agitation, which is one of the most common behavioral problems, may be the first manifestation of an underlying neuropsychiatric condition. However, this is not always the situation. Thorough investigation into possible medical conditions, including cardiovascular, pulmonary, and infectious diseases, is imperative. Pain from a variety of sources is frequently overlooked and therefore inappropriately treated. Accurate diagnosis of affective disorders and behavioral problems in the cognitively impaired older person can only be accomplished with observation of the person, discussions with the caregivers, and thorough medical and neurologic, as well as psychiatric evaluation.
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C
ombined research data and clinical experience using antidepressants in very old people (⬎age 75) suggest that 1) diagnostic criteria for very-late-life depression may differ from criteria for those ⬍ age 75 as well as from young and middle-age adults, 2) the two most reliable indicators of depression in very late life, especially in nursing homes, are irritability and withdrawal of interests, 3) very old depressed outpatients, as well as nursing home residents, respond to a variety of therapeutic interventions; in research studies, placebo response rates are very high, 4) plasma levels of tricyclic antidepressants need to be in the same therapeutic range as young and middle-age adults; side effects are more likely and more serious, 5) limited research data on selective seratonin (5-HT) reuptake inhibitors suggest that the response rate of very old depressed patients is variable and sometimes difficult to distinguish from placebo response, and 6) data are presented from studies indicating useful and non-useful outcome criteria, as well as the relationship of cognition to outcome in treatment.
DIAGNOSING AND TREATING DISORDERS OF AFFECT, BEHAVIOR, AND COGNITION IN DEMENTIA. Vinod Kumar, M.D.; George S. Alexopoulos, M.D.; George T. Grossberg, M.D.; Theresa Rummans, M.D., Pierre Tariot, M.D.
D
isorders of mood (depression), of behavior (agitation), and of cognition (dementia) are among the three most frequently encountered psychiatric challenges in elderly patients, and increasingly more attention is being focused on the accurate diagnosis and treatment of these problems. This symposium reviews in detail the methodology for the diagnosis and treatment of these disorders. The diagnosis of dementia is no longer thought of as exclusionary but, rather, is based on specific criteria that enable rapid and accurate evaluations. Similarly, the diagnosis of depression in elderly patients can be made effectively if one looks for the particular elements unique to this special population. New research is revealing that a diagnosis of late-onset depression may be predictive of yet to emerge dementia, and appropriate diagnosis and treatment may help ameliorate the effect of the illness later on. Disorders of behavior, including agitation, may be comorbid to either dementia or depression or both, significantly complicating the process of diagnosis. The treatment of the cognitive disorder in dementia patients, with the advent of the new cognitive enhancers, has brought with it exciting possibilities for patients, families, and caregivers. Similarly, the newer antidepressants have replaced the older tricyclics in most situations, giving the clinician a wider range of pos-
Am J Geriatr Psychiatry Supplement, Fall 1999
sibilities to treat depressed elderly patients with similar efficacy and without significant adverse side effects. Likewise, treatment of behavioral disorders associated with dementia and depression is now possible with alternatives to benzodiazepines and older antipsychotics, with the use of nonbenzodiazepine anxiolytics, antidepressants, and the novel antipsychotics. There will be adequate time made available at the conclusion of the presentations for in-depth discussion by those attending with the presenters of these important topics.
DIAGNOSIS OF DEMENTIA. George T. Grossberg, M.D.
I
ncreasingly, the diagnosis of dementia is one of inclusion. This presentation will review clinical, laboratory, and neuroimaging components of dementia diagnosis. A variety of screening tools including the MMSE, EXIT, Drawa-Clock, and the “7 minute AD Screen” will be analyzed. Risk factors and protective factors will be surveyed. The role of APO-E screening and cerebrospinal fluid testing will be discussed.
DIAGNOSIS OF AFFECTIVE DISORDERS AND BEHAVIORAL PROBLEMS IN THE COGNITIVELY IMPAIRED OLDER PERSON. Theresa Rummans, M.D.
A
ffective disorders and behavioral problems have a tremendous impact on the quality of life of the older person and his/her caregiver(s). The symptoms of depression may be similar and easily obtained in the noncognitively impaired person; however, depression in the person with dementia frequently is hard to recognize. Common symptoms of depression, including sadness, withdrawal, and feelings of worthlessness, observed in the noncognitively impaired person may present in atypical or unusual ways, such as irritability and aggression, in the cognitively impaired individual. Likewise, determining the etiology of behavioral problems in the cognitively impaired older person is difficult. Agitation, which is one of the most common behavioral problems, may be the first manifestation of an underlying neuropsychiatric condition. However, this is not always the situation. Thorough investigation into possible medical conditions, including cardiovascular, pulmonary, and infectious diseases, is imperative. Pain from a variety of sources is frequently overlooked and therefore inappropriately treated. Accurate diagnosis of affective disorders and behavioral problems in the cognitively impaired older person can only be accomplished with observation of the person, discussions with the caregivers, and thorough medical and neurologic, as well as psychiatric evaluation.
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