Primary Care of the Psychiatric Mental Health Client II

Psychiatric Treatments in the Older Adult Video Transcript

All right. Hello everyone, and welcome to this week. This is Professor Megan Hawk, and have a lecture for you today on Psychiatric Care of the Older Adult. The objectives are the same as what they are in your Moodle course. So I'm not going to read those to you word for word.

So, the older adult. The elderly currently make up 16% of the population. And that's up to date as of 2022. An older adult can be defined as an individual aged 65 and older, but while reviewing literature on this topic, I actually did find that some studies actually refer to younger patients as older adults, especially whenever there is the presence of severe mental illness.

Things like schizophrenia, diagnoses like schizophrenia typically have a lower life expectancy. So if you're reviewing literature, even grey literature on information for the older adult, you may even see ages like 55 rather than 65. But for the purpose of this lecture, we'll be referring to the older adult as aged 65-plus, but just keep that in mind.

And also we have an increasing aging population. The life expectancy in general is going up, and we are expected to have a higher and higher population of older adults as the decades go on. So there are some physical differences between the older adults and younger patients. So there are some things that just physiologically happen when we age. Less muscle mass, less total body water, more body fat, renal and hepatic functioning may decrease.

So whenever we're thinking about how medications might be impacted by this or how our patients might be impacted by the medications that they're taking, those physiologic changes can really help us to understand that. Also, the older adult is more prone to have medical comorbidities and polypharmacy. Polypharmacy can be described as having five or more medications on board. And we also need to keep drug-drug interactions in consideration.

OK. Before we dive into diagnoses here, I do want to take a second to talk about what also makes the older adult socially, psychologically different from a younger patient. Older adults might be dealing with loss of function, loss of independence, loss of family, loss of social circle, increased risk of falls, increased medical concerns, decreased mobility. So these are all very, very important things to assess for whenever we are talking to our patients, meeting our older adult patients for the first time, is seeing what is different about them socially, what their needs are, and what strengths they have. What do they have in their corner? Do they have a strong social network? Do they go to the senior center? Do they still do things? OK.

Let's see here. So, and other things that we talk here are part— are to be considered part of the normal aging process. We're going to talk about dementia, we're going to talk about depression, anxiety, and other diagnoses in the older adult, but none of these are expected with aging. Decreased cognitive function is not a normal part of aging. OK?

So we're going to start off with dementia here. So this is a general term for difficulties with cognitive functioning. Characterized by loss of executive functioning, think about— the old phrase was "balancing your checkbook," but really you're planning, you're organizing, you're staying on task. You could think about are they making and keeping their appointments? Are they able to keep track of their finances, and things like that?

Memory loss is kind of one of those more cardinal signs. Poor judgment— that might not be super apparent really early in the disease process. And getting lost in familiar places. That was a big red flag to me with one of my own patients who was starting to get disoriented and lost in the grocery store that she went to all the time. And the current number is 6.5 million Americans affected at this time. And that is up-to-date information as of 2023.

So there are some additional challenges for the patients with dementia. So behavioral and psychological symptoms of dementia, or BPSD, is a cluster of symptoms that can occur if a patient is experiencing dementia. And for anybody who's worked in memory care or long-term care facilities, you may have experienced this. You might not have realized what it was at the time.

So behavioral and psychological symptoms of dementia usually don't occur super early in the disease process, usually about towards the middle and more end stage. So these can include psychosis, anxiety, agitation, depression that might get worse in the evening time.

And then moving on to just different types of dementia. Alzheimer's dementia, we kind of use as that prototype. That's the most common. And when I'm referring to dementia in this lecture, Alzheimer's disease is more along the lines of what I'm talking about here, but there are other types of dementias that are really important to know about. You may or may not see a lot of these depending on where your clinical setting is, but dementia with Lewy bodies is very important to keep in mind because there are visual hallucinations with this disorder or with this disease. And we don't typically see visual hallucinations in schizophrenia. It's more common to have those be auditory.

And in dementia with Lewy bodies, they might say that they're seeing little people. That might be anecdotal, but small people. So if you have a patient just giving you a really bizarre, it's an older adult patient and you're thinking this just sounds different than what I'm used to hearing because they're saying that they're seeing like little— I had a patient once say she was seeing little Martian men. And the collaborating psychiatrist I worked with was strongly, strongly considering dementia with Lewy bodies. And think that patient went off to get neuropsychological testing, and I'm not sure what happened with that one. But then we also have vascular dementia, and we actually see a little bit more anxiety and depression with that type of dementia.

So there are some findings that you might see whenever you're interviewing, working with, speaking with a patient with dementia. Or you might not see these things. These are not 100% of the time present. But mood and affect, so mood is always how the patient describes it. That could be anything. Affect, we might see reactivity of affect in dementia, and what that means is that an outside stressor, it does not cause— it does not require much of an outside stressor to create a change in the affect of a patient. That's that reactivity that I'm talking about. So something bad might happen and it might plummet their mood. Something funny might happen, and then they might get maybe almost excessively giddy.

So just a really almost like a roller coaster with that reactivity is possible. Not always. Thought content is just what the patient talks about during the interview. This could be anything. But the thought process is how those ideas are organized. And if you are having any trouble with mental status examinations, there's a book that I just really, really like for that that is in the references at the end here called The Mental Status Examination Explained by Dr. David J. Robinson. It's a wonderful book if you're struggling with mental status examination findings and how to describe them.

So the patient with dementia might have trouble organizing their thoughts. It might just be illogical. There might be some poverty of thought, poverty of content. We see that in schizophrenia as well. Perceptual disturbances. Delusions and hallucinations can be common. Remember the behavioral and psychological symptoms of dementia we talked about. But then also dementia with Lewy bodies here, more visual.

Impairments in judgment, insight, memory, attention. Those are the most common things that we're going to see and there are ways to test those outside of the general spell world backwards sort of things that we normally do in our mental status examinations. So consider a mini-mental, consider a MoCA. So next is what do you do if you suspect even MCI, which is Mild Cognitive Impairment? What do you do if you suspect that, say you're outpatient, what are your next steps?

So any time that I was considering MCI, or any kind of other cognitive impairment in my patients, I would perform a mini-mental or a MoCA. These are screening tools only. So they're not diagnostic, and it's important to let the patient know what to expect with those tools. And then depending on the score, you can refer for neuropsychological testing. But you know other things that are important to look at are medical comorbidities, lab work, drug-drug interactions. Are there any new medications added? So there's other things to look for there too whenever there's mental status changes.

Which leads us into differentials for dementia. Again, dementia is not a normal part of the aging process, but we need to keep it in our mind as a potential diagnosis whenever we're seeing cognitive impairment with our older patients. So first one on here is delirium. So how do we differentiate delirium from dementia? Delirium is a very sudden mental status change. And anybody who's worked in emergency medicine, even some long-term care if you're getting older patients with UTIs, it is generally a more sudden change. Especially when we're comparing it with dementia, which is usually more gradual onset, delirium will resolve when the underlying issue is taken care of.

So for those of you who have seen mental status changes with urinary tract infections in older patients, also they don't have to be older. Sometimes I've seen mental status changes in 40-year-olds, but anyways. For those of you who have seen that, you get that patient some antibiotics and then things go pretty much right back to normal baseline functioning.

So any time we see a mental status change, we want to do all the things that I just mentioned. We want to get some blood work. CBC OK? CMP OK? Those electrolytes looking OK? Thyroid function looking OK? Any trouble with them? If they're falling, you can check like B12. Yeah. Substance use disorders. It's important to describe it this way. We have to do a very thorough assessment. We have to make sure we rule out any other cause. And some of those other causes are abusing substances.

"Now, I'm not accusing you or your family member of abusing substances, it's just something that we have to do to make sure that we've got documented that this is not due to a substance." So you can educate in that way so that it doesn't seem like a punitive thing. Because sometimes you can present the idea of a drug screen to your patient, and you might get some kind of different results. So sometimes that takes a little bit of discussion to get them to understand why we're doing that and what the importance of it is.

Depression. So depression can cause some overlap of symptoms, especially for an older adult who might maybe experience more lethargy or maybe a little bit more cognitive dulling with their depression. Developmental delays. Say we're just meeting an older patient and we don't really have a whole lot of information on them. Check the history. Do they have any kind of developmental delay? Because that is actually another population that is in general able to grow to older ages than previously. So we'll be seeing increased older adults with developmental delays.

Bipolar disorder, schizophrenia, important to rule out, especially since we noticed this overlap between dementia after the early stages when they might start to experience those symptoms. Absence seizures, if they're zoning out, having lapses of memory or these spaces where they don't know what was going on. Frontotemporal dementia, dementia with Lewy bodies, and I just go through all those different types of dementia to be able to know some of those differences.

Treatments. There is pharmacologic treatment, there's nonpharmacologic treatment. So pharmacologic treatment, we generally want to make sure that we've got another set of eyes before we go initiating these medications. You might inherit patients who are already on them. Donepezil is probably the most heard of medication for dementia, which is Aricept, and it's a cholinesterase inhibitor. And it's also a selective acetylcholinesterase inhibitor.

So cholinergic dysfunction accompanies age-related cognitive decline. So per Dr. Stahl— and we are looking at Stahl's Essential Psychopharmacology, not the Prescriber's Guide. On page 509, Dr. Stahl says, "Stimulating postsynaptic cholinergic receptors by increasing acetylcholine with acetylcholinesterase inhibition can hypothetically restore some of the loss function of degenerated cholinergic neurons."

And that's huge because that indicates that early enough in treatment, we might be able to restore some of the wiring, I guess, that has not been wired correctly. And that's a really big thing for our patients. So early detection is really key here. Memantine ER, or Namenda, is an NMDA receptor antagonist. And then Exelon, I struggle with that other name, is a cholinesterase inhibitor. And that one is an intermediate acting, whereas donepezil, or Aricept, is a long-acting medication.

All right. And then our nonpharmacologic options really focus heavily on psychotherapy. Oops. I didn't mean to do that. So our psychotherapy for the older adult, especially the older adult with dementia is going to focus on maintaining wellness, dignity, and functioning of the patient. Now, we can have that patient do reminiscence therapy, which is an approved type of therapy for the older adult. Kind of helps them, guides them through framing things that have happened in their life in a more positive way.

And then person-centered therapy is also another type of therapy. So a heart healthy diet is important, staying physically, socially active. And then in the case of the behavioral and psychological symptoms of dementia, knowing those triggers, modifying the environment. It doesn't always have to be about medication. Sometimes it's about making an environmental change. Oh, geez. There we go.

So depression and suicide in the older adult. Older adults might experience grief and loss more than our younger patients. They lose their social network. The depressive symptoms of the older adult must not be overlooked. While I was doing a literature review for this lecture, I did come across one study where they indicated that a lot of older adults' issues with low mood and depression were brushed off as normal grieving. And we need to be really careful with that and assessing them in the same way that we would assess our younger patients, and not overlooking true depression in our older patients. And helping them understand that as well.

Adults age 75 and older have one of the highest suicide rates. And men age 75 and older— I'm sorry about this. I think it was actually 65 to 75 have one of the highest, and then 75 and older have the highest. So I'm sorry about that typo. But yes, 75-plus have the highest suicide rate compared to other age groups. So if that doesn't the importance of really assessing these older patients, I don't know what does.

The older adult with bipolar disorder. We're going to see more and more of this, because our population is aging to older and older ages. And the life expectancy of our bipolar severe patients is maybe a little bit lower than the general population, but it's getting higher. So we can have late onset bipolar disorder versus early onset. Early onset is just those who— they experience bipolar symptoms in their 20s like the textbooks tell us, and then late onset would be somebody with genuine bipolar-related illness in their 60s.

Lithium is still our gold standard for bipolar disorder, even in the aging community, but we do have a much higher risk of toxicity in the older adult. So it's important to make sure that our patients know what the symptoms of toxicity look like: sedation, tremor, confusion. The tremor is huge for your patients on lithium, especially the elderly patients.

Our elderly patients are also more prone to dehydration. And dehydration with lithium is a bad combination because then that's going to increase the amount of lithium in the body because it's not as diluted in the total body water. So the elderly is likely to respond to subtherapeutic doses of lithium with the same efficacy. So we're likely not going to want to start our elderly patient off on 300 BID of lithium carbonate. They're probably not going to need it.

Keep an eye on the thyroid and the kidneys, as always— we keep an eye on that with our healthy patients. But our older patient might already be having some mild, if not worse, kidney issues, or renal issues. So we're going to want to keep an eye on that as well. And you don't necessarily need to dose— I'm going to tell you you don't necessarily need to dose for a lithium level. I would say 150 milligrams with an older patient to start with and see how it goes.

If that level is subtherapeutic, that's probably fine. If their symptoms are well controlled, don't worry about it if the level is subtherapeutic because the older adults— I once had an elderly female patient, the only thing that stabilized her mood was lithium. 300 BID was enough to send her into toxicity. 300 BID.

So the older adult patient with other mental health disorders. Schizophrenia, we've talked about the life expectancy already. Those who develop schizophrenia later in life do tend to have better outcomes than early onset, which I've found an interesting fact. And PTSD incidence is actually lower in older adults, which leads us to wonder, is there truly less trauma, or is it just underreported and undertreated?

So there are some general medication considerations when we're considering prescribing for the older adult. So start low, go slow. Start low, as in half to even a quarter of the regular starting dose might be fine. Go slow. We're going to titrate up and even titrate down, if that's what we're doing, a lot slower than we would for a patient who is younger. And don't abruptly stop your medication. That's important for all patients, but especially the elderly. They're just going to be more sensitive to those side effects. Just also be patient. Give them a little bit more time to reach efficacy with the medication.

All right. So American Geriatric Society Beers' Criteria. You're going to hear me talk a lot about this in the next several slides. From here on out, I'll just refer to it as the Beers' Criteria. So the American Geriatric Society does come out with this list. They update it as new information and studies come out. And it's used as guidance; it's not meant to be your end-all be-all, "I cannot prescribe this" and "This is safe."

Think back to our lecture about pregnancy, and having a conversation and looking at all the sides. And that's what we're doing with medications in the elderly as well. We're looking at all of those potential risks, and then weighing the risks versus the benefits for our patient. So Potentially Inappropriate Medications, or PIMS, are what is noted on the Beers' Criteria list.

Several classes of medications impact us as PMHNPs. Classes of medications— and these aren't necessarily the entire class. Some of them are specific medications within the class. But regardless, we have antipsychotics on there, benzodiazepines are on there, antidepressants, and anticholinergics. We'll talk about all of them.

Antipsychotic medications. So both first generation and second generation antipsychotics pose a risk to the elderly. As a refresher, first generations are your Thorazine, Haldol, Prolixin, and fluphenazine— oh, that is Prolixin— Trilafon or perphenazine. And then your second generations are your aripiprazole Abilify, cariprazine Vraylar, quetiapine Seroquel, or lurasidone Latuda, risperidone, paliperidone.

They all have a box warning. It's a class warning across class of antipsychotics.

So it's not specific to any one of them. It's a class warning for increased mortality in patients with dementia-related psychosis. It's very specific, but I still would exert some caution in prescribing these medications to the elderly in general, and the Beers' Criteria cautions against them as well.

Make sure you have good documentation. You want to make sure that you're documenting that you're having these conversations with your patients.

And they do have— older adults do tend to have an increased risk of the movement disorders that are associated with the antipsychotic medications. So those are, as a refresher again, akathisia, tardive dyskinesia, extrapyramidal side effects. You can review those in either this Fitzpatrick text or the synopsis— that Kaplan and Sadock's Synopsis of Psychiatry also has a really good section on movement disorders.

Antidepressants. So, in general, they can cause some clotting issues for older patients. The tricyclics, though, are on the Beers' list. And the reason they're on there is for their high anticholinergic properties. They also come with a risk of orthostatic hypotension, which is not great for the older adult because that increases their fall risks. So when we're looking at maybe having one of these tricyclic antidepressants on board with maybe an anticholinergic or an antipsychotic medication, we're looking at increasing that risk even further.

So anticholinergic medications and benzodiazepines. These ones are really meant to be used with caution. The anticholinergics are those medications that we can use to manage side effects of antipsychotics, benztropine, Cogentin, trihexyphenidyl, or Artane, are older medications used for abnormal involuntary movements. Cogentin can be used for tremor. And then Ditropan, oxybutynin is on here. That's also an anticholinergic. So your patients might be on that for urinary frequency, and maybe they're also on Cogentin.

So yeah, you can get too much and they can end up with urinary retention.

And then benzodiazepines, big, big fall risk in the elderly. You're going to come across elderly who are on benzodiazepines, who are on hypnotic sleep aids. You're going to see it. But the important piece for us is just because we see it, just because they're on it doesn't mean that we shouldn't be having these conversations with our patients.

Even if you're taking over care for a patient they've been on, I don't know, alprazolam for 10 years, we still need to have these conversations with the patients. We can't assume that their other provider has told them the risks. So that's a conversation that we need to be having and that we need to be documenting. The benzodiazepines, they increase the risk for falls, confusion, cognitive decline. It's well documented. OK?

But isn't my job to prescribe? So I'm going to go on a little bit of a soapbox here about de-prescribing because I don't think that it's talked about enough, especially for our older patients. Consider the role of the PMHMP as evaluating the need for medication. We're not— we need to be cautious to not get ourselves in the mindset that we must prescribe all the time, or that we must prescribe to every patient in every scenario because that's not always the case.

And in fact, the answer might be to take medication away, which our patients aren't prepared to hear because they don't think that that's the purpose that we serve. And we sometimes, I think, as potential providers, future providers, or current providers need to also remind ourselves of. Sometimes that's the most therapeutic thing that we can do is decreasing a dosage of a medication for an older adult.

Of course, we can prescribe if appropriate, but always evaluate the need. For some older patients on the same medication regimen for long periods of time with no re-evaluation, de-prescribing might be the answer. I wrote "is the answer"— I must have been really passionate about that at the time. You might try to lower their dose, and they might completely destabilize. So don't take what I'm saying here as gospel, but we need to reevaluate their medications and make sure that it's appropriate and make sure that they're aware of the risks and are able to provide us with an informed consent.

Nonpharmacologic treatment options for the older adult. Tai Chi is a really common one, and it's more of a modernized version of the ancient Chinese art, but it is more movement kind of medicine. Improves strength and ability to perform functional tasks. And those abilities to perform functional tasks is— the research is trying to kind of link that with a decreased fall risk. Like if the functional— if the increased ability to perform functional tasks is improved, will falls decrease?

Phototherapy, bright light therapy, not a whole lot of positive studies for older adults.

Psychotherapy options for our older adult patients. CBT, of course, addressing physical, emotional, and social issues. And for our older adults with insomnia, CBT-I. Let's not forget that there is a specific branch of CBT specifically for insomnia. And reminiscence therapy, I talked a little bit about this earlier. It's a treatment focusing on a reflection of life and aging, and telling of life events through a positive lens can be very, very therapeutic for our older patients.

So, some final considerations here. Allow your older patient time to talk to you if that's what they need. You'll notice very early on in your interactions with older patients which ones really need that time with you. And I suggest that you provide it to them. You might need to allow for longer appointment times with those patients. Remember to start low and go slow with dosing medications in the elderly, and consider de-prescribing when appropriate.

Keep in mind your nonpharmacologic options and determining whether or not your older adult patient is also thriving socially, cognitively, physically. You know, let's take all, the whole picture into account. And making use of your cognitive screening tools like the MMSE, which is the mini mental status exam, and the MoCA, which is the Montreal Cognitive Assessment.

There's a lot of references here. I really strongly encourage you to take a look at the Beers' Criteria. There's a pocket guide that I can— maybe I'll just put that into the course material anyway. So, Beers' Criteria, take a look. Very interesting and important. OK?

And then Robinson here, 2017, is that book I told you about with The Mental Status Examination Explained. And that is the end of the lecture, guys. Thanks for staying on to the end, and have a great rest of your day. Bye-bye.