The symptoms listed in Box 17.2 are referred to as ‘behavioural and psychological’, or ‘neuropsychiatric’, symptoms of dementia. Some are common (60% of people with dementia living at home exhibit one or more of these symptoms), most upset either the person with dementia or those around them, and they may lead to the prescription of psychotropic medication.

Assessment of the person with suspected dementia

Management

Medical issues

Tasks include establishing a diagnosis of dementia and its most likely aetiology, excluding treatable causes including depression and delirium as sole or contributing precipitants of confusion, and ensuring optimal physical health. The latter is important because patients with dementia often forget to mention symptoms, fail to attend appointments for investigations, and do not take medications reliably. Incidental physical pathology is common, so doctors should look for it. Attention should be paid to the effects of the dementia or other mental disorder on the family member(s) who care(s) for the affected person. Many carers are anxious, depressed or grieving, and may experience ‘carer burnout’.

Cholinesterase inhibitors (donepezil, galantamine and rivastigmine) can improve the cognitive symptoms of Alzheimer’s disease and slow its progression a little. Some treated patients become more alert and function better, but not all patients benefit. However, some patients worsen notably when medication is stopped, even in later stages. Cholinesterase inhibitors can cause nausea, vomiting, diarrhoea, vivid dreams and muscle cramps, but most patients do not develop these side effects if the dose is titrated up slowly. Memantine, an N-methyl-D-aspartate (NMDA) receptor blocker, may be of modest benefit when patients cannot tolerate or fail to benefit from a cholinesterase inhibitor.

Psychotropic drugs have a limited role in dementia management. Antipsychotic medications are used when delusions, hallucinations, misidentifications or aggression distress the patient or others. Evidence for efficacy is limited. Risperidone (up to 2 mg daily) is the drug of choice because it has been tested most thoroughly in this population, but it (and other antipsychotics) may raise the risk of stroke and should be avoided in patients with poorly controlled atrial fibrillation, hypertension, diabetes mellitus or previous stroke. If prescribed, drugs must be reviewed regularly, tapered and then ceased when the symptoms that prompted the prescription have remitted.

Antidepressants can treat comorbid major depression. Selective serotonin reuptake inhibitors (SSRIs) are the drugs of first choice.

Personal and family issues

People with mild dementia can express preferences about future care, assign enduring power of attorney and sometimes can make a will. The diagnosis should be explained with sensitivity and hope, given the availability of medications and excellent support services.

Assessment of activities of daily living is important. Are there difficulties with dressing, washing, toileting and bathing, or with cooking, housekeeping, shopping and handling money? How much help is needed and who gives it? What services are in place? Are relatives distressed by challenging or dangerous behaviours?

A diagnosis should be accompanied by advice to carers about strategies to minimise conflict. Argumentative patients should be humoured rather than challenged. Those who resist dressing or bathing should not be forced to conform to a timetable. Distraction, music and touch sometimes help. Carers need to ventilate concerns and have chances to rest. Home help, meals on wheels, day care, respite care, dosette boxes to organise medications, help with bathing and carer support groups may sometimes be helpful. Patients and carers should be referred to Alzheimer’s Australia for education, advice and carer support. Carers experience high rates of depression, anxiety, distress, isolation, physical ill health and financial hardship. These problems can be diminished by education, advice and support, and by treating any manifest psychiatric disorder.

Admission to a residential facility comes sooner for those who live alone or whose carer is frail, but a move from familiar surroundings can worsen confusion. Any shift should be carefully planned.

CASE EXAMPLE: dementia

A 75-year-old woman was referred to an old age psychiatrist by her general practitioner since the family was concerned regarding her progressive memory problems and irritability during the previous 6–12 months. She had been leaving the tap running and had burnt cooking pots on the stove several times. She was having trouble remembering familiar recipes despite having cooked them from memory for decades. During the previous 2 months she had become lost several times and had to stop playing bridge because she was forgetting to count the cards and could no longer remember all the rules. She herself was annoyed at her family for insisting on an assessment since she felt her memory was no worse than that of her friends. Assessment revealed the presence of a mild dementia syndrome and diagnostic work up suggested late onset Alzheimer’s disease as the most likely cause. Treatment included a trial of a cholinesterase inhibitor, and education and support for the family, including referral to Alzheimer’s Australia.

Delirium

Delirium is characterised by acute onset of fluctuating cognitive impairment and diminished attention. It affects at least 20% of patients aged over 65 who enter a general hospital. It is often unrecognised. If a proper history is taken, a story of recent abrupt cognitive decline with a fluctuating mental state over hours or days will emerge.

Prevention strategies should focus on orientation, early mobilisation, minimising the use of psychotropic drugs, preventing sleep deprivation, attention to hearing aids and spectacles, and prevention or treatment of dehydration.

Management of delirium involves treatment of its causes, supportive care, prevention of complications, and treatment of behavioural symptoms. Adequate lighting and a quiet space is preferred. Prevention of pressure sores and deep vein thrombosis, ensuring night-time sleep and encouraging daytime wakefulness, and close supervision and clear communication to both patient and family are vital. Psychotropic drugs should be used only when symptoms are causing marked distress, threaten safety or interrupt lifesaving treatment. Haloperidol (0.5–1.0 mg 2–3 times daily) has been the traditional agent of choice in these circumstances, but drugs such as olanzapine and risperidone are used increasingly in hospitals, as haloperidol can produce marked extrapyramidal side effects and can affect cardiac conduction.

Delirium can be frightening and bewildering. Families need support and information so that they can understand the changes seen in their relative. Recovered patients often need repeated reassurance and explanation of frightening memories of the delirious episode.

CASE EXAMPLE: delirium

A general practitioner received a telephone call from a hostel (low-level aged care facility) regarding an 85-year-old female resident who had been her patient for some years. The staff reported that during the previous 3 days she had become increasingly irritable and agitated, showing fluctuating levels of confusion, which were more pronounced in the evening and at night. She was usually a very pleasant and quiet person. Assessment revealed the presence of a hyperactive delirium and diagnostic work up identified a urinary tract infection as the most likely cause. Treatment involved treating the underlying cause of her delirium with fluids and an antibiotic, as well as ensuring the safety of the patient and educating the staff.

Depression

About 1–2% of older people fulfil criteria for a major depressive disorder and 20% have mild but significant depressive symptoms. Risk factors include female sex, previous depression, pain, physical or sensory handicap, personality disorder, adverse life events, lack of a confiding relationship and poverty. Depression can be triggered by physical conditions (e.g. cancer, stroke and degenerative neurological disorders) or medications (e.g. corticosteroids, L-dopa and methyldopa). Cerebrovascular disease is an important contributing factor in some late-life depressions.

Suicide rates are quite high among older men. Those who commit suicide often live alone and have serious, disabling, painful physical illnesses. Manipulative overdoses are uncommon in old age; any expression of suicidal intent must be taken seriously. For more information on depression, see Chapter 6.

Clinical features

Symptoms of depression are outlined in Chapter 6 and are similar in both older and younger patients. Psychotic features (nihilistic delusions of poverty, disease or guilt) and hallucinations are uncommon. Depressed older people may be reluctant to admit to low mood even when other symptoms are prominent. Around two-thirds of depressed elderly people presenting for psychiatric treatment have had a previous episode.

Major depression can be hard to detect in people with serious physical illness. Somatic complaints may stem from new or preexisting physical pathology or depression, or both. Depression is likely if physical symptoms are out of keeping with physical signs, but heart failure, respiratory disease, renal failure and cancer also precipitate anorexia, insomnia and fatigue.

Late-life depression has a significant mortality because of its association with serious physical illness. Otherwise, prognosis is similar to that of younger age groups. Between 80% and 90% of patients recover or show significant improvement with treatment, but relapse rates are high. Usually, continuing antidepressant treatment is required, especially if there is a past history of depressive relapses.

Assessment

Patients may believe that depression is a normal part of ageing. In some cultures, emotional distress is expressed in somatic terms. Enquiries about mood and other relevant symptoms are necessary when depression is suspected.

Relevant elements of the history and mental state examination include questions about persistence and severity of depression, appetite, food and fluid intake, weight, sleep, energy and suicidal ideas. A physical examination and investigations (e.g. full blood count, erythrocyte sedimentation rate (ESR), clinical chemistry including calcium, vitamin B12, folate and thyroid function tests, and chest X-ray) can exclude physical causes.

Management

Social and psychological therapies

Supportive psychotherapy is useful. Family counselling may assist in improving relationships. Cognitive behaviour therapy has a useful role in people with a practical outlook, and includes recording a schedule of pleasurable activities and positive reinforcement for tasks performed. Other strategies include attention to nutrition, regular exercise and social interaction.

Physical treatments

SSRIs and other modern antidepressants are the drugs of choice for moderate to severe depression. Starting doses are halved for old, frail people, but many require a standard adult dose. Electroconvulsive therapy (ECT) is indicated for marked psychomotor retardation or psychotic symptoms and in those who will not eat or drink and where there is a high risk of suicide.

CASE EXAMPLE: depression

A 72-year-old retired school teacher was referred by his general practitioner to an old age psychiatry service, since treatment for his depression (the third episode he had experienced in 20 years) had been unsuccessful so far and during his last visit he mentioned feeling himself to be a burden to his family and wanting to die. Assessment revealed the presence of sleep problems, marked depressed mood and anhedonia, especially during the morning, mood-congruent delusions (he was convinced that his family was financially ruined because of him, although this was not true), loss of appetite and weight, and prominent suicidal ideation. Diagnostic work up indicated a major depressive episode with mood-congruent delusions (psychotic depression) as the most likely diagnosis. Treatment involved admission to a psychiatric ward because of the severity of his illness and the risk of suicide, and after unsuccessful treatment with a different antidepressant combined with an antipsychotic, a course of 16 ECTs resulted in significant improvement. He was discharged on combined prophylactic antidepressant and low-dose antipsychotic medication with regular follow-up visits from members of the aged psychiatry treatment team.

Bipolar disorder

Mania and bipolar disorder arising after age 50 should be presumed to be organic in origin until proven otherwise. Potential precipitants include antidepressants, ECT, stroke, head injury and medications such as corticosteroids and L-dopa.

Elderly manic patients are overactive and show pressure of speech, flight of ideas, insomnia, disinhibition and poor judgment. Mood is often irritable and in some elderly patients manic and depressive symptoms coexist. Delusions and hallucinations can occur. Patients may be so pressured in thought and speech that they appear to have delirium or dementia.

Usually, admission to hospital is necessary. Atypical antipsychotics are indicated. Mood stabilisers are used acutely and in prophylaxis. Lithium is the treatment of choice, but has a low therapeutic index, and substantial side effects. In frail older people, ideal plasma levels are 0.4–0.6 millimoles/L for treatment and prophylaxis. Sodium valproate is better tolerated, but evidence for its efficacy is less well established.

For more on bipolar disorder, see Chapter 7.

CASE EXAMPLE: bipolar disorder

A 68-year-old man was admitted to a psychiatric ward after he had to be brought to hospital by his case manager who was employed by the local aged psychiatry assessment and treatment team. The patient had been diagnosed with bipolar disorder in his early twenties and had had several episodes of both depression and mania throughout his life, with prolonged periods of intercurrent normal functioning between these episodes. However, over the previous 4 weeks he showed increasing symptoms of mania with disinhibition, insomnia and euphoria, after his lithium medication had been stopped in hospital 6 weeks earlier when he was treated for kidney disease. Acutely, he developed grandiose delusions, believing he had supernatural powers. Assessment and diagnostic work up revealed the presence of a manic episode in the context of bipolar disorder. Treatment involved atypical antipsychotics, sodium valproate, psychoeducation and social support.

Anxiety disorders

Around 10% of the elderly experience significant symptoms of anxiety. Half of them have always been anxious, but anxiety disorders can arise following physical illness, bereavement, burglary and other adverse events. Panic attacks can simulate angina or myocardial infarction. Many anxious people have comorbid physical disease. Anxiety can lead to avoidance behaviour (e.g. an accidental fall may be followed by reluctance to go out).

Anxious patients need reassurance. Mild episodes often remit spontaneously, but conditions associated with avoidance or panic merit intervention. Anxiolytic medications should be avoided to prevent falls and dependence. Better options include an explanation of the nature of anxiety symptoms, relaxation training and graded exposure to stressors. Cognitive behaviour therapy is effective, but underused due to a lack of trained practitioners. If non-drug treatments fail, a medium-acting benzodiazepine may be warranted for a few days (e.g. oxazepam 7.5 mg twice daily). Some anxious patients, even those in whom depression is not prominent, are helped by the regular prescription of an SSRI antidepressant.

For more on anxiety disorders, see Chapter 8.

CASE EXAMPLE: anxiety

An 80-year-old woman visited her doctor asking for medication to help her sleep. She had recently been widowed after 50 years of marriage and felt unsafe alone in the house. After her neighbour experienced a home invasion, she felt anxious all day, but especially at night. Assessment and diagnostic work up revealed significant symptoms of anxiety in the context of recent bereavement. Physical examination was normal and investigation revealed normal thyroid function. Treatment focused on grief-focused cognitive behaviour therapy and avoiding benzodiazepine dependency.

Schizophrenia and delusional disorder

Clinical features

Schizophrenia is described in Chapter 5. It can arise for the first time in old age and is then more likely to affect women than men. In such cases, organic causes should be considered. Delirium, dementia and mood disorder are differential diagnoses; all may present with delusions, hallucinations and disturbed behaviour.

Most older people with schizophrenia have had it for decades. Some remain psychotic, but negative symptoms tend to predominate. Many of these patients spent years in old psychiatric hospitals and have few social and personal care skills. Complications include susceptibility to the side effects of antipsychotics, polypharmacy and the loss of caring relatives. Isolation, poverty and substandard accommodation are common.

Delusional disorder is uncommon, developing over months or years. Delusions are banal and unsystematised: neighbours are accused of banging on walls and throwing rubbish over fences. Less often, patients are convinced that malign entities tap their telephones or irradiate them. Risk factors include female sex, a suspicious personality and a family history of psychosis.