Shriti Patel, MD Associate Program Director of Psychiatry Residency Eastern Virginia Medical School Department of Psychiatry and Behavioral Sciences

Shriti Patel, MD Associate Program Director of Psychiatry Residency Eastern Virginia Medical School Department of Psychiatry and Behavioral Sciences

Disclosures Board Certified in Adult and Geriatric Psychiatry I have no potential or actual conflict of interest in relation to this presentation

Question 1 An 86 year old widowed white retired physician is brought to the ED after stating I want to end it all, we are all going to die, what is the point?. He reports insomnia, irritability, feeling lonely. He admits to having a loaded gun at home. Which individual risk factor puts him at highest risk for suicide? a. Former Profession b. Age c. Widowhood d. Access to guns e. Presence of irritability

Answer Question 1 a. Former Profession b. Age c. Widowhood d. Access to guns e. Presence of irritability Recommended Reference 1. Y Conwell et. al. Risk Factors for Suicide in Later Life. Biological Psychiatry. 2002; 52: 193-204 2. Gold, Katherine J., Ananda Sen, and Thomas L. Schwenk. Details on Suicide among U.S. Physicians: Data from the National Violent Death Reporting System. General hospital psychiatry 35.1 (2013): 45 49. PMC. Web. 25 Feb. 2017. 3. Kellerman AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun ownership. New Eng J Med 1992;327:467 472.

Answer Question 1 Risk factor a characteristic, variable, or hazard that increases the likelihood of development of an adverse outcome, which is measurable, and precedes the outcome.

American Foundation for Suicide Prevention: https://afsp.org/about-suicide/suicide-statistics/ One fourth of all suicides occur in persons 65 Other major risk factors: depression, physical illness, living alone, male sex, substance use Violent suicides (e.g. firearms, hanging) are more common than non-violent methods, despite the potential for drug overdosing Highest risk group: elderly white male over age 85

Answer Question 1 a. physician - higher rate of suicide compared to general population undiagnosed/untreated mental illness treatment less sought out, stigma of receiving treatment better understanding of lethal means (in US firearms, in Europe overdose) c. widowhood being single, suffering loss, is a risk factor, often increasing in later life, but not as significant as age alone. d. access to firearm ready availability is associated with increased risk for suicide Risk changes with quality loaded/unloaded, locked/unlocked, storage Most firearm related suicides have had guns in home for months to years

Question 2 Which of these non-pharmacologic (psychosocial) approaches have the most extensive and consistent evidence supporting its use in managing neuropsychiatric symptoms of a patient with dementia? a. Participation in pleasant events b. Training of caregivers and staff c. Exercise d. Personalized Music

Answer Question 2 a. Participation in pleasant events individual 20 min interactions 2-3 x per week outcomes: less depressive symptoms, some decline in agitation b. Training of caregivers and staff psycho-education, patient centered care, communication strategies outcome: less agitation c. Exercise studied in long term care setting outcomes: decreased NPS, improved physical function d. Personalized Music better than group music outcomes: decreased agitation when administered before times of risk Recommended Reference Chenoweth et. al. Caring for Aged Dementia Care Resident Study (CADRES) of person-centered care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial. Lancet Neurology. 2009; 8(4):317-25. Testad et. al. The effect of staff training on agitation and the use of restraint in nursing home residents with dementia: a singleblind, randomized controlled trial. Journal of Clinical Psychiatry. 2010;71 (1): 80-86.

Question 3 Which of the following medications are FDA approved for dementia with agitated behaviors? a. Valproic Acid b. Citalopram c. Risperidone d. Lorazepam e. None of the Above

Answer Question 3 a. Valproic Acid b. Citalopram c. Risperidone d. Lorazepam e. None of the Above Any medication used for agitation in dementia is off-label. Recommended Reference 1. Reus et al. The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia. American Journal of Psychiatry. (May 2016) 173:5 2. Fleisher AS, Truran D, Mai JT, et al. Chronic divalproex sodium use and brain atrophy in Alzheimer disease. Neurology. 2011;77(13):1263-1271. doi:10.1212/wnl.0b013e318230a16c. 3. Porsteinsson AP, Drye LT, Pollock BG, et al. Effect of Citalopram on Agitation in Alzheimer s Disease The CitAD Randomized Controlled Trial. JAMA : the journal of the American Medical Association. 2014;311(7):682-691. doi:10.1001/jama.2014.93.

Answer Question 3 evidence is limited, but there is more literature supporting modest efficacy of antipsychotics and citalopram compared to other medications a. valproic acid antiepileptic medication, mood stabilizer Limited small studies suggesting improvement of aggressive behaviors Risk: gait imbalance, tremor, elevated LFT/ammonia, sedation, increased progressive brain volume loss b. citalopram selective serotonin reuptake inhibitor CIT-AD study showed some benefit over 9 week period (at 30mg dose) Risks: cardiac risk factors at doses over 20mg. c. risperidone antipsychotic APA recommends that nonemergency antipsychotic medication should only be used for the treatment of agitation or psychosis in patients with dementia when symptoms are severe, are dangerous, and/or cause significant distress to the patient importance of risk/benefit discussion with caregiver, including FDA black box warning for antipsychotic medications d. lorazepam - benzodiazepine limited small studies showing temporary benefit (1-2 hours) Side effects: oversedation, exacerbation of confusion and disinhibited behaviors, fall risk, tolerance

Question 4 A 67yo man has lost 40 lb in the past 6 months, is weak, spends most of his time in bed, and no longer participates in family activities or watches sporting events on television. His family is concerned that he has a serious undiagnosed medical problem. He tends to sit quietly and let his family answer questions, but when pressed, he indicates that he cannot swallow solids or liquids because his throat is blocked. His family reports that he eats and drinks small amounts. The patient believes he has cancer that the doctors have yet to find. According to the medical records he provides, radiography and computed tomography of the chest are normal, and upper endoscopy is unremarkable. Several sets of blood work have been obtained, none of which indicate dehydration, anemia, or hepatic or renal dysfunction. What is the most effective treatment for his illness? a. Sertraline b. Electroconvulsive Therapy c. Olanzapine d. Donepezil

Answer Question 4 a. Sertraline b. Electroconvulsive Therapy c. Olanzapine d. Donepezil Recommended Reference Petrides G, Fink M, Husain MM, et al. ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE. J. ECT. 2001;17(4):244 253. Kerner N, Prudic J. Current electroconvulsive therapy practice and research in the geriatric population. Neuropsychiatry (London). 2014 Feb; 4(1): 33 54.

Answer Question 4 Delusions have a higher prevalence in late-onset major depression (>60 yo) Psychotic depression has a poorer prognosis than nonpsychotic depression and is less responsive to antidepressants Electroconvulsive Therapy shows better efficacy, faster response, and higher remission rates for management of psychotic depression a. sertraline can treat depression alone, but must also treat somatic symptoms of psychosis rapidly c. olanzapine can treat psychotic symptoms, but must treat underlying depression d. donepezil may be modestly protective for cognition, but not mood

Question 5 76 yo female with memory complaints in context of depression, pain from osteoarthritis, neuropathic pain, along with urinary incontinence, diabetes, dyslipidemia, reflux, hypothyroidism, insomnia. MoCA is 20/30, and attention poor, but no major functional deficits. Her blood work was normal. Amongst the medications in her list, which of these has the lowest risk for confusion? a. oxybutynin b. quetiapine c. mirtazepine d. amitriptyline e. acetaminophen/diphenhydramine

Answer Question 5 a. oxybutynin - anticholinergic b. quetiapine - dose dependent anticholinergic properties c. mirtazapine - at low doses, very weak antagonism of muscarinic receptors d. amitriptyline - anticholinergic e. acetaminophen/diphenhydramine - anticholinergic Recommended Reference: Chew ML, Mulsant BH, Pollock BG, et al. A model of anticholinergic activity of atypical antipsychotic medications. Schizophr Res 2006; 88(1-3): 63 72 https://www.guideline.gov/summaries/summary/49933/american-geriatrics-society-2015-updated-beers-criteria-for-potentiallyinappropriate-medication-use-in-older-adults

Questions? Old age is not a disease - it is strength and survivorship, triumph over all kinds of vicissitudes and disappointments, trials and illnesses. - Maggie Kuhn