Elderly with dementia

Depression. Like delirium, depression is an illness that is common among the elderly and that can occur either apart from or concurrently with dementia. Elderly depressed patients often have poor concentration and poor motivation and appear... 

Kolanowski, A., Fick, D., Waller, J., Ahern, F. (2006). Outcomes of antipsychotic drug use in community-dwelling elders with dementia. Archives of Psychiatric Nursing, 20, 217-225. 

Jeste DV, Okamoto A, Napolitano J, Kane JM, Martinez RA. Low incidence of persistent tardive dyskinesia in elderly patients with dementia treated with risperidone. Am J Psychiatry 2000 157(7) 1150-5. 

However, vascular dementia, which is the second most important cause of cognitive impairment and dementia associated with aging in the US, is the most preventable form aifecting the elderly. 

Roth, M., Mountjoy, C.Q., Huppert, F. A., Hendrie, H., Verma, S., and Goddard, R., 1986. CAMEX A standardized instrument for the diagnosis of medical disorder in the elderly with special reference to the early detection of dementia. British Journal of Psychiatry. 149 698 701. 

In fact no consistent correlation has been found between the appearance, distribution and number of amyloid plaques and either neuronal loss or the degree of dementia, although the latter correlates with the number of neurofibrillary tangles, which tend to precede plaques in appearance by some years. Also cortical amyloid deposits can be found in non-demented elderly patients. Thus the basic question appears to be does the disease process, whatever that is, cause the development of AzD as well as the production of jS-amyloid or is there production of S-amyloid, which then causes AzD Consensus supports the latter but it is not proven. 

Supplementation with antioxidant micronutrients, for example, vitamin E and selenium, in the elderly and in dementia subjects (Tolonen et al., 1985) has indicated that such treatments may be of some limited benefit. The value of ascorbate as a cerebroprotective antioxidant against excitotoxic neuronal injury has been proposed (Griinewald, 1993). 

McGeer, P.L., Harada, N., Kimura, H., McGeer, E.G. and Schulzer, M. (1992). Prevalence of dementia amongst elderly Japanese with leprosy apparent effect of chronic drug therapy. Dementia 3, 146-149. 

Psychotic symptoms in late life (greater than 65 years of age) are generally a result of an ongoing chronic illness carried over from younger life however, a small percentage of patients develop psychotic symptoms de novo, defined as late-life schizophrenia. The 6-month prevalence rate of schizophrenia in the elderly is around 1%. However, other illnesses presenting with psychotic symptoms are common in this population, as approximately one-third of patients with Alzheimer s disease, Parkinson s disease, and vascular dementia experience psychotic symptoms. The majority of data for antipsychotic use in the elderly comes from experience treating these other disease states. 

Kryzhanovskaya, L. A. el al. (2006). A review of treatment-emergent adverse events during olanzapine clinical trials in elderly patients with dementia. /. Clin. Psychiatry, 67, 933-45. 

There is less risk of developing motor complications from monotherapy with dopamine agonists than from L-dopa. Because younger patients are more likely to develop motor fluctuations, dopamine agonists are preferred in this population. Older patients are more likely to experience psychosis from dopamine agonists therefore, carbidopa/L-dopa may be the best initial medication in elderly patients, particularly if cognitive problems or dementia is present. 

Klotz U, Avant GR, Hoyumpa Aet al. (1975) The effects of age and liver disease on the disposition and elimination of diazepam in adult man. J Clin Invest 55(2) 347-359 Kompoliti K and Goetz CG (1998) Neuropharmacology in the elderly. Neurol Clin 16(3) 599-610 Lanctot KL, Best TS, Mittmann N et al. (1998) Efficacy and safety of antipsychotics in behavioral disorders associated with dementia. J Clin Psychiatry 59(10) 550-561 Landi F, Onder G, Cesari M et al. (2005) Psychotropic medications and risk for falls among community-dwelling frail older people an observational study. J Gerontol A Biol Sci Med Sci 60(5) 622-626... 

Memantine is approved for treatment of moderate to severe Alzheimer s disease. It is an antagonist at glutamatergic NMDA-receptors. Memantine is well tolerated and has a small beneficial effect at six months in moderate to severe AD (McShane et al. 2006). For patients with dementia one has to be careful wit all kind of medications that may affect the central nervous system. Delirium and hallucinations are common adverse effects in patients with dementia. Agitation may be due to delirium and external causes should be ruled out before adding another psychoactive drug. Sleep disturbance is common in demented elderly patients. Sleep deprivation may in a patient with dementia induce delirium. Nonpharmacological treatment for delirium or hallucinations should be considered first. 

Dementia. In the elderly, you may have difficulty distinguishing depression from the early stages of dementia. Depressed patients often report memory problems and may even ask, Do 1 have Alzheimer s disease It is usually not that their memory itself is impaired. Their forgetfulness is more the result of apathy and poor concentration that leads them to overlook the things going on around them. The result is a false dementia or pseudodementia. On the other hand, patients with true dementia often become depressed as well. 

The final category is termed the sleep-wake schedule disorders. These are seen in people who get their days and nights turned around. The most common examples are shift workers and travelers with jet lag. Additionally, in the elderly, especially those with dementia, a malfunction in the circadian biological rhythm that regulates sleep can leave them awake and alert at night but drowsy and sleeping during the day. 

Delirium. Delirium, the waxing and waning of consciousness and lucidity, can be difficult to distinguish from dementia. Both affect multiple areas of intellectual functioning. Both tend to affect the same groups of people, namely, the elderly and those with brain injuries. And the two are not mutually exclusive. Patients with dementia can also become delirious in fact, the brain impairment of dementia increases vulnerability to delirium. 

Hearing Loss. Like the patient with aphasia, the patient with hearing problems often finds it difficult to communicate. If not mistaken for dementia, hearing problems can certainly complicate the course of mild-to-moderate dementia. Therefore, all elderly patients who appear to be having intellectual problems should have a hearing examination. 

Benzodiazepines should be used with caution in dementia patients. Used improperly, they can disinhibit patients and worsen behavior, or they can accumulate and lead to a state of intoxication. To minimize the risk of accumulation, benzodiazepines that are easily metabolized are preferred for elderly patients. Specifically, lorazepam (Ativan) and oxazepam (Serax) are easier for elderly patients to tolerate than other benzodiazepines. 

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