Lesley McKarney, PhD, Editorial Director, Geriatrics & Aging
April 23-24, 2004
The conference explored ways in which the fields of geriatric medicine and geriatric psychiatry can work together more effectively to identify common grounds, share information, form vision and goals, build good relationships, integrate services and build a more comprehensive approach to health care.
Bridging the Gap (Dr. Goran Eryavec and Dr. Gabriel Chan)
In their opening presentation, Eryavec and Chan observed that individuals over the age of 85 are now the fastest growing segment of the Canadian population. Physicians and nurses are more often facing seniors with multiple disabilities and diseases such as dementia, delerium, arthritis, fall fractures and so on. The over 65 age group is placing a greater demand on community services, acute and long term care, yet there are inadequate resources to meet their needs in terms of medical expertise, funding, assessment and treatment beds. They proposed that
In geriatric medicine, more focus is needed on prevention and early detection of diseases of the older population.
In geriatric psychiatry, the rapid expansion of new medications and treatments for the mentally ill, and the increasing complexity of their medical conditions and comorbidities of the older population, require constant medical attention and review.
Emphasizing the theme of the conference, 'Bridging the Gap', Drs Chan and Eryavec suggest that different disciplines could work together to provide excellent overall health care to older adults through a more multidisciplinary approach to health promotion and detection, by providing more integrative health care delivery and better education of health care professionals, and by supporting family caregivers and encouraging more research.
Reducing the Risk of Dementia (Dr. Kam-Tong Yeung)
In his presentation, Yeung cited the risk factors for Alzheimer's Dementia (AD) as being a positive family history of dementia, gender (females are at greater risk than males), APOE genotype, less than six years of education, and Down's Syndrome. Arthritis, on the other hand, appears to be a protective factor.
According to a recent community autopsy series, the most common pathology in demented individuals is combined AD and CVD, and common risk factors for AD and Vascular dementia (VaD) include age, APOE 4 genotype, midlife hypertension, and cholesterol. Other risk factors that are modifiable include education, head injuries, vitamin B12 intake, alcohol consumption, and smoking, among others. Stroke increases the risk and severity of AD, Yeung explained, and stroke patients tend to present earlier and with more severity. He proposed that stroke prevention and hypertension treatment are logical strategies for reducing the risk of dementia. Lifestyle modifications (e.g., diet, exercise, weight reduction, alcohol consumption) and the use of statins and NSAIDs can also reduce stroke and AD risk.
Management of Behavioural Disturbances in Dementia (Dr. Nathan Herrman)
A long list of behavioural disturbances that are often associated with patients with dementia, including physical violence and aggression, are not included as part of the DSM IV diagnostic criteria of dementia, yet they pose a very serious management problem for caregivers, explained Herrman. Non-pharmacological approaches to behaviour management in dementia patients include altering the level of stimulation, bright light, environmental white noise, music therapy, pet therapy, activities, exercise, social interaction, and behaviour modification. He pointed out that there is very little evidence in the literature that these behavioural interventions are effective. Moreover, some studies have demonstrated that none of the pharmacologic, non-pharmacologic, or behavioural intervention techniques available are necessarily superior to one another.
Some dementia-related behaviours (for example, wandering) do not respond to pharmacological intervention, said Herrmann, and it is therefore advisable to carefully identify target symptoms that could benefit from pharmacological intervention. He stressed that particular caution must be used with the administration of typical antipyschotics due to numerous, well-documented side effects such as orthostatic hypotension, anticholinergic, and extrapyramidal effects.
There is also new evidence for a small but significant increased risk for cerebrovascular adverse events in dementia patients treated with the atypical antipsychotics, in particular olanzapine and risperidone. Nevertheless, atypical antipsychotics are still considered first-line therapy for behavioural disturbances in dementia patients, as well as SSRI's (citalopram), and cholinesterase inhibitors (donepezil). Second-line therapies include anticonvulsants (carbamazepine and possibly valproate), heterocyclic antidepressants (trazodone), SSRIs, and cholinesterase inhibitors. Lastly, Herrmann suggested that beta-blockers, benzodiazepines, and anxiolytics only be considered as third-line therapies in dementia patients.
Treatment of Geriatric Depression (Dr. Franklin Wong)
Wong highlighted the complexities surrounding the diagnosis and treatment of depression in older patients. It can be particularly difficult, he conveyed, to distinguish between depression as a result of bereavement and clinical depression. Wong often recommends a "wait and see approach" in such cases, except where patients are expressing suicidal ideation. Particular attention must be paid to suicide risk among all elderly patients, he stressed, as 12% of suicides in Canada each year occur in the over 65 age group, and this figure is largely considered an underestimate.
The question of whether the patient is exhibiting symptoms of depression, dementia, or both can often confound doctors. Wong suggested that any signs of depression should be treated first with medication, and the patient should be reassessed at a later time for continuing memory problems, which would indicate underlying dementia.
He also outlined the medical conditions and medications strongly associated with depression in older adults, and pointed out that when left untreated, depression can increase both the morbidity and mortality rates in patients with debilitating medical illnesses like cancer, IHD, CHF, post MI, and post CVA. If there is uncertainty around a diagnosis of depression in the medically ill, he added, it is better to treat than not treat, and to focus on mood and depressive cognitions such as decreased self-esteem, excessive guilt, sense of hopelessness and worthlessness, and death wishes.
Driving and Dementia (Dr. Goran Eryavec)
Given that 110,000 new cases of dementia are diagnosed in Canada each year, and that the number of older drivers on Canadian roads expected to more than double by 2020, the increased risk of accidents in older drivers and drivers with dementia, and the risk for public safety in general, is a growing concern. Eryavec discussed the problems and challenges MDs and allied health professionals face in accurately assessing driving ability in the older population without unfairly penalizing seniors.
Currently, the Canadian Consensus Conference guidelines recommend that individuals with a MMSE of less than 24 be prohibited from driving. However, there is a growing body of literature that suggest the MMSE as a poor predictor of crash rates or on-road driving performance, according to Eryavec. While the MMSE still has plays an important role in alerting physicians to 'drivers at risk' and those who need an on-road assessment, it should not be the only measure of driving ability. Similarly, the on-road assessment, in its present format, is not a surefire way of testing individuals, as patients deemed unsafe to drive by their physicians can often pass standard driving tests. Driving and dementia is a complicated issue, says Eyravec, and requires a screening procedure using patient interviews and medical history, caregiver reports, and assessment of current medications and medical conditions that can increase the crash risk in older patients.
