Category of illness Cognitive impairment Mood disorders Anxiety disorders Alcohol abuse/dependence Schizophrenic disorders Somatization Personality disorder Other psychiatric disorder Distribution of Psychiatric diagnoses(%) Community Medical-surgical residents Inpatients 5.9 30.2 6.5 18.5 5.5 5.2 0.9 2.6 0.1 0 0.1 0 0 8.3 0 7.9
Author Country N Blazer et al (1980) Ben Arie et al(1987) Copeland et al(1987) Kua(1990) Livingston et al(1990) Madianos et al(1991) Lobo et al(1991) Helmchen et al(1996) Suh & Cho (1998) Hong & Cho(1999) USA South Africa UK Singapore UK Greece Spain Germany Korea Korea 992 439 1070 612 705 215 1000 516 1019 768 Prevelence (%) 3.7 13.7 11.2 5.3 15.9 9.7 6.6 17.8 10.1 6.7
Author Country Prevalence(%) Madonald(1991) Illife et al(1991) Oxman et al (1990) Evans & Katona(1993) Borson et al(1986) UK UK USA UK USA 30.6 21.2 21 36 24.4
Dementia Depression * Insidious onset * No psychiatric history * Conceals disability * Near-miss answers * Mood fluctuation day to day * Stable cognitive loss * Tries hard to perform but is unconcerned by losses * Short-term memory loss * Memory loss occurs first * Associated with a decline in social function OR * Abrupt onset * History of depression * Highlights disabilities * Don't know answers * Diurnal variation in mood * Fluctuating cognitive loss * Tries less hard to perform and gets distressed by losses * Short- and long-term memory loss * Depressed mood coincides with memory loss * Associated with anxiety
Category Advantages Disadvantages First-line agents SSRIs Bupropion Benign side effects Once-daily dosing Benign side effects Relatively unlikely to cause rapid cycling Sexual side effects Interact with many medications prescribed for elderly patients Expensive T.i.d dosing required Contraindicated in patients with seizures, Eating disorder Very expensive Venlafaxine Benign side effects Sexual side effects Expensive Nefazodone Benign side effects May have therapeutic window between 300 and 500 mg/day Expensive
Category Advantages Disadvantages Second-line agents Tricyclics May be more effective than non- Tricyclics in severe depression Inexpensive Once-daily dosing Dangerous side effects (orthostatic hypotension, delayed cardiac conduction) Trazodone Inexpensive Dangerous side effects (orthostatic hypotension) Rarely causes priapism Third-line agents MAOIs Lithium Psychostimulants (methylphenidate, amphetamines) Inexpensive Effective in atypical Depression Inexpensive Immediately effective Benign side effects Dietary and medication restrictions Required Potentially fatal interaction with Meperidine, sympathomimetics, SSRIS Only two-thirds as effective as above agents No controlled studies Development of tolerance common MAOIs = monoamine oxidase inhibitors ; SSRIs = selective serotonin reuptake inhibitors ; Tid = three times per day.
Reversible dementias Irreversible dementias
Four domains of Alzheimer s disease Cognition ADL Mood & Behavior Caregiver burden
Language Executive function Visuospatial Orientation
25 --------------------- Symptoms MMSE score 20 ---------------------- Diagnosis 15 ----------------------- Loss of functional independence 10 -------------------------------- Behavioral problems Nursing home placement 5 ------------------------------------------- 0 Death ------------------------------------------ 1 2 3 4 5 6 7 8 9 Years
Vascular dementia (VaD) Definition: VaD is an etiologic category of dementia that include clinical forms of dementia resulting from hypoxic-ischemic or hemorrhagic cerebrovascular disease(cvd) or cardiac and circulatory disorders
Vascular dementia Abrupt onset Stepwise deterioration Onset earlier than AD male>=female Preventive by risk factors control
VaD AD + CVD AD post-stroke dementia infarcts, white matter lesions (WMLs) vascular risk factors Source: Erkinjuntti
Dementia with Lewy Bodies (DLB) Dementia syndrome Plus 2 of 3: Visual hallucinations Fluctuating consciousness Parkinsonism
Fronto-Temporal dementia Onset between 45 and 65 years Equal incidence in men and women Mean duration of illness: 8 years(range: 2-20yrs) Family history of dementia in ½ of cases Insidious onset and gradual progression Early decline in social interpersonal conduct Early impairment in regulation of personal conduct Early emotional blunting Early loss of insight