The GM Editorial Team report from the 12th National Medicine for Old Age Psychiatrists conference

Cardiac update
Parkinson's disease
Falls and syncope
Managing pain and agitation in severe dementia


Cardiac update

There is an increase in cardiac mortality in schizophrenic patients1 and major depression is associated with a 2.7 increase in ischaemic heart disease (IHD) mortality.2 IHD is a major cause of death in the UK and modifiable risk factors include smoking, hypertension, hypercholesterolaemia and diabetes. Non-modifiable factors include family history, sex and age.

The acetylcholinesterase (AChE) inhibitors donepezil, rivastigmine, galantamine are used to treat Alzhemer’s disease. Adverse cardiovascular events with these drugs are very uncommon. However, there is evidence that therapy is associated with a small but significant increase in the risk of syncope.1

These drugs increase parasympathetic activation and theoretically can: cause sinus bradycardia, sino-atrial block, aggravate sinus node disease and aggravate atrio-ventricular block.

There is no consensus on how to manage this cardiovascular risk, and memory clinics vary widely in their practice. Also one-off 12-lead ECG and prolonged (24 hour) monitoring not good predictors of adverse events. Furthermore, there are no high-risk groups to target.1

It has been suggested that pulse rate is checked at baseline and at follow-up with monthly pulse checks during titration of the AChE inhibitor, and six-monthly checks thereafter. Should bradycardia (less than 50 bpm) be noted, even if asymptomatic, it would be wise to investigate its cause before beginning or continuing treatment. Those with mild bradycardia (50–60 bpm) should be monitored more frequently, to ensure that the relative bradycardia does not become symptomatic.

If a patient taking an AChE inhibitor presents with syncope or seizures an underlying cardiovascular cause should be strongly suspected. The drug should be stopped and the patient referred to a physician for further investigation.

If examination reveals no causal relationship with the drug, or if a pacemaker is fitted, the drug may be restarted.

Symptoms such as falls and dizziness often have complex and multi-factorial causes, with dizziness tending to be transient and usually unrelated to cardiovascular problems. Referral to an elderly care physician for multidisciplinary assessment should be considered in these situations.

Atrial fibrillation and flutter are common arrhythmias with a risk of tachycardia and thromboembolism. Causes to be considered include hypertension, ischaemia, sepsis, lung disease and thyroid disease.

For persistent/permanent AF, treatment includes rate control beta-blockers, verapamil, digoxin (only if no renal impairment) and ablation.

For paroxysmal AF treatment is usually with amiodarone, sotalol, flecainide, and ablation.

Offering patients anticoagulants could help prevent thousands of strokes and premature deaths from AF, according to NICE. It now recommends that the CHA2DS2-VASc tool should be used to assess stroke risk score in people with symptomatic or asymptomatic paroxysmal, persistent or permanent AF, atrial flutter, or a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm.

Patients with a CHA2DS2-VASc score of 2 or above, taking bleeding risk into account, should be offered anticoagulation. Novel oral anticoagulants (NOACs), should be offered where appropriate—apixaban, dabigatran etexilate, edoxaban and rivaroxaban. The NOACs do not require the same regular level of monitoring or dose adjustments as warfarin.2

Another major cardiovascular issue is heart failure, which has a prevalence of 0.4–2% and increases rapidly with age. The average age of presentation is 74 years and it has a poor prognosis. NICE recommends taking a careful and detailed history, and to perform a clinical examination and tests to confirm the presence of heart failure.3

Patients with suspected heart failure and previous myocardial infarction (MI) should be referred urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within two weeks. Serum natriuretic peptides (B-type natriuretic peptide or N-terminal pro-B-type natriuretic peptide) should be measured in patients with suspected heart failure without previous MI.3

Treatment options include ACE inhibitor/ARB, beta-blockers, spironolactone/eplerenone, diuretics ivabradine and device therapy.

The take-home message is that cardiology has changed a lot as there is much more intervention now available. If in doubt, refer to a specialist.


Report based on a talk by Dr Ceri Davies, Consultant Cardiologist, Barts Health NHS Trust


1. Rowland JP, et al. Advances in Psychiatric Treatment 2007; 13 (3): 178–84




Parkinson’s disease

Traditional teaching in regard to diagnosing Parkinson’s disease (PD) took into account a combination of slowness of movement, stiffness and shaking (tremor) in addition to a loss of dopamine producing nerve cells. The UK Brain bank diagnostic criteria, however, makes no mention of neuropsychiatric problems.

Guidance from both NICE and SIGN emphasise the importance of specialist review both to establish and review the diagnosis of PD and also to manage treatment.

Diagnosing PD is not always that easy and there is up to 50% error rate, which is increased in primary care. There is a 10% error rate by consultant neurologists and 2% error rate by movement disorder specialists.

The NICE guidelines recommend that suspected PD patients should be referred to a specialist untreated and that diagnosis should be reviewed every 6–12 months. Diagnostic accuracy is increased through the use of standard diagnostic criteria eg. UK Brain Bank.

Brain Bank Criteria for PD includes three steps. Step 1 is diagnosis of parkinsonian syndrome; step 2 is a review of the exclusion criteria for PD and step 3 is a review of the supportive criteria for PD. Step 1 is bradykinesia and at least two of the following: muscular rigidity, 4–6 Hz rest tremor and postural instability.

Exclusion criteria includes history of repeated strokes, repeated head injury, definite encephalitis, neuroleptic drugs, cerebellar signs, early severe autonomic involvement, early severe dementia and supranuclear gaze palsy.

Step 3 requires three of the following: unilateral onset, rest tremor present, progressive, persistent asymmetry, excellent (70–100%) levodopa response, severe levodopa-induced chorea, levodopa response more than five years and clinical course more than 10 years.

Diseases mimicking PD include: multiple strokes “lower body parkinsonism”, essential tremor, drug-induced syndromes, multiple system atrophy and progressive supranuclear palsy.

Older patients tend to have a slowly progressive disease with a mean duration of 15 years. The severity varies and only a few patients show only minor disability after 20 years and some are severely disabled after 10 years.4

Non-motor symptoms can dominate the clinical picture of advanced PD (but also can antedate the diagnosis) and they correlate with advancing age and disease severity. The PDS survey found that they have a major impact on quality of life.5 They can also predict nursing home placement (falls, hallucinations, dementia) and therefore are costly (care burden, institutionalisation). In addition, they are often under-recognised and inadequately treated.

A large study looked at the prevalence of non-motor symptoms. Of the 149 people recruited 20 years ago in the Sydney multicenter follow up study of PD, one third survived. Dementia was present in 83% of 20-year survivors. Problems experienced by people who survived 20 years from diagnosis included falls, which occurred in 87% of patients, and 28% sustained fractures. Hallucinations were experienced by 74% and 50% were using antidepressants.6

The frequency of depression is also high in PD patients at 40%, which is twice the rate of severe depression seen in other equivalently disabled patients. Psychosis is also a big problem as is dopamine dysregulation syndrome, REM behavioural sleep disorder and impulse control disorders.7

Patients on dopamine agonists are at risk of impulse control disorders and these affect up to 17% of agonist-treated patients. Impulsive behaviour can include gambling, buying, sexual behaviour (hypersexuality), binge eating, punding and others.

Palliative principles are important and need consideration throughout the disease. Early identification and assessment is needed for prevention and treatment of pain and other physical, psychosocial and spiritual problems. An advanced care plan should be used when a patient is being transferred from one place of care to another. It is recommended that a copy of this plan is placed into the patient’s medical record with a copy in the patient’s home, or care home.

To conclude, non-motor symptoms have a major impact on quality of life. Amongst the non-motor symptoms, neuropsychiatric symptoms are common, often under recognised and are major predictors of care home admission. The evidence base for management of many of these symptoms is developing. Questions still remain to whether old age psychiatry has a role in the management of advanced PD and how best to work together? Also how can we best offer community support to Parkinson’s patients with psychiatric problems?


Report based on a talk by Dr Doug MacMahon, Consultant Physician, Coventry


4. Ishihara LS, et al. J Neurol Neurosurg Psychiatry 2007; 78(12): 1304-9


6. Hely MA, et al. Mov Disord 2008; 23(6): 837–44

7. Brown R, et al. Mov Disord 2005; 20: 190–99


Falls and syncope

The annual incidence of falling in older age groups is 30% in patents aged 65–69 years and 50% in those aged over 85 years.

There are over 200 published risk factors for falls ranging from poor vision and reduced lower limb strength to multiple medications, environmental hazards and dementia. The most common causes of falls reported are trips, slips and loss of balance.

In one study 27% of 704 patients suffered injuries as a result of a fall, and the proportion suffering injuries increased with age.8 The consequences can be severe leading to fractures, pressure sores and also hypothermia. In addition, there can also be a loss of confidence, which restricts activities and reduces mobility leaving the patient living within an ever-shrinking world. One in 10 patients who fall are too afraid to leave home, which can lead to institutionalisation.

There are many myths surrounding falls and the elderly population and one is that moving patients to a nursing home will stop them falling over. One study found that there was an annual 30–56% incidence of falling in a nursing home population.9 Another study also found that there were 1.7 falls per person per year in residential homes.10

Little objective evidence is available for how and why falls occur in this population. A Lancet study aimed to provide such evidence by analysing real-life falls in long-term care captured on video. They captured 227 falls from 130 individuals (mean age 78 years). The most frequent cause of falling was incorrect weight shifting, which accounted for 41% of falls, followed by trip or stumble (21%), hit or bump (11%), loss of support (11%), and collapse (11%). Slipping accounted for only 3% of falls. The three activities associated with the highest proportion of falls were forward walking (24%), standing quietly (13%), and sitting down (12%).11

The prevention of falls in the elderly trial (PROFET) provided evidence of the benefits of structured interdisciplinary assessment of older people presenting to the accident and emergency department with a fall. It aimed to devise a practical approach to streamlining referrals from accident and emergency departments to specialist falls services. Significant positive predictors of further falls were; history of falls in the previous year, falling indoors, and inability to get up after a fall. Negative predictors were moderate alcohol consumption, a reduced abbreviated mental test score, and admission to hospital as a result of the fall. A history of falls, falling indoors and a reduced abbreviated mental test score were found to predict loss to follow up.12

Balance impairment and muscle weakness are the most prevalent risk factors for falls and therapeutic exercise is the most effective component of a multi-factorial intervention. A tailored programme for falls prevention can reduce the risk of falls by up to 54%, but not all exercises are effective in preventing falls.

In order to be effective, exercise programmes should challenge balance and improve strength through resistance training and exercise in a standing position.

It must also be tailored to the individual, ie. pitched at the right level, taking falls history and medical conditions into account. As well as this it needs to be sufficiently progressive, be carried out 2–3 times a week, be continued over a duration of at least 50 hours and be delivered by specially trained instructors.

Another myth is that you cannot stop demented patients falling. One study examined the change in fall rates after relocation of nursing home residents from one facility to another and to identify resident risk factors for changes in falls following relocation. Dementia and not being bedbound were associated with being a faller after the move. Individuals who were ambulatory or wheelchair mobile had a significant risk of increasing the number of falls after the move, and individuals with dementia had a strong but insignificant trend in this direction.13 Physiotherapy, however, has been shown to improve or maintain mobility skills of patients with severe dementia.14

In conclusion most falls occur when moving or changing posture and 85% are multi-factorial in origin. Strength and balance training are key and there are small numbers of patients that require specialist evaluation.


Report based on a talk by Dr Mark Cottee, Consultant in Geriatric Medicine, St George’s Hospital


8. Lord SR, et al. Aust J Public Health 1993; 17(3): 240–45

9. Rubenstein LZ, et al. J Am Geriatr Soc 1988; 36(3): 266–78

10. Lord SR, et al. J Am Geriatr Soc 1991; 39(12): 1194–200


12. Close JC, et al. Emerg Med J 2003; 20(5): 421–25

13. Friedman SM, et al. J Am Geriatr Soc 1995; 43(11): 1237–42

14. Pomeroy VM, et al. Clin Rehabil 1993; 7: 163–170


Managing pain and agitation in severe dementia

The World Health Organization defines palliative care as: “The active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families.”

Among people with dementia, men, older people, and those with pre-existing comorbid conditions have decreased life expectancy and survival in community studies.15 Dementia is a progressive neuro-degenerative disease and the commonest cause of death is aspiration pneumonia secondary to dysphagia.

One study looked to estimate survival after a diagnosis of dementia in primary care, compared with people without dementia, and to determine incidence of dementia. It found that median survival was much lower than in screened populations. The high risk of death in the first year after diagnosis may reflect diagnoses made at times of crisis or late in the disease trajectory. Late recording of diagnoses of dementia in primary care may result in missed opportunities for potential early interventions.15

Symptoms of advanced dementia include dyspnoea, pain, agitation and restlessness, pressures ulcers, aspiration and eating problems. Acute pain can include dental, headache/migraine and heart attack, whereas chronic pain would stem from ulcers, contractures and lack of activity, poor positioning, and arthritis.

Barriers to pain recognition in patients with dementia are verbal communication of pain, remembering pain has been experienced and identifying where pain is located. It is a myth that people with dementia do not experience pan and that people with dementia experience less pain. Anxieties around using analgesia in older people have also been an issue.

Managing pain without drugs could be done through movement, massage, physiotherapy, occupational therapy and distractions or activity.

Pharmacological options for mild pain include paracetamol and ibuprofen. Moderate pain can be treated with mild opioids like codeine, but more severe pain usually requires stronger opioids like diamorphine or fentanyl.

Side effects such as constipation should be managed and polypharmacy and renal or liver disease should be considered along with gastroprotection and monitoring for urinary retention.

Causes of agitation in advanced dementia include pain and discomfort, delirium or even dying. The “active” phase of dying can cause restlessness, which occurs in 25–80% of dying people.

Eating problems can be an issue in severe dementia and careful hand feeding may be necessary. Feeding should be regular, but should be stopped when the patient becomes distressed. Weight loss is accepted and interaction should be continued. There is no evidence that artificial nutrition and hydration prolongs life or improves nutritional status or quality of life in people with dementia.

Don’t let eating/swallowing problems come as a surprise so ensure a conversation has occurred with the person with dementia and their family or advocate early around the time of diagnosis. It is also useful to consider advance care planning.

Tips for managing end-of-life care in dementia include taking a ste p back; talking to the family; thinking about pain but also discomfort and resisting the temptation to “do something”. It is also important to identify the “dying” patient.


Report based on a talk by Dr Liz Sampson, Reader, CRU Division of Psychiatry, UCL, London, Liaison Psychiatry, North Middlesex University Hospital


15. Rait G, et al. BMJ 2010; 341: c3584