The 13th National Medicine for Old Age Psychiatrists conference, chaired by Dr Rajen Shah, Consultant Old Age Psychiatrist, took place at 20 Cavendish Square, London. This report includes presentations from the conference.
The National Medicine for Old Age Psychiatrists conference is an annual event that is now in its 13th year. Its aim is to provide old age psychiatrists with a comprehensive review of the common medical conditions that affect older patients. Topics reviewed at the conference included common eye problems, Parkinson’s disease, urinary incontinence, heart failure, stroke and TIA, and epilepsy.
Prescribing and multiple morbidity
Elderly patients often receive multiple drugs for their multiple diseases. This greatly increases the risk of drug interactions as well as adverse reactions, and may affect compliance. The balance of benefit and harm of some medicines may be altered in the elderly. Therefore, elderly patients’ medicines should be reviewed regularly and medicines that are not of benefit should be stopped.
Non-pharmacological measures may be more appropriate for symptoms such as headache, sleeplessness, and light-headedness when associated with social stress as in widowhood, loneliness, and family dispersal.
In some cases prophylactic drugs are inappropriate if they are likely to complicate existing treatment or introduce unnecessary side-effects, especially in elderly patients with poor prognosis or with poor overall health. However, elderly patients should not be denied medicines that may help them, such as anticoagulants or antiplatelet drugs for atrial fibrillation, antihypertensives, statins, and drugs for osteoporosis.
Inapproprate prescribing is prescribing drugs that are contraindicated, at an inappropriate dose/duration, prescribing a drug that is likely to adversely affect prognosis and failure to prescribe a drug that could improve patient outcome.
In the very old, manifestations of normal ageing may be mistaken for disease and lead to inappropriate prescribing. Care needs to be taken not to confuse age-related muscle weakness and difficulty in maintaining balance with neurological disease. Dizziness/light-headedness not associated with postural or postprandial hypotension is unlikely to be helped by drugs.
Over 20% of people aged over 60 years take five or more drugs and in the past decade in this age group, the number of items prescribed per year has increased from 21.2 on average to 40.8. Although this is not necessarily inappropriate prescribing as each individual item may have an appropriate indication.
It can become a problem when these multiple medications cause pharmacokinetics and the dynamics change with age.
Pharmacokinetic changes can markedly increase the tissue concentration of a drug in the elderly, especially in debilitated patients. The most important effect of age is reduced renal clearance. Many aged patients thus excrete drugs slowly, and are highly susceptible to nephrotoxic drugs.
Acute illness can lead to rapid reduction in renal clearance, especially if accompanied by dehydration. Hence, a patient stabilised on a drug with a narrow margin between the therapeutic and the toxic dose (eg. digoxin) can rapidly develop adverse effects in the aftermath of a myocardial infarction or a respiratorytract infection.
The hepatic metabolism of lipid soluble drugs is reduced in elderly patients because there is a reduction in liver volume. This is important for drugs with a narrow therapeutic window.
Another challenge is that adverse drug events are common in elderly patients. They usually have atypical presentation and vague symptoms can often mask presentation of adverse drug events. There is also a need to take into account issues around quality of life, personal and social factors.
Confusion is often the presenting symptom (caused by almost any of the commonly used drugs).
Other common manifestations are constipation (with antimuscarinics and many tranquillisers) and postural hypotension and falls (with diuretics and many psychotropics).
Polypharmacy is associated with increased drug interactions, adverse drug reactions, falls, hospital admissions and readmissions and mortality.
In the USA, between 2007 and 2009, 99,628 hospital admissions were in individuals over 65 years. Of these, 16.6% were admissions in older adults due to adverse drug events and 88% were preventable. Only 4.1 % were in younger adults and 24% of these were preventable.1
NICE guidance says to always consider whether a drug is indicated at all, limit the range and reduce dose. It also states that drugs should be reviewed regularly, regimens simplified, and disposal and repeats explained clearly. In addition, non-pharmacological alternatives should be considered along with appropriate formulation?2
Frail elderly patients may have difficulty swallowing tablets; if left in the mouth, ulceration may develop. They should always be encouraged to take their tablets or capsules with enough fluid, and whilst in an upright position to avoid the possibility of oesophageal ulceration.
Guidelines provide up-to-date, validated prescription information to doctors and pharmacists to ensure elderly patients receive best possible care and help reduce potentially inappropriate prescriptions.
There is no internationally agreed standard, but the STOPP/START tool is accepted practice in the UK. This screening tool is based on the STOPP/START prescription criteria and are a set of inappropriate combinations of medicines and disease (STOPP) and a set of recommended treatments for given conditions (START). It is designed to identify medication where the risks out weigh the benefits in the elderly and vice versa and have been shown to be a valid, reliable and a comprehensive tool that enables clinicians to optimise a patient’s drug treatment in the context of his/her current diagnoses.
In conclusion, prescribing in the elderly can be complex as elderly patients are at risk of inappropriate prescribing and adverse drug events. A significant number of hospital admissions in the elderly are related to avoidable adverse drug events.
Take the opportunity to make an overall review of elderly patients’ medication charts during admission and refer to the START/STOPP toolkit as part of a comprehensive geriatric assessment if in doubt. Pharmacists should be empowered to deliver more comprehensive clinical medication reviews that are considered and actioned by GPs and other prescribers.
Report based on a talk by Dr Mark Cottee, Consultant in Geriatric Medicine, St George’s Hospital
The bladder is a hollow muscular organ with two main purposes: to store and void urine. Continence is the complex co-ordination between the bladder, urethra, pelvic floor muscles, endopelvic fascia, and nervous system. Urethral pressure must exceed the pressure of the bladder.
The muscular wall in the bladder is called the detrusor muscle and this muscle can generate action potentials in response to stretch, but it also receives parasympathetic axons, which release acetylcholine (Ach) to stimulate contraction and thus emptying of the bladder.
Two muscular sphincters surround the urethra: the upper sphincter (internal urethral sphincter) and the lower sphincter (external urethral sphincter) and these regulate micturition.
Micturition is controlled by a reflex centre in the sacral regions of the spinal cord. Filling of the urinary bladder activates stretch receptors, which send action potentials to the micturition centre. The micturition centre then activates parasympathetic neurons, which produce contractions of the detrusor muscle and relaxation of the internal urethral sphincter.
A normal bladder holds approximately 500mls and the first sensation to void is about 250mls in normal bladder function.
Age-related changes include decreased bladder capacity, increased involuntary detrusor contractions, decreased bladder contractility during voiding, decreased voided volume and increased urine production at night leading to nocturia and enuresis that can be associated with falls.
In women, there is decreased oestrogen levels, atrophy of collagen in urethra and vagina and decreased urethral pressure. In men, age-related changed include benign prostatic hypertrophy and this can affect 70% by the age of 70 years.
The definition of incontinence is: ‘involuntary loss of urine or stool in sufficient amount or frequency to constitute a social and/or health problem.’
Bio-psychosocial aspects of incontinence include falls, social isolation, decreased level of independence, decreased mobility, depression, increased risk of institutionalisation and decreased quality of life.
Classifications include: stress incontinence, urge incontinence, bladder emptying problems (atonic bladder or outflow obstruction) and functional/ transient incontinence.
Stress incontinence is the most common type of urinary incontinence in women (50%). It is leakage with an increase in intra-abdominal pressure (coughing, laughing, sneezing, running, lifting, walking) caused by urethral sphincter malfunction and is associated with weakening of pelvic floor muscles.
Treatment includes fluid management, reduction of intra-abdominal pressure and pelvic floor exercises. Duloxetine can help increase the muscle tone of the urethra, which should help keep it closed.
Urge incontinence is loss of urine due to an involuntary bladder spasm (contraction) that leads to detrusor over activity, urgency, frequency, inability to reach the toilet in time, and nocturia. There are multiple triggers and it is most common in older women.
Non-pharmacological management includes bladder retraining and pharmacological options include oxybutynin, tolterodine, solifenacin and mirabegron.
Urinary incontinence is common in the elderly and is associated with falls and social isolation. Patients often feel stigmatised. Methodical assessment begins with an accurate history and examination. Patient education is one of the key elements to treatment and successful treatment has a huge impact on quality of life.
Report based on a talk by Dr Louise Hogh, Clinical Director of Elderly Care, Kingston Hospital
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.
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.3
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.4 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 nonmotor 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.5
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.6
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.
To conclude, non-motor symptoms have a major impact on quality of life. Amongst the nonmotor 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
Heart failure: investigation and management
There should be a cardiac assessment before prescribing cholinesterase inhibitors for Alzheimer’s disease. This is because they increase parasympathetic activation and theoretically can cause sinus bradycardia, aggravate sinus node disease and aggravate atrio-ventricular block. There has, however, been a low level of significant cardiac events in open label studies.
Patients should have an ECG if heart rate is under 50bpm on a pulse check, they have syncope or irregular heart rate (arrhythmia).
Atrial fibrillation (AF) is the most common cause of irregular heart rate and there is a risk of tachycardia and thromboembolism. Causes can range from hypertension, ischaemia, sepsis, lung disease and thyroid disease.
A beta-blocker or digoxin should be considered as treatment for rate control, but digoxin should not be prescribed if the patient has renal impairment. Refer to a cardiologist for echo/DC cardioversion and advise patient if warfarin is suitable and sustainable.
Treatment for persistent/permanent AF is rate control with beta-blockers and digoxin, anticoagulation and ablation. Treatment for paroxysmal AF is amiodarone, sotalol, flecainide, anticoagulation and ablation.
Anticoagulation can be with the novel oral anticoagulants that include dabigatran, apixaban, rivaroxaban. There is no need for INR checks and the dose can be reduced for patients with renal impairment. There is no antidote for these treatments.
Symptoms of heart failure include shortness of breath, orthopnea and paroxysmal nocturnal dyspnoea, oedema, reduced exercise tolerance, chest pain and palpitations.
Prevalence is 0.4–2% and it increases rapidly with age. The average age for diagnosis of heart failure is 74 years and it has a poor prognosis.
Treatment is with ACE-inhibitors or angiotensin receptor blockers, beta-blockers, spironolactone or eplerenone, diuretics, ivabradine or device therapy such as implantable cardioverter defibrillator or cardiac resynchronisation therapy.
Other interventions include transcatheter aortic valve implantation, mitra-clip, valvuloplasty, or left atrial appendage closure, atrial septal defect closure and patent foramen ovale closure.
In summary, routine use of ECG in cholinesterase inhibitor treatment is not required unless the patient is symptomatic or bradycardic. AF and heart failure are common and associated with significant comorbidity. New treatments are now available for elderly patients with heart disease.
Report based on a talk by Dr Khaled Alfakih, Consultant Cardiologist, Lewisham and King’s College Hospitals
Update on TIA and stroke
Transient ischaemic attack (TIA) can be diagnostically challenging as the symptoms and signs have generally resolved by the time of assessment and there is no single reliable test.
Diagnosis requires assessment by a clinical expert as episodes are usually unwitnessed and retrospective and a physician has to rely heavily on the history given by patient. In additon, inter-observer agreement is poor even amongst neurologists.
The clinical features of a TIA should mimic known stroke syndromes depending on which artery territory is involved. Loss of consciousness or alteration in consciousness is (almost) never caused by a TIA. Symptoms not acceptable as evidence of TIA in isolation include: loss of consciousness, falls, faintness, dizziness, generalised weakness, confusion, incontinence, amnesia and sensory symptoms confined to part of one limb or face.
Common TIA mimics are syncope/presyncope, migraine, epilepsy, vestibular problems and functional anxiety symptoms.
If a patient has had a suspcted TIA, review (and record) the history to ascertain whether another diagnosis is more likely? Start aspirin 300mg once daily if the patient is not already on an antiplatelet drug or anticoagulant and refer urgently to TIA clinic. Tell the patient not to drive and consider admission if the patient is not recovered or is experiencing recurrent, ‘crescendo’ attacks.
Investigations in the TIA clinic include brain imaging (MRI or CT), carotid imaging (doppler ultrasound or MRA) and cardiac investigations. Blood tests should also be taken.
If a patient has a stroke they should be admitted to a stroke unit and started on aspirin 300mg. An assessment of swallow needs to be carried out to guide nutritional support and make sure that the patient has optimal hydration.
Physiology such as blood pressure, glucose, oxygenation and temperature should be proactively managed. As should prevention of complications auch as pneumonia, thromboembolism, pressure sores and depression.
Early rehabilitation results in a substantial improvement in dependency and mortality and on discharge (transfer of care), rehabilitation should continue at home.
Revascularisation for ischaemic stroke includes intravenous thrombolytic drug or direct clot removal with mechanical thrombectomy.
In summary, a TIA is a challenging diagnosis and many conditions are wrongly labelled as TIA. A true TIA is a high risk condition and needs immediate management.
Incidental cerebrovascular findings on CT/MRI are very common and hyperacute treatment of stroke has improved considerably with stroke unit care. Mechanical thrombectomy offers the very best chance for some patients. Aggressive management of cardiovascular risk factors will achieve the most benefit.
Report based on a talk by Dr Adrian Blight, Consultant Stroke Physician, St George’s Hospital, London
Advances in ophthalmology
Glaucoma is an eye condition where the optic nerve is damaged by the pressure of the fluid inside the eye. In acute glaucoma there is an imbalance between intraocular pressure (IOP) and ocular blood flow (OBF) and there is a risk of provoking or worsening glaucoma with age.
Chronic glaucoma can be treated with eye drops, laser treatment or surgery. There are many eye drops now available and first line is prostaglandin analogues.
Selective laser trabeculoplasty is an out-patient procedure that is painless, safe and effective in about three quarters of people. It is also a repeatable procedure and it allows a patient to replace or reduce the number of eye drops that they take.
Refractive treatment includes laser correction such as Lasik, corneal surgery, clear lens extraction (refractive lens exchange) and cataract surgery.
The take home messages are: think about acute glaucoma and do an annual check for chronic glaucoma and narrow angles. There should also be an annual diabetic retinal screening and annual cataract assessment so patients can be considered for early surgery.
Report based on a talk by Dr Dilogen de Alwis, Consultant Ophthalmologist at Croydon Day Hospital
Diabetes, dementia and other diseases
Diabetes prevalence just keeps increasing and risk factors include a family history of type 2 diabetes, non-white ethnicity, ageing, hypertension, dyslipidaemia, obesity, lack of exercise and drugs such as thiazides, beta-blockers, atypical, antipsychotics, steroids and ventolin tablets.
There is evidence that psychiatric illness can increase the risk of diabetes. Depression doubles the risk of future diabetes and in schizophrenia this risk is slightly less, but traditional antipsychotics can increase the risk greatly.7
In addition, cognitive impairment progresses to dementia more quickly if a patient is diabetic. Therefore, good links between psychiatry for the elderly and medical departments are crucial, but stretched for various reasons.
Symptoms of hypoglycemia in the elderly are poor concentration, confusion, sweating, trembling, weakness, inco-ordination, unsteadiness and light headedness. These symptoms may change over the years, yet they are often still not recognised in emergency rooms and dismissed as confusion or even a fit. Staff just don’t seem to appreciate the significance of them and a lot of patients also deny having them.
But why do they matter so much? A longitudinal cohort study from 1980–2007 of 16,667 patients with a mean age of 65 years and type 2 diabetes in northern California looked at whether hypoglycaemic episodes severe enough to require hospitalisation are associated with an increased risk of dementia. This was in a population of older patients with type 2 diabetes followed up for 27 years. It found that older patients with type 2 diabetes and a history of severe hypoglycaemic episodes were associated with a greater risk of dementia. Whether minor hypoglycaemic episodes increase risk of dementia is unknown.8
A further study looked at whether hypoglycemia commonly occurs in patients with diabetes and negatively influences cognitive performance. Also whether cognitive impairment in turn can compromise diabetes management and lead to hypoglycemia. During the 12-year follow-up period, 61 participants (7.8%) had a reported hypoglycaemic event, and 148 (18.9%) developed dementia. Those who experienced a hypoglycaemic event had a twofold increased risk for developing dementia compared with those who did not have a hypoglycaemic event.9
Similarly, older adults with diabetes who developed dementia had a greater risk for having a subsequent hypoglycaemic event compared with participants who did not develop dementia.
Report based on a talk by Dr Simon Croxson, Consultant physician
Management of epilepsy in elderly patients
Epilepsy is defined as a disorder of the brain characterised by an enduring predisposition to generate epileptic seizures and by the neurobiologic, cognitive, psychological, and social consequences of this condition.10
It is defined by any of the following conditions: at least two unprovoked (or reflex) seizures occurring more than 24 hours apart; one unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years; or a diagnosis of an epilepsy syndrome.10,11
There is at least a 20% misdiagnosis rate in epilepsy and the consequences of this include inappropriate prescribing of anti-epileptic drugs (AEDs), delayed treatment as well as implications on employment, driving, psychosocial effects and stigma. There is also an impact on health economic costs.
AEDs minimise the impact of seizures on a dayto- day basis and will achieve seizure freedom in over 70% of patients. They are only effective while taken (no disease modifying effect) and may have early and late side effects. They don’t (necessarily) fix other problems such as mood and memory.
There are 24 mono‐therapy options of AEDs, which means that there are 276 two‐drug combinations and potentially 2,024 three‐drug combinations. Different AEDs work for different seizures. Therefore, the choice of treatment is individualised.
Drug factors include ease of use (interactions, formulation, speed); efficacy spectrum; effectiveness, tolerability and safety; cost effectiveness/availability and ‘rational” prescribing (mix mechanisms).12
Patient factors include seizure type, frequency and severity, syndromic classification, childbearing age and comorbidities.12
Epilepsy is more than seizures. It is about managing drug side effects, mood and behaviour, cognitive complaints, bone health, and potential neurodisability.
Quality of life issues are equally important and reduced seizures are associated with less falls and less time off work.
In summary, healthcare professionals should refer all suspected seizures to an epilepsy specialist. A detailed history is important along with witness accounts and home videos if available.
An EEG is not a diagnostic test and active management should be a multimorbid approach that includes mood and bone health as well as seizure control.
Report based on a talk by Hannah Cock, Professor of Epilepsy & Medical Education, Consultant Neurologist, St George’s hospital
10. Fisher RS, et al. Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia 2005; 46(4): 470–72
Kidneys and older people
Microscopic changes of an ageing kidney include nephrosclerosis and nephron hypertrophy. Macroscopic changes include kidney volume (mostly secondary to nephroscerosis), renal cysts and tumours, and renal artery atheroscerosis.
Nephrosclerosis is caused by an ischaemic injury of the nephrons that is thought to result from arteriosclerosis and hyalinosis of small arteries. It increases from 2.7% in age 18-29 years to 73% in kidneys in ages 70-77 years.
One study found that age-related nephrosclerosis occurs in healthy adults, and is not detected by age differences in CKD risk factors, urine albumin, or glomerular filtration rate.13
Nephron hypertrophy is when nephron size (both glomerulus and tubule) increases in a variety of metabolic risk states such as obesity and diabetes due to cellular hypertrophy and hyperplasia. It is less clear if this is part of ‘normal’ ageing.
General principles in the management of chronic kidney disease (CKD) are treatment of reversible causes of renal failure and preventing or slowing the progression of renal disease.
This can be done by treating hypertension (ACE inhibitors reduce proteinuria too). Tight glycaemic control if possible is the aim in patients with diabetes as intensive blood glucose control significantly reduces the risk of progression of CKD and proteinuria.
As CKD is also associated with abnormalities of lipid metabolism (especially in patients with proteinuria), patients should be encouraged to take exercise, achieve a healthy weight and stop smoking.
Other principles include the treatment of the complications of renal failure, adjusting drug doses when appropriate for the level of estimated glomerular filtration rate and identification and adequate preparation of the patient in whom renal replacement therapy will be required.
An issue in the elderly is dehydration and patients in hospital14 and care homes15 can be dehydrated on admission. In one study 37% were dehydrated on admission and 62% were still dehydrated at 48 hours. Dehydration manifestations include dry axilla, dry mucus membranes, increased skin turgor, fatigue, reduced fluid intake, renal failure, serum osmolality, hypernatraemia, dry mouth, feeling thirsty, tachycardia, urine colour, volume and osmolality.
Report based on a talk by Dr Iain Wilkinson, Consultant Geriatrician, Surrey and Sussex Healthcare NHS Trust
The 14th National Medicine for Old Age Psychiatrists Conference will be held on 26–27th November at 20 Cavendish Square, London. For further details go to: http://oldagepsychiatry.co.uk/