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GERI-DDD Flashcards

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1
Q

What are some important issues we have to deal with around mental health and aging?

A
  • cognitive loss
  • psychological diseases of old age
  • psychosocial issues of the elderly
  • medial legal issues (MDM capacity, DPOA)
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2
Q

Is confusion inherent to ONLY aging?

A

Not necessarily, no!
ITS a symptom!
DDX1. dementia 2. delirium 3. depression *the three D’s

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3
Q

How is confusion variable?

A
  • constant vs intermittent
  • acute vs chronic
  • differs from symptoms of mental illness in younger people
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4
Q

Do we get new cases of schizophrenia in elderly pts?

A

NOPE!

PROBLEM IS we give- antipsychotic which can make confusion worse

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5
Q

What is the hallmark of dementia?

A

MC LOSS OF RECENT MEMORY

  • insidious onset
  • impaired judgment
  • behavioral issues (sleep disturbance, aggression/agitation-coping)
  • early vs late issues
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6
Q

What diseases CAUSE dementia?

A 
Alzheimer's disease (70%) 
multi-infarct 
Lewy Body 
HIV
frontal-temporal
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7
Q

What diseases are ASSOCIATED with dementia?

A

Parkinson’s disease B12 deficiency Thyroid disease Liver disease

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8
Q

Probably criteria to diagnose dementia

A
  • clinical exam r/o others
  • mental status evaluation
  • deficits in >2 cognitive areas
  • progressive decline
  • normal level of consciousness
  • onset between 40-90yrs
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9
Q

Is there a specific test we can do to diagnose dementia?

A

No,

CLINICAL diagnosis

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10
Q

What is the last thing that happens clinically when you reach a state of dementia with Alzheimers?

A

functional decline

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11
Q

What is the progression of brain changes and clinical manifestations in Alzheimers?

A

Amyloid plaques –> neurofibrillary tangles –> brain cell loss –> memory loss –> functional decline
Brain changes occur w/o CP

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12
Q

What are the risks for Alzheimers disease?

A

Nonmodifiable: age, family hx, APOE-4 gene, Downs syndrome

Modifiable: head trauma, HTN, DM, smoking, depression

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13
Q

How does age affect your risk for Alzheimer’s?

A

-prevalence of AD doubles q 5yrs >60
-85yo has 50% risk of AD
-2x parents w/ AD, 1st degree relative w/ AD: risk is double that of general population = 54%
risk by 80yo

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14
Q

What are probable criteria that can lead you to making a diagnosis of Alzheimer’s Disease?

A
  • no other cause
  • supportive factors: + family hx, cerebral atrophy, normal EEG, normal lumbar puncture
  • clinical criteria + histopathology
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15
Q

What happens in early Alzheimer’s Disease?

A
  • gradual memory loss
  • preserved level of consciousness
  • impaired ADLs
  • subtle language errors
  • impaired spatial perception
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16
Q

What happens in late Alzheimer’s Disease?

A
  • aphasia: no speaking
  • apraxia: no purposeful actions
  • agnosia: no recognizing/interpreting
  • inattention
  • left-right confusion
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17
Q

Agnosia, aphasia and apraxia are shared with other dementias - what would lead you to think that this is specifically Alzheimer’s?

A

WORD FINDING ISSUES! apathy/indifference delusion disorientation

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18
Q

What is Lewy Body Dementia? How does it present?

A
  • mild Parkinsonism symptoms shaking, tremor, gait
  • unexplained falls
  • visual hallucinations
  • fluctuating cognition
  • extreme sensitivity to antipsychotic meds
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19
Q

What does a diagnosis of Lewy Body dementia require clinically/symptom-wise to be confirmed?

A
  • *a diagnosis requires a progressive decline in your ability to think, as well as two of the following:
  • fluctuating alertness and thinking (cognitive) function
  • repeated visual hallucinations
  • Parkinsonian symptoms
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20
Q

What is frontotemporal dementia? How does it present?

A
  • onset before 60
  • language disarray
  • profound personality changes -behavioral issues(impulsive, hypersexual
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21
Q

What are the types of frontotemporal dementias?

A
  • Progressive Supranuclear Palsy: PSP a degenerative disease of specific regions of the brain
  • Primary Progressive Aphasia: language slowly impaired, not other mental functions
  • Semantic Dementia: loss of word meaning
  • ALS w/ Dementia: Amytrophic lateral sclerosis neurodegenerative dz
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22
Q

What is vascular dementia? How does it present?

A

-stepwise deterioration 2/2 ischemic events –> can be small and transient -TIA, lunar infarcts, focal infarcts or they can be massive; every time there’s an event, there’s a stepwise decline in function/cognition

  • normal level of consciousness
  • functional loss may correlate w/ cerebrovascular events (CT/MRI)
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23
Q

What are the types of vascular dementia?

A

cortical, subcortical, white matter lesions, mixed or specific

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24
Q

What categories of dementia will have changes show up on imaging?

A

Vascular dementia –> cortical/subcortical infarcts, white matter lesions
Frontotemporal dementia –> marked atrophy in frontal and/or temporal lobes

**Lewy Body and Parkinson’s dementias don’t have remarkable imaging

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25
What are the strengths/limit for the MMSE?
PROs-standardized, widely used - reproducible validity - quickly administered - useful scoring CON-does not test executive function - not correlative w/ capacity - screening tool - education dependent - not culturally valid
26
What does the Montreal Cognitive Assessment (MoCA) test for?
* more executive function testing | - visuospatial/executive -naming -memory -attention -language -abstraction -delayed recall -orientation
27
Treatment and management for dementia
* NO TX treat dementia but there ways to slow it down - education of pt and family - Rx - develop strategy for caregiver respite - long-term care planning - facilitate environmental success - stimulate cognitive function w/ challenges - promote feelings of pleasure - don't force it (easy to get frustrated)
28
What are some general strategies to help protect cognitive function?
- treatment of vascular risk factors- HTN) - neuroprotection- diet, moderate EtOH - building up neuronal reserves -cognitive activity, physical activity, social & leisure
29
What is the efficacy for cholinesterase inhibitors?
low efficacy --> most of them don't show a real benefit past 6 months they can help slow cognitive decline in someone w/ dementia Wait b4 prescribing
30
What is delirium? How does it present?
- acute onset , stress causing metabolic changes - waxing and waning course - common in the hospital - memory, orientation, perception, sleep, speech, consciousness and psychomotor hypo and hyperactive or mixed changes,
31
What is the differential diagnosis for delirium?
VAST! -medications - infection - - surgery - dehydration - laboratory abnormalities - associated w/ other disease, cancer, collagen vascular disease, MI, dementia, depression
32
What is the prevalence of delirium among hospitalized older adults?
11-41% (hospitalized for medical illness) 40-52% (postop hip fracture) 10-39% (postop noncardiac surgery) 13-44% (postop cardiac surgery)
33
Why is delirium so dangerous, especially in the hospital?
SYPMTOM marked increase in mortality rate - -treat the underlying problem
34
Assessment for delirium
- vitals - PE to diagnose infectious process or other acute medical conditions -UTI - Cr, Na, K, Ca, glucose - CBC w/ diff - review old and new anticholinergic meds, sedating meds -review the need for foley, IVs, etc.
35
When would be an appropriate time to use a benzodiazepine in an elderly pt?
AVOID just bc delirisus if the pt is agitated, not responding to a sitter, and safety is an issue while being treated for a reversible medical condition
36
Why are benzodiazepines and other anticholinergic drugs so dangerous in elderly pts?
``` because of their side effects! -hot as a hare -dry as a bone -blind as a bat -red as a beet - mad as a hatter ** benzos can also cause rebound anxiety ```
37
Drugs w/ mild anticholinergic activity (important ones)
``` bupropion chlorthalidone codeine diazepam digoxin fentanl furosemide f luvoxamine ```
38
Drugs w/ moderate anticholinergic activity
carbamazepine | amantadine
39
Drugs /w high anticholinergic activity
amitriptyline clozapine doxepin diphenhydramine
40
Which medication classes should you check to see if your pt is on if they develop delirium?
* *KEY meds to cause delirium! - narcotics - benzodiazepines - anticholinergics - antipsychotics
41
What percentage of elders experience depression?
40% often do not recognize or acknowledge their depression --> elderly males at highest suicide risk
42
Symptoms of depression
Sleep - increased or decreased (early morning awakening) Interest - decreased Guilt/worthlessness Energy - decreased or fatigued Concentration/difficulty making decisions Appetite and/or weight increase or decrease Psychomotor activity - increased or decreased Suicidal ideation
43
What are risk factors for depression?
-chronic medical illness -loss of a loved one -relocation - diability
44
How are elderly pts more likely to present with depression?
more likely to have somatic complaints or hypochondriasis
45
What diseases are closely linked to depression?
- Parkinson's disease - Alzheimer's disease - stroke *s/p stroke - increased likelihood for major/minor depression
46
What are common symptoms of depression?
-loss of energy and enthusiasm -sleep change: early morning awakening -weight loss -anxiety and perplexing
47
What is the Ddx for depression?
- hypo/hyperthyroidism - vitamin deficiency B12, D, folate - anemia - infection - UTI
48
How can we distinguish between delirium and depression based on presentation?
delirium: AMS/encephalopathy - fluctuating consciousness, impaired cognitive testing depression: "pseudodementia" - appears demented but performs well on cognitive testing
49
How can we distinguish between delirium and depression based on signs and symptoms?
delirium: acute/subacute onset, fluctuating, sleep-wake disruption, often reversible depression: gives up easily on cognitive tests, "i don't know", poor eye-contact, flat affect, cries easily
50
How can we distinguish between delirium and depression based on time course?
delirium: occur in a person w/ dementia depression: abruptly, often w/ major stressor
51
How can we distinguish between delirium and depression based on prognosis?
delirium: may "predict" dementia- postop delirium depression: independent risk factor for dementia
52
How can we diagnose depression?
PHQ-2- lack of interest, depression mood? yes to both is 83% sensitive! PHQ-9
53
How do we treat depression?
-medication (SSRIs) -counseling -education CBT PST (problem solving therapy) TIP (treatment initiation and participation) ECT (electroconvulsant therapy)
54
What medications are useful to treat depression?
1. SSRI - primary treatment, risk of serotonin syndrome 2. SNRI - better for neuropathic pain (e.g. Remeron) **check Na in 2 wks if on other rx that affect ADH -diuretics, NSAIDs, monitor for GIB/NSAID/ASA 3. Buproprion - no sexual SE, no weight gain, no GIB 4. TCAs - anticholinergic, increase HR, orthostasis, monitor EKG!
55
What can both SSRIs and SNRIs cause?
hyponatremia due to SIADH | OTHER DDX HYPO
56
What are other major mental health issues that the elderly encounter?
- loneliness - boredom - vulnerability - impaired self-assessment skills - loss: home, loved ones, respect of the community -substance abuse -EtOH abuse
57
What is the relationship between elderly pts and EtOH?
- 5.6% binge drinking in the last month | - 2 million elders have alcohol issues -high risk drinkers: 15% men, 12% women -stressful life events may be triggers
58
How can we screen for alcohol use in elderly pts?
Ask!!Screening: CAGE-C: cut down A: annoyed G: guilty E: eye-opener Lab: -gamma-glutamyl transpeptidase (GGT) enzyme in liver that indicates liver dz - mean corpuscular volume (MCV) --> suggestive of folate/B12 deficiency - carbohydrate-deficient transferring (CST) 4-5 EtOH proportion of transfer w/ fewer chains increased
59
What are some end of life issues we deal with when working w/ elderly pts?
- recognition of time limitations - hearing bad news - accepting bad news - preparing for death
60
What is capacity?
-MDM capacity w/ DPOA medical decision making capacity - can make a decision about their own trajectory of care
61
What are the guidelines for determining capacity?
- cognitive status (level of dementia, delirious?) - understand problem and its consequences - risks vs benefits of treatments
62
Assessment of capacity
age - physical health - ADLs - mental and emotional health - substance abuse - acceptance of services - financial resources - environment - orientation
63
Does the client understand....
- the situation? - the potential consequences of the situation - their own limitations in the situation and the alternatives available?

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