Geriatric Mental Health

Question 1

4 domains of capacity assessment

Answer 1

treatment
finances
admission to LTC
driving

Question 2

indications for CBT in elderly

Answer 2

willing to take responsibility
can identify automatic thoughts
interested in a here and now focus
solution oriented
seeking symptom resolution

Question 3

7 types of psychotherapy

Answer 3

CBT
interpersonal 
psychodynamic 
problem solving therapy
life review and reminiscence
group
bibliotherapy

Question 4

4 components of interpersonal psychotherapy

Answer 4

1. grief
2. role transition
3. interpersonal role dispute (conflict with adult children)
4. interpersonal deficit

Question 5

7 steps of problem solving therapy

Answer 5

1. problem identification
2. identification of goal
3. brainstorming solutions
4. weighing pros/cons of solutions
5. select a solution
6. implement action plan to carry out solution
7. evaluate outcome

Question 6

what is reminiscence therapy

Answer 6

based on Eriksons stage theory, 12 session group format, goal is for patient to experience empowered view of self vis life review and reminiscence photographs/clothing/music etc.

Question 7

major pharmacokinetic changes in elderly

Answer 7

Circulatory system: decrease plasma albumin
GI: decrease intestinal and splanchnic blood flow (decrease rate of absorption)
Kidney: decreased GFR
Liver: decreased size, decreased hepatic blood flow
Muscle: decreased lean body mass, increased adipose tissue

Question 8

Geriatric “friendly” antidepressants

Answer 8

SSRIs, Venlafaxine, Manerix (moclobemide), Mirtazepine

Question 9

3 indications for anti depressants

Answer 9

depression, anxiety, BPSD

Question 10

6 classes of anti depressants

Answer 10

SSRIs, SNRI, NaSSA (noradrenergic/specific serotonergic AD), NDRI, tricyclics, MAOI

Question 11

SSRIs

Answer 11

Citalopram - note cardiac effects
Escitalopram
Sertraline

Question 12

SNRIs

Answer 12

Venlafaxine - note cardiac effects

duloxetine - good for depression + pain

Question 13

NaSSAs

Answer 13

Mirtazapine - can cause sleep disturbance and weight loss

Question 14

NDRI

Answer 14

Buproprion - activating, use for SSRI induced sexual dysfunction

Question 15

Tricyclics

Answer 15

nortriptyline, desipramine, doxepine (for insomnia - up to 6mg)

Question 16

MAOI

Answer 16

Moclobemide - reversible

isocarboxazid, phenelzine, tranylcypromine - irreversible

Question 17

mood stabilizers/anti convulsant

Answer 17

Lithium (note drug interaction with NSADs and antihypertensive)
valproate
carbamazepine
lamotrigine - bipolar depression
gabapentin and pregabalin

Question 18

atypical anti psychotics

Answer 18

risperidone, olanzapine, quetiapine, aripiprazole, clozapine

Question 19

typical anti psychotics

Answer 19

haldol, loxapine, methotrimeprazine

Question 20

antipsychotic use in dementia

Answer 20

Dementia + risperidone or olanzapine = increased risk of stroke
Dementia + risperidone, olanzapine or quetiapine = 1.6 fold increase in death rate

Question 21

indications for antipsychotics in elderly with dementia

Answer 21

1. severe and persistent behavioral and psychological symptoms which are distressing to the patient or put patient at risk AND do not respond to non pharmacological intervention
2. acute management delirium
3. continuation of tx of psychotic disorders preceding dementia

Question 22

side effects/risks of antipsychotics in elderly with dementia

Answer 22

increased risk of stroke/mortality
increased risk of Parkinsonism, changes in mobility, increased falls, tremor, rigidity
sedation, hypotension, worsening cognitive impairment

Question 23

Approach to neuropsych symptoms in elderly with dementia

Answer 23

depression/anxiety –> memantine –> SSRI
Sleep disturbance –> Lorazepam, trazodone, zopiclone
agitation/aggression/psychosis –> mild (not physically aggressive or causing sig. distress) = SSRI
severe or non response to SSRI = Risperidone, olanzapine, aripiprazole

Question 24

Risperidone

Answer 24

most likely of atypicals to cause EPS

best supported atypical for NPS

Question 25

Olanzapine

Answer 25

more sedating than risperidone or abilify | most likely to cause metabolic side effects

Question 26

abilify

Answer 26

most likely to cause akathisia

Question 27

quetiapine

Answer 27

more sedating than risperidone or abilify | may be used for parkinsons disease dementia or DLB at low doses

Question 28

citalopram

Answer 28

may cause hyponatremia | best supported SSRI for NPS

Question 29

escitalopram

Answer 29

may cause hyponatremia

Question 30

sertraline

Answer 30

may cause hyponatremia

Question 31

Carbamazepine

Answer 31

sedation, gait disturbance, neutropenia, hyponatremia | high potential to cause drug interactions, drug level monitoring required

Question 32

haloperidol

Answer 32

most likely to cause EPS | may be used in Emergency tx where other IM meds not available

Question 33

what is the most likely atypical antipsychotic to cause EPS

Answer 33

risperidone

Question 34

what is the most likely atypical antipsychotic to cause akathisia

Answer 34

abilify

Question 35

what is the best supported atypical antipsychotic for NPS

Answer 35

Risperidone

Question 36

what atypical antipsychotic is most likely to cause metabolic side effects

Answer 36

Olanzapine

Question 37

what atypical antipsychotic may be used for parkinsons disease dementia or DLB

Answer 37

quetiapine

Question 38

what is the best supported SSRI for NPS

Answer 38

citalopram

Question 39

what typical antipsychotic is most likely to cause EPS

Answer 39

Haloperidol