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Flashcards in Geriatric Psychiatry Deck (36)
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1

Primary types of psychiatric illness in the elderly

Dementia (DSM 5 includes Major Neurocognitive Disorder [NCD], Mild Neurocognitive Disorder, Delirium)

Psychosis

Substance abuse

Depression

2

DSM criteria for dementia

Evidence of modest cognitive decline from a previous level of performance in 1+ cognitive domains (complex attention, executive function, learning/memory, language, perceptual motor, or social cognition) based on 2 factors: 1) Concern of the individual, a knowledgeable informant, or clinician, 2) modest impairment in cognitive performance documented by standardized neuropsychological testing or other clinical assessment

The cognitive deficits do NOT interfere with capacity for independence in everyday activities

3

Special considerations when treating geriatric patients

Multiple comorbidities

Varied diseases (more degenerative and certain types of cancer)

Unusual disease/illness presentations

Differentiating normal aging process vs. disease

Underreporting

Purpose of treatment - emphasis on palliative care

Medication - start low, go slow

4

Most common type of dementia; risk factors include female, family hx, head trauma, and Downs syndrome

Alzheimer’s

5

Types of dementia seen in elderly include Alzheimer’s, vascular, progressive disorders, and reversible causes. What are 2 progressive disorders causing dementia in elderly pts?

Pick’s disease (frontotemporal dementia)

Lewy body dementia (neurocognitive symptoms + Parkinson-like features + visual hallucinations)

6

What are some reversible causes of dementia in elderly?

Drug-induced

Thyroid disease

Metabolic disorders

Hematomas

Normal pressure hydrocephalus

7

What are some symptoms of dementia in elderly?

Depression (look for weight loss, anxiety, irritability, sadness, social withdrawal): pseudodementia

Memory loss

Communication

Difficulty with performing tasks, organization, and coordination

Problems with disorientation (e.g., getting lost)

Personality change

Inappropriate behavior (esp w/ frontotemporal dementia)

Psychotic sxs (i.e., hallucinations, delusions, paranoia)

Agitation

8

General steps in evaluation of dementia in elderly

H and P — most important (get info regarding onset and characterization - type/manner of cognitive deficit)

Progression

Determine comorbid conditions and other signs/symptoms

Neurologic exam and mental status exam

Functional status (OT) — dressing, bathing, cooking, financial organization, etc.

Neuropsych testing

Labs

Radiology

9

What part of evaluation of dementia in elderly attempts to establish a baseline (helpful in early disease) and quantifies results of cognitive deficit?

Neuropsychological testing

10

What labs and radiology are important to order in evaluation of dementia in elderly?

Labs — endocrine panels, B12, folate, CBC, CMP, HbA1C

Radiology — CT, MRI, PET scan

11

The first step in treatment of dementia in elderly is to attempt to determine and treat the cause (as well as rule out other potential conditions). It is also important to consider treatment of comorbidities like diabetes, HTN, etc.

There is no perfect treatment, but you can attempt to slow the progression and increase pt functionality. One pharmacologic option is ______ which is an acetylcholinesterase inhibitor, and another is ______ which is an NMDA antagonist

Donepezil; memantine

12

What medications should be avoided in the treatment of dementia (and most other conditions) in the elderly?

Anticholinergic medications — these can impair cognitive function, esp in the elderly!!!

AVOID DIPHENHYDRAMINE AND HYDROXYZINE

13

Black box warning regarding treatment of psychosis in geriatric pts with dementia

Antipsychotic meds are associated with increased mortality — including olanzapine, aripiprazole, risperidone, quetiapine, and others.

Most deaths were either due to heart-related events or infections (mostly PNA)

14

Third most common cause of psychosis in elderly outpatients; characterized by thought disturbance with themes that tend to be from the current environment and situations, with poverty of thinking and irrationality, and with hallucinations (often visual)

Psychosis due to Delirium

15

What are some causes of psychosis due to delirium in the elderly?

Inappropriate drug use
Withdrawal from drugs
Infection
Urinary retention
Constipation
Physiologic abnormalities
CV problems
Intracranial strokes
Seizures
Hemorrhages
Sensory/sleep deprivation

16

Second most common diagnosis in elderly outpatients, accounting for most psychosis in this population; characterized by somatic troubles, persecution, guilt, and/or poor self-esteem

Psychosis due to MDD with Psychotic Features

17

Most common diagnosis accounting for psychosis in elderly pts; characterized by simple delusions that are often of a paranoid nature — i.e., pts believe that items are being stolen from them, that they are being abandoned, and/or their spouse and children are being disloyal

Psychosis due to Alzheimer’s type Dementia

18

Risk factors for substance use in the elderly

Female gender

Marital status (single, separated, or divorced) and living alone

Absence of hobbies and socialization

Health concerns

Possible pharmacokinetic changes that take place in elderly may lead to increased potential for abuse of benzos or opiates

19

Specific consequences of substance abuse in the elderly are dependent on the drug/substance of abuse. What are some general consequences?

Cognition impairment

Depression and other mood alterations (i.e., irritability and anxiety)

Sleep alteration

Balance and vestibular problems (leads to falls/fractures)

Delirium

Increase risk for developing other medical conditions

20

Effective way to treat benzodiazepine dependence in older persons

Gradual taper

21

Initial tx for substance abuse in elderly depends on substance being abused. It is important to treat withdrawal signs/symptoms — you cannot go cold turkey with intense and chronic alcohol abuse or you risk _____ and _____

Delirium tremens; death

22

Primary causes of depression in elderly

Deteriorating health

Cognitive decline

Loss of independence

Loss of spouse and friends

23

Signs/symptoms of depression in elderly

Overall similar to all depressive disorders but with an increase in somatic symptoms and less evident symptoms in affective-mood domain

Specifically — anxiety, fatigue and hypersomnolence, somatic complaints, cognitive impairment, weight loss, insomnia, anhedonia, agitation

24

Major depression criteria

Anhedonia or depressed mood for 2 weeks and 4 or more of the following:

Feelings of worthlessness or guilt
Decreased ability to concentrate
Fatigue
Psychomotor agitation
Insomnia or hypersomnolence
Weight/appetite changes
Recurrent thoughts of suicide or death

25

T/F: there is a specific questionnaire called the Geriatric Depression Scale used to dx depression in elderly, but should be used with caution in pts with dementia

True

[score of >5 suggests depression and warrants f/u with comprehensive assessment, score of >10 almost always indicates depression]

26

______ and _____ onset depression in elderly with absence of social factors should raise suspicion for underlying, non-psychiatric cause, including dementia, normal bereavement, and adjustment d/o with depressed mood

Recent; abrupt

27

How do you differentiate between dementia and depression in elderly population?

Mental status exam — focus on your pts “insight”:

Depressed pts WILL often have insight, though little effort

Dementia pts have LITTLE/NO insight

28

Treatment for depression in the elderly

Medication
Psychotherapy
CBT
Exercise (walking, water aerobics)
Diet
Lifestyle mods (i.e., socialization)

29

Goals of CBT in tx of depression in elderly

Replace negative perspective/irrational thinking with rational and positive cognition

30

How long is a typical initial anti-depressant trial in elderly?

4-6 weeks

31

When treating depression in elderly pts, what medication should you use with caution in your cardiac pts?

TCAs like nortriptyline

32

_____ should be used with caution in elderly due to ability to cause seizures in this pt population

Buproprion

33

_____ may be used to tx depression in elderly and helps promote sleep, but should be used in low doses due to caution of orthostatic effects

Trazodone

34

______ and _____ are SNRIs utilized in tx of depression in elderly who have comorbid pain conditions

Venlafaxine; duloxetine

35

______ is used as an antidepressant in elderly and is known to increase appetite

Mirtazapine

36

Cautions in using SSRIs in elderly

Serotonin syndrome

May increase falls

GI effects

Insomnia

Agitation