MRCPsych Paper B - Old Age Flashcards
(123 cards)
1
Q
Atypical antipsychotics increases risk of vascular events by a factor of how much?
A
2
2
Q
MAPT gene is located in which chromosome?
A
ch17
3
Q
APP gene is located in which chromosome?
A
ch21q
4
Q
Geriatric bipolar disorder targe serum lithium level
A
0.4-0.7 mmol/L
*usually 0.40-0.60mmol/L, can increase to maximally 0.70 or 0.80 at 65-79yrs and to maximally 0.70mmol/L over 80yrs
5
Q
10yr probability of conversion from MCI to dementia
A
30-40%
6
Q
Risk of developing TD in the elderly vs younger adults (how much more)
A
5-6x
7
Q
Most common symptom of late paraphrenia/ late onset schizophrenia
A
persecutory delusions, 90%
*auditory hallucinations, 75%
8
Q
Prevalence of psychotic symptoms among older individuals with major neurocognitive disorder (AD)
A
40%
9
Q
Apolipoprotein allele that is protective? that is a risk factor?
A
APOE E2 - protective, APOE E4 - susceptible
10
Q
Measure for ADL function in the elderly
A
Barthel Index
11
Q
Most likely neurological findings in vascular dementia
A
Focal neurological findings - unilateral brisk DTR, asymmetrical hyperreflexia or weakness
12
Q
Most common cause of death in AD
A
pneumonia
13
Q
instrument for the ddx of dementia
A
Cambridge examination for mental disorders of the elderly (CAMDEX-R)
14
Q
CASE: Geria px + cognitive difficulties + slurring of consonants + staccato pattern
A
Cerebellar degeneration
15
Q
NIA-AA criteria for probable dementia
A
criteria for dementia + insidious onset, worsening condition, cognitive deficits (amnestic presentation -most common or non-amnestic presentation -language, visuospatial, or executive), no evidence of substantial CVD
16
Q
PDs usually seen in late life
A
HD SOAP
histrionic, dependent, schizoid, OC, avoidant, paranoid
17
Q
Cortical dementias
A
AD, FTD/ Pick disease
18
Q
Cortico-subcortical
A
LCC
LB, CJD, corticobasal degeneration
19
Q
EEG findings in CJD
A
periodic complexes - bi- or triphasic against slow voltage background
20
Q
Delirium scale with good symptom coverage and distinguishes it from from other disorders (dementia, depression, and schizoprenia)
A
Delirium rating scale (DRS)
21
Q
Neurobehavioral syndrome: squalor (dirty and unpleasant), pathological hoarding, lack of insight, no desire for help
A
Diogenes syndrome
*greek philosopher living in a barrel
22
Q
Assessment of dementia for people with LD
A
Dementia questionnaire for People with LD (DLD)
23
Q
Cardinal manifestations of progressive supranuclear palsy
A
Postural instability and falls (backward)
24
Q
Variant CJD is characterized by early…
A
anxiety and depressive symptoms,
*early 20s, … then personality changes, then progressive dementia. Ataxia, myocolonus. Death in 1-2yrs
25
A feature seen commonly in early onset depression when compared with late onset depression
episodic memory dysfunction (temporal lobe dysfunction)
* vs late onset depression: deficits in attention and executive function (frontal lobe dysfunction)
26
Signs it is pathological grief
intense guilt related to issues beyond those surrounding the death of the loved one, preoccupation with death (excluding being with the deceased), morbid preoccupation with worthlessness, marked psychomotor retardation, prolonged severe functional impairment, hallucinations (excluding transient voice of the deceased)
27
First choice medication for elderly with delirium (in a surgical ward)
haloperidol
28
Huntington's disease
autosomal dominance, CAG trinucleotide repeats, HTT gene, ch4p, onset 30-40s
29
Most common psychological and behavioral symptom in Huntington's disease
apathy/ reduction in drive
30
Deficits on tests of attention and visuospatial ability maybe especially prominent in...
LBD
31
Psych drug that can aggravate psoriasis and acne
Lithium
32
Most common psychiatric side effects of rivastigmine
anorexia, dizziness, nausea, vomiting
33
Most common psychiatric side effect of levodopa
nightmares & vivid dreams 30%, night terrors 7%, delirium 5%, delusional disorder 3%
34
Most prevalent personality disorder in the elderly
OC
35
Most effective antipsychotic for psychosis/ agitation/ BPSD in dementia
risperidone
36
Most effective antipsychotic for agitation in dementia
olanzapine
37
Most effective antipsychotic for overall BPSD in dementia
aripiprazole
38
Most prevalent anxiety disorder among the elderly
Specific phobia (esp. fear of falling - basophobia)
39
Compared to early onset depression, late onset depression in the elderly ten to present more often with symptoms of...
psychomotor changes (30%)
40
antipsychotic treatment for Parkinsons with psychosis unrelated to levodopa
Quetiapine
*clozapine is efficacious but limited by agranulocytosis; pimavanserin - another option, atypical antipsychotic
41
Biological changes associated with normal ageing
decrease brain weight (17%), reduced cortical gray matter, ventricular enlargement, increased transport across BBB, decreased cerebral flow
42
Pharmacokinetic changes in ageing
decreased gut motility, decreased gastric acid secretion, 35%-50% decline in renal function, serum creatinine is not 100% reliable
elderly have more body fat, less water, and less albumin, increased vol of distribution and longer duration of action for fat-soluble drugs, decreased liver size, more prone to accumulation due to declining kidney function, eGFR used as measure for renal function
43
Antipsychotic with great risk of severe postural hypotension for the elderly
risperidone, clozapine
*alternatives to treatment: amisulpride, sulpride, aripiprazole, haloperidol
44
Anti-dementia drug that demonstrated benefits in treating hallucinations in LBD
rivastigmine
*newer data finds donepezil is effective as well in LBD
45
Knife-edge atrophy is found where?
behavioral FTD variant, frontal lobes
46
test of executive function in an elderly with schizophrenia
Tower of London/ Hanoi
47
Gingko biloba increases the risk of ...
bleeding
48
rate of VH in LBD
80%
49
test to measure the likelihood of vascular dementia pathology
Hachinski ischaemic score (HIS), 4/12 cut off indicative of vascular dementia
50
most common sensory modality in the hallucinations of Parkinsons related psychosis
visual
51
core clinical features of LBD
fluctuating cognition, recurrent visual hallucinations (80%), REM sleep behavior disorder, parkinsonism
52
case: elderly + being isolated + neglecting himself + living in filthy poor conditions
Diogenes syndrome
53
case: elderly + hearing impairment + delusions (persecutory, partition) + hallucinations
lates onset schizophrenia
54
case: elderly + blindness (cataracts) + hallucinations + independent/ relatively normal
Charles Bonnet syndrome
55
scale for the elderly focusing on cognitive and subjective symptoms more than physical symptoms
geriatric depression scale (GDS)
56
scale for the elderly useful to detect depression in people with dementia
Cornell scale for depression
57
scale for the elderly useful for hearing impaired subjects
Brief assessment schedule depression cards (BASDEC)
58
scale for the elderly for standard screening people with dementia
MMSE
59
less appropriate scale for the elderly due to a number of somatic items
Hamilton rating scale
60
neuroimaging in Alzheimer's disease CT Scan
cortical atrophy over parietal and temporal lobes, dilation of 3rd ventricle
61
neuroimaging in Alzheimer's disease SPECT
reduced cerebral blood flow in the temporal and posterior parietal lobes
62
neuroimaging in Alzheimer's disease PET scan
reduced oxygen and glucose metabolism in temporal and posterior parietal (30%)
63
neuroimaging in Alzheimer's disease MRS
reduced levels of N-acetyl aspartate
64
case: elderly + treatment resistant (one of which is SGA)
clozapine
65
case: elderly + Parkinson's disease + psychosis
atypical antipsychotic - quetiapine, before clozapine
66
side effect of antidementia cholinesterase inhibitor that is related to excessive cholinergic stimulation
insomnia
67
most common side effect of antidementia meds on the cardiovascular system
bradycardia
68
most frequent gastrointestinal side effect of antidementia meds
nausea
69
case: recurrent strokes + step-wise deterioration in cognitive function
multi-infarct dementia/ vascular dementia
70
case: progressive cognitive decline + dysfunction + fluctuating cognition + recurrent visual hallucinations (Liliputian) + neuroleptic sensitivity
Lewy body dementia
71
case: worsening memory + increased tone with rigidity + abnormal jerky movements + strong family history of dementia
Huntington's disease dementia
72
case: memory problems + urinary incontinence + broad-based short stepped gait + CT: ventricular enlargement
Normal pressure hydrocephalus
73
case: memory problems + falls + depressed mood + tremors + cog wheel rigidity + motor and cognitive symptoms develop more than 12mos from each other
Parkinson's disease dementia
74
case: elderly memory problems + falls + depressed mood + tremors + motor and cognitive symptoms develop within 12mos from each other
Lewy body dementia
75
case: elderly with memory loss + disinhibited behavior + CT: knife blade atrophy of frontal and temporal lobes
Pick's disease dementia
76
case: elderly with changing pattern of cognition + history of trauma + clotting disorders + aspirin/ warfarin intake
chronic subdural haematoma
77
case: gait ataxia + dementia + urinary incontinence
normal pressure hydrocephalus
78
case: progressive frontal dementia + hallucinations & delusions (grandiosity) + lightning pain with tabes dorsalis + personality changes
General Paresis of Insane (GPI) (from untreated syphilis)
79
case: elderly treated for resting tremors - psych SE: acute confusional state + paranoia + visual hallucinations
dx: Parkinson's disease
tx: levodopa
*euphoria, depression, insomnia, abnormal dreams
80
case: elderly treated for swollen legs - psych SE: visual halos, confusion
dx: cardiac failure
tx: digoxin
81
case: elderly treated for polymyalgia rheumatica - psych SE: hypomanic, confused
dx: autoimmune disease (polymyalgia rheumatica)
tx: prednisolone/ corticosteroids
*iatrogenic depression, mania, confusion
82
case: elderly treated for vtach - psych SE: confusion, agitation, paranoid delusions
dx: ventricular tachycardia
tx: amiodarone
*altered mental status, hallucinations, delirium
83
case: elderly recent onset memory loss + early morning headache & nausea
dx: cerebral tumor
tx: dexamethasone for compression symptoms, surgical evacuation for best treatment of choice
84
case: adult (~45yo) with alcohol use disorder + fluctuating alertness and asterixis
dx: hepatic encephalopathy, from hepatlic failure
tx: neomycin & lactulose
85
case: elderly + grandiose delusions + irritability + memory loss + abnormal pupils
dx: GPI - neurosyphilis
tx: antibiotic therapy - IM procaine penicillin x 10-21 days
86
case: 45yo chronic alcoholic + apathy, fatigue, irritability, depression and cognitive impairment
dx: chronic thiamine deficiency - Wernicke's encephalopathy + Korsakoff's psychosis - beri beri
tx: thiamine
87
case: elderly + atrophic gastritis + fatigue, tingling and numbness of hands and feet, depression + memory problems
dx: vitamin B12 deficiency - pernicious anemia
*diarrhea or constipation, loss of appetite, swollen red tongue, bleeding gums
tx: vitamin B12
88
case: elderly (~57yo) + mouth ulcers, diarrhea. lassitude (lack of energy) + impaired cognition + depression + dementia
dx: folate deficiency
*grey hair, peptic ulcers
tx: folate supplements
89
case: adult (~45yo) with lethargy, tiredness, constipation, low mood, and memory problems
dx: hypothyroidism
tx: thyroxine
90
case: elderly usually in the 60s + paralysis of EOM, cervical dystonia, ataxia + dementia
dx: Progressive supra nuclear palsy
*balance issues, falls (retropulsion), slurred speech, personality changes,
91
case: elderly (~50s) + clumsiness, uncontrollable twitching of face and shoulders, ataxia + cognitive impairment + family history
dx: Huntington's disease
92
case: adult (~25yo) + jaundice, wing-beating tremor of shoulders, rigidity + memory problems
dx: Wilson's disease
*flapping tremor of wrists, wing-beating tremor of shoulders, Kayser-Fleisher rings (greenish corneal deposits)
93
case: elderly with gradual change in personality + increasing disinhibition, forgetfulness + collecting multiple items over the course + family history of memory problems
dx: Pick's disease
*repetitive behaviors - counting, checking, cleaning, collecting, hoarding, pathological gambling, touching and grabbing rituals, superstitious acts
94
case: adult (~43yo) with lymphoma + clumsiness, problems with coordination + cognitive impairment
Progressive multifocal leucoencephalopathy
*AIDS, chronic corticosteroid therapy
95
case: elderly (~59yo) with rapidly progressive dementia + myoclonus, ataxia
dx: sporadic CJD
*cortical blindness
96
chromosome location: Presenilin 1 gene
chromosome 14
*associated early onset Alzheimer's diseaese
97
chromosome location: Presenilin 2 gene
chromosome 1
* associated with early onset Alzheimer's disease
98
chromosome location: beta-amyloid precursor protein gene
chromosome 21q
*associated with early onset Alzheimer's disease
99
chromosome location: APOE4 gene
chromosome 19
*associated with late onset Alzheimer's type
100
investigation: elderly (79yo) with progressive short term memory loss x 18mos + difficulties ADL
dx: Alzheimer's disease
inv: CT - medial temporal atrophy
101
investigation: elderly (83yo) with progressive cognitive decline + apathy + visual hallucinations + PMH Parkinson's disease
dx: Lewy Body Dementia
inv: DaTSCAN - reduced striatral dopamine uptake
102
investigation: elderly (67yo) with memory loss, language difficulties, disinhibition, personality changes + over 1 year
dx: fronto-temporal dementia
inv: HMPAO SPECT scan - decreased perfusion in the frontal lobes
103
investigation: elderly (63yo) with recent memory problems + rapid decline + abnormal twitching and gait disturbances
dx: CJD
inv: CT - atrophy of cortex and cerebellum
104
investigation: elderly (67yo) + memory problems x last 6mos + hypertension, TIAs
dx: vascular dementia
inv: MRI - focal white matter lesions
105
EEG: generalized periodic 1-2hz sharp wave complexes
sporadic CJD, NOT in variant form
106
EEG: episodic discharges every 1-3secs (with variable focal waves over temporal areas)
Herpes simplex encephalitis
107
EEG: (initial loos of alpha waves), later flattened trace
Huntington's disease
108
EEG: triphasic waves and slowing of the normal background
Hepatic encephalopathy
109
antidementia medication: neuroprotective and disease modifying
memantine (10mg bid)
110
antidementia medications: on rivastigmine, likes it and does not want to switch + unlikely to cause gastrointestinal effects
rivastigmine transdermal patch (9.5/24h)
111
antidementia medications: safest choice for patients with cardiovascular disease and multiple other medications
rivastigmine
112
antidementia medications: acetylcholinesterase inhibitor that is well tolerated / relatively minimal side effects
donepezil (10mg OD)
113
antidementia medications: vascular dementia
low dose aspirin, statins, diabetic and BP control
114
core features of Lewy Body Dementia
Parkinsonism + progressive cognitive decline + visual hallucinations
*fluctuating consciousness
115
core features of frontotemporal dementia/ Pick's disease
insidious onset and gradual progression, striking loss of insight, personality change and behavioral disorder
*emotional blunting, disinhibition
116
core features of Creutzfeldt-Jakob disease
rapidly deteriorating dementia + myoclonus + cerebellar and extrapyramidal signs + death in 1 year
*cortical blindness
117
neuropsychometric test: executive function
Wisconsin card sorting test, Stroop test, Tower of London test, controlled word association
118
neuropsychometric test: practically useful episodic memory linked to daily functioning
Rivermead behavioural memory test
*everyday memory problems
119
neuropsychometric test: nonverbal intelligence
Ravens progressive matrices
120
neuropsychometric test (?): measure of ADLs
Blessed dementia rating scale
121
clinical features of multi-infarct dementia
abrupt onset + history of multiple strokes + stepwise deterioration
122
clinical features of Binswanger's disease
subcortical dementia + gradual intellectual decline + generalized slowing
123
clinical features of CADASIL
onset during 40s, subcortical dementia, history of migraines
*autosomal dominant, chromosome 19q
