Old Age Flashcards
(8 cards)
Depression in the elderly
Be aware of how depression may present differently – consider using adapted rating scales e.g. Geriatric rating scale alongside PHQ-9
Differentials to be aware of include adjustment disorder and grief reactions
Remember to risk assess - gain understanding of home environment and support network, eating and drinking, risk of malnourishment etc.
Psychosis in the elderly
Differentials to be aware of include abnormal grief reaction, depression, Lewy body dementia
Use same psychosis screening questions as with any other psychiatry history
Psychosis in the elderly management
Reduction of sensory impairment
Exclusion of organic cause, substance misuse or Lewy Body Dementia
Low-dose antipsychotics (be mindful of comorbidities or drug interactions)
Risk assessment - Early intervention psychosis team if risk to self or others
Dementia management
Offer group cognitive stimulation
Consider group reminiscence therapy
Validation and multi sensory therapy
Psychotropic medication
- Acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine) - used in mild to moderate Alzheimer’s
- Memantine (NMDA antagonist) - if severe Alzheimer’s
- Antipsychotics last resort - lowest effective dose for shortest time (6 weeks) as olanzapine and risperidone has increased risk for cardiovascular accidents
MMSE
- mild AD 21-26
- moderate AD 10-20
- severe AD <10
Pharmacology for non-alzheimer’s
Donepezil or rivastigmine for dementia with Lewy bodies - galantamine if not tolerated
Only consider acetylcholinesterase inhibitors in people with vascular dementia if there is suspected comorbid Alzheimer’s, Parkinson’s dementia or dementia with Lewy bodies
Do not offer to patients with frontotemporal dementia
Antipsychotic can be used acutely in agitated patients who are at risk of harming
themselves
- antipsychotics can worsen Lewy body dementia
Vascular dementia
Characterised by ‘step-wise’ progression and multi-faceted impairment of cognitive function
Key is to prevent further cerebrovascular disease by optimal control of major risk factors in people with a history of stroke or TIA
Risk Factors: Age, Male, HTN, Hypercholesterolaemia, obesity - aim to manage these as best as possible
- Hypertension - anti-hypertensives
- Elevated LDL cholesterol - statin
- Diabetes mellitus - optimise glycaemic control
- Atherosclerotic ischaemic disease - Antiplatelet therapy (aspirin) + lifestyle modification
- Comorbid Alzheimer’s disease, Parkinson’s disease dementia or DLB - consider AChE inhibitors or memantine
- Cardioembolic disease - anticoagulation or antiplatelet therapy, lifestyle modification
- Carotid stenosis >70% present - carotid endarterectomy
Lewy body dementia
Characterised by fluctuating cognition, visual hallucinations (particularly of small/tiny things), REM sleep behaviour disorder
Lewy body dementia management
Adaptations for patient (with an occupational therapist)
- Reality orientation, environmental modifications
Optimising physical health
Psychological therapies (e.g. reminiscence therapy)
Pharmacological therapies
- Acetylcholinesterase inhibitors may provide symptomatic relief
- Mild/moderate - donepezil or rivastigmine, galantamine otherwise
- Severe - donepezil or rivastigmine, memantine otherwise
- Clonazepam used for REM seep disturbance
- SSRI added for co-morbid depression
- Parkinson’s medications (levodopa/carbidopa) could relieve the tremors, but they could worsen the psychosis
- Antipsychotics are dangerous and should not be used (they cause severe reactions – confusion, Parkinsonism, death)
- Acute behavioural disturbance may be treated with short-acting benzodiazepines e.g. lorazepam - short term only
