Old age Flashcards
(13 cards)
Overview LBD and features on hx suggestive
DLB accounts for 15%–20% dementia cases at autopsy. DLB arises from accumulation of a synaptic protein α-synuclein as Lewy Bodies in the brainstem, limbic cortex and neocortical regions. It is characterised by fluctuating but progressive deficits in multiple cognitive domains. This is the central and essential feature of Lewy Body dementia syndrome which often manifests as delirium in the beginning. Visual hallucinations and aggression of the patient in this scenario warrants a differential diagnosis of delirium, arguably the most common syndrome to be considered in such a situation. The candidates, however, should consider other features in the history, such as chronic progressive course, vivid visual hallucinations, extrapyramidal symptoms, and falls in arriving at the most likely diagnosis – Lewy Body dementia. In general, clinical features that support the diagnosis include repeated falls, syncope, transient loss of consciousness, severe autonomic dysfunction, depression, systematised delusions, or hallucinations in other sensory and perceptual modalities. They lack diagnostic specificity however, and can be seen in other neurodegenerative disorders.
Imaging in DLB
MRI
occipital hypometabolism on 18F-flurodeoxyglucose Positron Emission Tomography (PET) is suggestive of Lewy Body dementia
Management DLB
- control of distressing psychotic symptoms, addressing behavioural problems and psychosocial interventions.
- Cholinesterase inhibitors, such as donepezil in slowing down the progress of cognitive symptoms, as well as behavioural symptoms especially with early and assertive treatment. (more beneficial in Lewy Body dementia than in Alzheimer’s dementia)
- Certain medications need to be avoided as they can aggravate the clinical picture; for example, first generation antipsychotics which are likely to lead to exaggerated extrapyramidal signs, sedation, immobility, or neuroleptic malignant syndrome (NMS) with fever, generalised rigidity and muscle breakdown. This is an essential and integral part of the management of Lewy Body dementia in view of its serious risk. (second generation antipsychotic medications like quetiapine only). The role of memantine is less clear.
There are no therapies that have proven to be curative or stop the disease progression. - Physical exercise and cognitive training are, however, shown to be beneficial and recommended for patients with dementia
- Early diagnosis will also allow families and caregivers the time to plan for the expected decline.
- Preventive steps to improve safety in the nursing home environment should be taken, given the tendency to recurrent falls and rapid attentional fluctuations.
- Families will also have time to develop a better understanding of their role in patient care, including assistance with daily activities, and provision of social and cognitive stimulation.
- Dementia Behaviour Management Advisory Services (DBMAS).
Diagnostic criteria DLB
DSM-5: Dementia with Lewy Bodies Diagnostic Criteria The diagnostic criteria for probable DLB require: The presence of dementia. At least two of three core features: o fluctuating cognition with pronounced variations in attention and alertness, o recurrent visual hallucinations that are typically well formed and detailed, and o spontaneous Parkinsonian (motor signs) with onset at least one year later than cognitive impairment. Suggestive clinical features include: Rapid eye movement (REM) sleep behaviour disorder, Severe neuroleptic sensitivity, and Low dopamine transporter uptake in basal ganglia demonstrated by SPECT or PET imaging. In the absence of two core features, the diagnosis of probable DLB can also be made if dementia plus at least one suggestive feature is present with one core feature. Possible DLB can be diagnosed with the presence of dementia plus one core or suggestive feature.
Overview assessment of pt in setting of nursing home
psychiatrist role in managing stress levels of colleagues, staffs, and family; collecting historical and collateral data; reviewing nursing home records for clarity; committing to ongoing explanation regarding features of illness (dementia and delirium); balancing statutory obligations around management while ensuring patient’s rights; seeking advice about local dementia services; reviewing current supports for the family.
Initial management plan DLB in nursing home setting
planning for risk management including absconding and the impact of aggression;
considering stimulus / environmental strategies; recommending judicious use of specific medications and other specific environmental and nursing interventions; articulating favourable evidence for cholinesterase inhibitors for Lewy Body dementia; stating that first generation antipsychotics should be avoided in Lewy Body dementia as a general principle; consideration of involuntary / guardianship options; record keeping and communicating to necessary others; identifying potential barriers
Behavioural assessment of agitation and verbal aggression in dementia
· Demonstrate exploration of the aggressive episode & the risk;
· Check for a medication induced disorder OR symptoms of depression, hallucinations, delusions;
· Explain the concept of Behavioural and Psychological Symptoms of Dementia (BPSD);
· Recommend further assessment involving members of a multi-disciplinary team;
· Counsel about referral to community support services and / or Alzheimer’s Association.
· Show an awareness of literature and College guidelines on management of BPSD;
· Make mention of scales and rating instruments for BPSD: agitation, aggression, wandering;
· Involve a bi-cultural clinician or consider involving a language and cultural interpreter.
Symptoms of moderate Alzheimers disease
The moderate (confused) phase of Alzheimer’s disease often lasts the longest (between 2 to 10 years) and
presents with severe memory and cognitive decline, motor skill changes and behavioural changes.
Noticeable gaps in memory and thinking and, while they tend to be able to distinguish familiar from unfamiliar
faces, people with Alzheimer’s disease can have trouble remembering the name of their spouse. People can
become disoriented to time and place. They also lose awareness of recent experiences and may not be able
to express themselves effectively because of a reduction or confusion of words.
Behavioural and Psychological Symptoms of Dementia (BPSD)
Behavioural and Psychological Symptoms of Dementia (BPSD) are also known as neuropsychiatric
symptoms. They are a heterogeneous group of non-cognitive symptoms and behaviours that form a major
component of the dementia syndrome irrespective of its subtype. They are as important as cognitive
symptoms because they strongly correlate with the degree of functional and cognitive impairment.
Symptoms include agitation, abnormal motor behaviour, anxiety, elation, irritability, depression, apathy,
disinhibition, suspiciousness / delusions, and hallucinations. People can become easily frustrated, especially
as their skills decline or in response to demands of carers and the environment.
As part of BPSD people can have trouble losing bladder or bowel control as well as experiencing changes in
sleep patterns or appetite. It is estimated that BPSD affects up to 90% of all dementia patients over the
course of their illness.
BPSD is thought to be independently associated with poor outcomes, including distress among patients and
caregivers, long-term hospitalisation and misuse of medication.
Tests / Instruments BPSD
· Brief Psychiatric Rating Scale (Overall and Gorham, 1962),
· Sandoz Clinical Assessment Geriatric (Shader et al., 1974),
· Alzheimer’s Disease Assessment Scale (Mohs et al., 1983),
· Cambridge Examination for Mental Disorders (Roth et al., 1986),
· Behavioural Pathology in Alzheimer’s Disease Scale (BEHAVE-AD) (Reisberg et al., 1987
Hamilton Depression rating scale
Beck Depression Inventory
Diagnosis of BPSD
obtaining a clinical history, direct observation, psychiatric and physical
examinations, and reports by care providers; exclusion of physical problems (e.g. an infection, pain,
constipation or poor eyesight or hearing) or mental illnesses such as depression. Laboratory tests can
assess for the presence of medical conditions that can trigger or exacerbate the clinical presentation of
BPSD. It is important to exclude unmet medical needs.
Tools for assessing BPSD. There are also tools to assess particular BPSD areas and pain:
Tools for assessing BPSD are the clinician-administered Neuropsychiatric Inventory (NPI) which assesses
ten behaviours as well as appetite and sleep in the person with dementia. It can help to distinguish between
the different types of dementia. Recent versions also include a Caregiver Distress Scale.
The Behavioural Pathology in Alzheimer’s Disease (BEHAVE-AD) measures BPSD and is generally clinician
rated in Acute, Primary, Community and Residential Care settings and can be used to measure change as a
result of interventions.
There are also tools to assess particular BPSD areas and pain:
1) Aggression (RAGE=Rating Scale for Aggressive Behaviour in the Elderly)
2) Agitation (CMAI=Cohen-Mansfield Agitation Inventory; PAS=Pittsburgh Agitation Scale)
3) Depression (CSDD=Cornell Scale for Depression in Dementia; GDS=Geriatric Depression Scale)
4) Pain (PAINAD=Pain Assessment in Advanced Dementia; the Abbey Pain Scale;
PACSLAC=Pain Assessment Checklist for seniors with Limited Ability to Communicate)
agitation).
Generic principles of management BPSD
engaging the person in enjoyable and meaningful activities, which
could range from making music to exercising,
spending quality time with the person, like chatting or sharing a task together,
developing a structured daily routine,
trying to ensure continued social relationships,
encouraging the person to engage in past pleasurable activities,
reducing unnecessary noise and clutter,
providing people with familiar personal items and maintaining a comfortable sleeping environment
