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Flashcards in Old Age Psych Deck (37)
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1

How does depression in the elderly present?

Similar to younger people but with more:
Physical symptoms
Agitation/retardation
Memory problems (pseudo dementia)

2

Epidemiology of depression in the elderly

15% in the community
30% in hospital
Multiple bereavements, social isolation, poverty, physical illness and chronic pain are more common in the elderly

3

What is late-onset schizophrenia?

Positive symptoms more prominent than negative
More common in women
Especially if: isolated, single, widowed or childless
Reduce sensory impairment
Exclude organic cause
Low dose antipsychotics

4

What is Charles Bonnet syndrome?

Complex visual hallucinations secondary to visual impairment alone

5

What is dementia?

An acquired chronic and progressive cognitive impairment
Sufficient to impair activities of daily living

6

How is dementia diagnosed?

Low MMSE
Effect on ADLs
Symptoms present in clear consciousness for at least 6 months

7

What might cause a low MMSE?

Dementia
Delirium
Psychiatric illnesses
Learning disability
Sensory impairment
Language barrier
Feeling unwell, tired, irritable

8

What comprises the activities of daily living?

Financial management
Using toilet
Washing
Dressing
Grooming
Shopping
Cooking
Housework
Mobilising

9

What is the epidemiology of dementia?

5% over 65 yrs
20% over 80 yrs
Alzheimers = most common 2/3
Vascular dementia
Lewy body dementia

10

What are the clinical features of dementia?

Forgetfulness
Disorientation
Loss of independence
Poverty of thought + speech
Anxiety
Depression

11

What behavioural and psychiatric problems might you expect to see with dementia?

Wandering
Sleep disturbance
Delusions
Hallucinations
vocalisations: swearing, shouting, screaming
Inappropriate behaviour incl sexual disinhibition
Aggression

12

What are the risk factors for developing Alzheimer's ?

Age
Genetics
Vascular risk factors e.g. HTN
Low IQ
Head injury

13

What are the familial forms of Alzheimer's?

Early onset: AD causing increased beta- amyloid
Presenilin 1 gene Chr 14
Presenilin 2 gene Chr 1
Beta-amyloid precursor protein APP gene Chr 21
Late onset: >65 AD
Apolipoprotein E4 allele Chr 19

14

Is inherited risk greater if a parent has early or late onset Alzheimer's

Early
Familial alzheimers:
Chr 21 = APP gene
Chr14 = presenelin 1
Chr 1= presenelin 2
Down's >= 60 yrs = 50% prevalence

15

Why are people with Down's syndrome at greater risk of Alzheimer's?

Most likely due to extra copy of APP gene

16

What is the pathology seen in Alzheimer's ?

Atrophy: due to neuronal loss, particularly hippocampus early, temporal and parietal later
Plaque formation: APP abnormally cleaved into beta-myeloid which aggregates into insoluble lumps, dystrophic neuritis filled with hyperphosphorylated tau protein surround these
Intracellular neurofibrillary tangles (hyperphosphorylated tau)
Severity of dementia most assoc with the number NFTs
Cholinergic loss

17

What is the clinical presentation in Alzheimer's ?

Insidious onset
Amnesia: disorientation
Aphasia: issues finding words= muddled speech
Agnosia: recognition problems e.g. Faces
Apraxia: inability to dress etc despite normal motor function

18

What is vascular dementia?

Caused by infarcts due to thromboembolism or arteriosclerosis
RF: old age, male, smoking, HTN, DM, hypercholesteraemia, AF
May have had MIs or TIAs

19

What is the pathology seen in vascular dementia?

Arteriosclerosis
Cortical ischaemia
Infarction, seen on CT as multiple lucencies

20

What is the clinical presentation in vascular dementia?

Stepwise progression
Sudden deterioration following infarcts
Many tiny infarcts cause a smoother more subtle deterioration
Symptoms reflect sites of lesions
May present with neuro signs e.g. Hemiparesis or aphasia
Night time confusion

21

What is the pathology seen in DLB?

Lewy bodies:
Eosinophilic intra cytoplasmic neuronal structures of alpha synuclein and ubiquitin
Found in congrats gyrus and neocortex

22

What is the clinical presentation in DLB

2/3
Fluctuating confusion with marked variation in alertness
Vivid visual hallucinations (people or animals)
Spontaneous parkinsonian signs

Also: repeated falls, syncope, transient loss of consciousness
Short term memory affected

23

Why is it imperative that patients with DLB are not prescribed antipsychotics?

Extreme neuroleptic sensitivity!
Can result in death

Do not misdiagnose as delerium.

24

What is the mirror sign?

Sometimes seen in dementia
Sufferers no longer recognise their own reflection

25

What is sun-downing?

Confusion in dementia worsens in the evening
Exact cause unknown
Possibly due to increased risk of illusions in poor light

26

What factors protect against Alzheimer's ?

Being educated
Being physically active

27

What is delerium?

Sudden presentation of clouded consciousness
Poor attention
Presentation fluctuates
Underlying physical cause
Resolves once treated (although may take some time)

28

What are reversible dementias?

Present with cognitive impairment, may resolve if treated
Sub dural haematoma, SOL, normal pressure hydrocephalus
Hypothyroidism, hyperparathyroidism, cushing's, addison's
B12 deficiency, folate deficiency, thiamine deficiency, niacin deficiency

29

What is pseudo dementia?

Memory problems in severe depression can resemble dementia
Low mood precedes cognitive issues
Past history of depression
'I don't know' rather than being keen and making mistakes

30

What is the management of dementia?

Adaptations
Social support
Support carers
Optimise physical health
Psychological therapies
Psychotropic medication