Old Age Psychiatry

Question 1

What is delirium?

Answer 1

Also known as ‘acute confusional state’

Acute (hr-d onset), fluctuating syndrome of disturbed:

Consciousness
Attention
Cognition
Perception

Question 2

What is the ICD-10 criteria for the diagnosis of delirium?

Answer 2

Impairment of consciousness and attention
Global disturbance in cognition
Psychomotor disturbance
Disturbance of sleep-wake cycle
Emotional disturbances

Question 3

Describe the illness course of delirium

Answer 3

Sudden onset
Fluctuating course
Gradual resolution: up to 6-months
Following effective treatment of underlying cause

Question 4

List the three clinical presentations of delirium

Answer 4

Hyperactive delirium
Hypoactive delirium
Mixed delirium

Question 5

Describe hyperactive delirium

Answer 5

Psychomotor agitation
Increased arousal
Inappropriate behaviour
Hallucinations: commonly visual
Delusions: commonly persecutory
Restlessness and wandering are common

Question 6

Describe hypoactive delirium

Answer 6

Psychomotor retardation
Appear quiet or withdrawn
Lethargy
Reduced appetite
Excess somnolence (drowsiness)

Question 7

Describe mixed delirium

Answer 7

Combination of hyperactive and hypoactive delirium with varying presentation over time

Question 8

Name three predisposing factors for delirium

Answer 8

Elderly or very young
Pre-existing dementia
Sensory impairment: eg. visual or hearing
Post-op (especially cardiac)
Alcohol abuse; benzodiazepine-dependent; poor nutrition
Serious and/or multiple illnesses; polypharmacy
Lack of stimulation

Question 9

Provide five precipitating factors for delirium

Answer 9

Delrium is usually multifactorial

UTI; chest infections; infected pressure sore; sepsis
Hyperglycaemia; hypoglycaemia; electrolyte abnormalities
MI; heart failure; stroke; intracranial bleed
Thyroid dysfunction; PE; COPD exacervation
Urinary retention; constipation; malnutrition
Severe uncontrolled pain; major surgery
Medication changes; alcohol intoxication or withdrawal
eg. opiods; benzodiazepines; steroids
Hospital admission; emotional stress; sleep deprivation

Question 10

Name five complications of delirium

Answer 10

High mortality (20% during admission, up to 50% at 1yr)
Increased duration of stay
Nosocomial infections
Institutionalisation and/or re-admission
Increased risk of:
Dementia
Falls
Pressure sores
Continence problems
Functional impairment; distress for self/carers

Question 11

What is the association between delirium and dementia?

Answer 11

Delirium causes neuronal death ➔ Independent cause (3x more likely) for dementia development and progression

Pre-existing dementia is a predisposing factor for delirium

Question 12

Request three investigations for suspected delirium

Answer 12

Cognitive testing: 4AT; MoCA; Addenbrooke's
Urinalysis
Sputum culture; CXR
FBC; CRP
U+Es; calcium
HbA1c
TFTs
Haematinics: eg. B12; folate
EEG

Question 13

What are the management principles for delirium

Answer 13

Identify and treat underlying causes
Environmental and supportive measures
Avoid sedation unless severely agitated or a risk
Regular clinical review and follow-up

Question 14

Name four environmental and supportive measures in the management of delirium

Answer 14

Maintain hydration and nutrition
Physical environment
eg. Safe environment; good lighting; noise reduction; clocks and calendars; hearing and visual aids
Human environment
eg. Same staff; firm clear communication; routine; prevent transfer
Control of distressing physical symptoms
Avoid unnecessary procedures
Promote healthy sleep patterns

Question 15

Name three physical environmental factors for optimal management of delirium

Answer 15

Safe environment
Adequate lighting
Noise reduction
Clocks and calendars
If appropriate, hearing and visual aids

Question 16

Name two human environmental factors for optimal management of delirium

Answer 16

Same group of staff
Firm clear communication
Routine
Prevent transfer
Education for those interacting with patient

Question 17

Outline the managment of a person with delirium who is distressed or considered a risk to themselves or others?

Answer 17

Verbal and non-verbal de-escalation
Short-term haloperidol
Lowest clinically appropriate dose; titrate to symptoms
Use with caution or none if Parkinson’s or Lewy body

Question 18

Differentiate dementia from delirium

Answer 18

Delirium has altered consciousness and attention

Dementia:

Gradual onset (months to years); progressive deterioration
Normal consciousness; perceptional disturbances occur later
Normal sleep-wake cycle

Delirium:

Acute onset (hours to weeks); fluctuating course
Impaired consciousness; perceptional disturbances common
Disrupted sleep-wake cycle
Disordered thinking, language impairment, inattention
Euphoric, fearful, depressed or angry

Question 19

What physical examination should be performed in delirium?

Answer 19

ABC
Conscious level with AVPU or GCS
Vital signs - o2, pulse, BP, temp, capillary blood glucose
Nutritional and hydration status
CV exam
Respiratory exam
Abdominal exam - check for urinary retention and rectal exam for faecal impaction
Neurological exam including speech

Question 20

What are the differentials for delirium?

Answer 20

Dementia
Mood disorders
Late onset schizophrenia
Dissociative disorders
Hypothyroidism and hyperthyroidism

Question 21

What is the general management of delirium?

Answer 21

Treat underlying cause
Stop any potential offending drugs, laxatives or catheter if needed

Reassurance and re-orientation

Provide appropriate environment, quiet, well-lit side room, reassurance, family or friend

Manage any disturbed or stress behaviour, low dose haloperidol or olanzapine
Avoid benzos unless delirium is due to alcohol withdrawal

Question 22

What is paraphrenia?

Answer 22

Paranoid delusions with or without hallucinations, but without the deterioration of intellect or personality.
Patients remain well orientated to time and space.

Question 23

What is an encapsulated delusion?

Answer 23

An unshakeable belief in something for which there is no evidence nor common acceptance. Occurs in the absence of other signs of psychiatric illness.

Question 24

What is dementia?

Answer 24

A syndrome of generalised decline of memory, intellect and personality, without impairment of consciousness.
Leads to functional impairment.

Question 25

What are the microscopic changes in dementia?

Answer 25

Neurofibrillary tangles and beta amyloid plaques.

Question 26

What are the macroscopic changes in dementia?

Answer 26

Cortical atrophy, widened sulci and enlarged ventricles.

Question 27

What are the irreversible causes of dementia?

Answer 27

Neurodegenerative - different types of dementia Infections - HIV, encephalitis, syphilis, CJD Toxins - alcohol, barbiturates, benzos Vascular - vascular dementia, multi-infart dementia, CVD Traumatic head injury

Question 28

What are the reversible causes of dementia?

Answer 28

Neurological - normal pressure hydrocephalus, intracranial tumours, chronic subdural haematoma Vitamin deficiencies Endocrine - cushing's, hypothyroid

Question 29

What are the risk factors for Alzheimer's?

Answer 29

Advancing age Family history 25-50% Genetics Down's Low IQ Cerebrovascular disease - can co-exist with AD Vascular risk factors - past stroke/MI, smoking, HTN, diabetes and high cholesterol.

Question 30

What is the ICD-10 classification of dementia?

Answer 30

A. Evidence of 1. decline in memory - evident in learning of new info 2. decline in other cognitive abilities, deterioration in judgement and thinking B. preserved awareness of the environment for a period long enough to demonstrate A C. decline in emotional control or motivation, or change in social behaviour e.g. emotional lability, irritability, apathy, coarsening of social behaviour. A present for at least 6 months

Question 31

What are the clinical features of Alzheimer's?

Answer 31

Loss of memory, initially inability to recall then long term memory. Disorientation to time and place Impairment of cognitive and executive functions, executive functions; problem solving, abstract thinking, reasoning Visuospatial - lost, bad driving Language disturbances Apraxia Agnosia - impaired recognition of sensory stimuli Non cognitive symptoms - hallucinations, thought creation, behaviour

Question 32

What is the ICD-10 criteria for Alzheimer's?

Answer 32

General criteria for dementia must be met, no evidence for any other cause Early onset - <65, rapid onset and progressive, memory impairment, aphasia or apraxia, inability to read or acalculia Late onset - general criteria, >65, slow gradual onset, predominance of memory impairment over intellectual impairment.

Question 33

What are the clinical features of vascular dementia?

Answer 33

``` Stepwise deterioration Memory loss Emotional - depression, and personality changes earlier than memory loss. Confusion Neurological signs or symptoms ``` Can be mixed and also have features of Alzheimer's

Question 34

What are the features of dementia with lewy bodies?

Answer 34

day to day fluctuations recurrent visual hallucinations motor signs of parkinsonism - tremor, rigidity, bradykinesia Recurrent falls, syncope depression those with parkison's with dementia after 12 months = parkinson's with dementia, within 12 months of one another = DWLB

Question 35

What are the symptoms of frontotemporal dementia?

Answer 35

Usually between age 50-60 FH common Disinhibition, apathy, restlessness, worsening of social behaviour Repetitive behaviour Language problems - difficulty to find words, problems naming Memory is preserved in early stages, but insight lost

Question 36

What is seen in Huntington's?

Answer 36

Autosomal dominant so strong family history Abnormal choreiform movements of hands, face, shoulders, gait abnormalities Dementia presents later

Question 37

What is seen in normal pressure hydrocephalus?

Answer 37

Average age of onset after 70 | Triad of dementia with prominent frontal lobe dysfunction, urinary incontinence and gait disturbance

Question 38

What is seen in CJD?

Answer 38

Onset before 65 Rapid progression, death within 2 years Disintegration of higher cerebral functions Dementia with neurological signs

Question 39

What areas of impairment in dementia should be explored in an OSCE?

Answer 39

My Cat Loves Eating Pigeons ``` Memory Cognition Language Executive functioning Personality ```

Question 40

What is seen in dementia in a MSE?

Answer 40

Appearance and Behaviour: may be unkept, inappropriate behaviour, uncoordination, restless Speech: slow, confused, wrong words, repetitive Mood: low or normal Thought: may have delusions Perception: hallucinations are a core features in DLB, may have illusions Cognition: memory impairment, impaired attention, disorientation Insight: may be preserved initially

Question 41

What are the investigations for dementia?

Answer 41

If present with memory impairment, refer to memory clinic ``` Bloods: FBC - infection, anaemia CRP U&Es Calcium - hypercalcaemia LFTs - alcoholic liver disease Glucose, B12, folate, TFTs ``` ``` Urine dipstick rule out UTI CXR for pneumonia, lung ca Syphilis serology, HIV Brain imaging - early onset, sudden decline, focal CNS signs rule out SOL CT, MRI ``` ECG, EEG LP if meningitis or CJD Genetic testing e.g. Huntington's Cognitive assessment - MMSE, AMT, ACE Addenbrooke's, MOCA

Question 42

What are the differentials for dementia?

Answer 42

``` Normal ageing, mild cognitive impairment Delirium Trauma; stroke, hypoxic, traumatic brain injury Depression - pseudodementia Late onset schizophrenia Amnesic syndrome Learning distability Substance misuse Drug side effects e.g. opiates, benzos ```

Question 43

What are the scores for an MSE?

Answer 43

Normal 25-30 Mild 21-24 Moderate 10-20 Severe <10

Question 44

What is asked about in the MMSE?

Answer 44

``` Orientation to time Registration - repeat words back to you Naming Reding Ask to repeat back words ```

Question 45

What frontal lobe tests can be done?

Answer 45

Verbal fluency and initiation - recall as many words with the letter e.g. S, aim >15 Cognitive estimates - educated guesses e.g. age of oldest person in the country Clock drawing - executive function Similarities - how are objects alike e.g. orange and banana both fruits Motor sequencing - demonstrate and repeat movements

Question 46

What is the general management of dementia?

Answer 46

Supportive treatment e.g. OT input home safety Environmental control measures; motion sensors, call bells Acetylcholinesterase inhibitors Contact DVLA Advanced planning - LPA Mental Capacity Act Treat agitation Treat low mood and insomnia Functional support, social support Support for carers

Question 47

What is the pharmacological management for dementia?

Answer 47

For mild to moderate Alzheimer's - AChE inhibitors e.g. donepezil Memantine NMDA receptor antagonist if severe or intolerant to AChE inhibitors Antipsychotics or antidepressants for behaviour changes

Question 48

How does AChE inhibitors work?

Answer 48

Centrally acting | Compensate for the depletion of acetylcholine in the cerebral cortex and hippocampus in AD.

Question 49

What is pseudodementia/Ganser's syndrome?

Answer 49

A dissociative disorder, very rare Thought people develop it consciously or subconsciously to avoid an unpleasant situation. Common to occur on a background of head injury or serious illness

Question 50

What are the four principal features of pseudodementia?

Answer 50

Approximate answers - incorrect answer but suggests they understand the question Clouding of consciousness Somatic conversion symptoms e.g. hysterical paralysis Hallucinations, visual or auditory Investigations e.g. bloods, urine drug screen, CT, MRI to rule out any organic causes

Question 51

What are the risk factors for vascular dementia?

Answer 51

``` Stroke/TIA HTN AF DM Smoker Hyperlipidaemia ```

Question 52

What are the two classifications of vascular dementia?

Answer 52

Stroke related: as a result of cerebrovascular disease | Small vessel related: due to arteriosclerosis

Question 53

What is lewy body dementia?

Answer 53

Abnormal protein (Lewy bodies) deposition in the substantia nigra and neocortex leading to cholinergic and dopaminergic neurone loss

Question 54

How is Lewy Body dementia investigated and then managed? What drugs must be avoided?

Answer 54

DaTscan 1. rivastigmine or donepezil 2. galantamine 3. memantine Avoid neuroleptics as can induce parkinsonism

Question 55

What are the types of fronto-temporal dementia? What features are common to all 3?

Answer 55

Picks disease Chronic progressive aphasia (CPA) Semantic All have a gradual onset Memory is often preserved Personality changes No insight

Question 56

What causes Picks disease and how does it present?

Answer 56

Picks bodies and fronto-temporal atrophy - disinhibition - impaired social conduct - increased appetite

Question 57

How is depression differentiated from dementia?

Answer 57

Depression has: - rapid onset - biological symptoms (Weight loss/sleep disturbance) - mini mental state test can be variable - global memory loss (vs dementia more recent)