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Psychiatry > Old age psychiatry and dementia > Flashcards

Old age psychiatry and dementia Flashcards

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1
Q

At what age do you start under old age psychiatry?

A

> 65

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2
Q

What happens with aging in terms of cognitive, physical, and social changes?

A

Reduced abilities and accumulative wisdom
Reduced functioning/complex needs and positive adaptation
Loss and isolation and freedom from responsibility

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3
Q

Why does older adult services exist?

A 
Differences in presentation
Differences in needs
Impact often deteriorating physical health
- Causation/differential diagnosis
- Management
- Risk factors
Impact of mental health condition
- Physical health
- Suicide
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4
Q

What is the impact of physical health?

A

Bidirectional relationship
- Physical illness is a risk factor
- Consequences of mental illness on physical health
Sensory impairments direct risk factors for MH problems
Considerations for treatment
- Increased body fat, decreased muscle, decreased relative body water
- Decreased renal blood flow and function
- Interactions

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5
Q

How common is depression in older adults?

A

23% lifetime risk of developing over 75
Prevalence 3-15% higher in OA population - higher in care homes/hospital
Higher rates of suicide in OA
Approx 1/3 co-morbid with harmful drinking
Under-recognised and under-diagnosed

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6
Q

Why is depression commonly under-recognised and under-diagnosed in OA?

A

Depression w/o sadness
Biological symptoms thought of as physical illness
Less likely to seek help
Vague presentations

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7
Q

What is depressions relationship with physical health?

A

Bidirectional relationship

Higher physical morbidity and mortality

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8
Q

How might vascular depression present?

A 
Changes to cortical circulation
White matter hyperintensities on MRI
Cognitive impairment
Psychomotor retardation and apathy
Poor insight
Poor response to antidepressants
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9
Q

What are reversible causes of depression?

A 
Drugs
- Beta blockers
- Opioids, antipsychotics, benzos
- Parkinson's medications
- Digoxin
Metabolic
- Anaemia, B12/folate
- Hypercalcaemia/hypothyroidism
- Hyper/hypokalaemia/natraemia
Infective
- Post viral 
- Neurosyphilis
Intracranial
- Post-stroke/subdural haematoma
- Parkinson's disease
- SOL
- Dementia
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10
Q

How do you treat depression in OA?

A

Same as for younger adults - SSRI/SNRI - often sertraline as cardiac safe and fewer interactions
Start low and go slow with antidepressants
Psychological therapies/social inclusion
ECT

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11
Q

What is the prognosis of depression in OA?

A 
Cerebrovascular changes are major risk factor
Good prognostic factors
- Onset < 70
- Absence of physical illness
- Good previous recovery
- Religious beliefs
2x increased risk of Alzheimer's
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12
Q

What are the differentials for psychosis in OA?

A 
Dementia/depression
Secondary to hyperactive delirium?
Primary mental illness - often doesn't present in older adults apart from late onset
- Schizophrenia
- Late onset schizophrenia
- Delusional disorder
- Affective disorder
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13
Q

What are the psychotic elements of psychotic depression?

A 
Nilhilistic delusions
Hypochondriacal delusions
Delusions of poverty
Auditory hallucinations (2nd person derogatory)
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14
Q

How do you treat psychotic depression?

A

Anti-depressants +/- antipsychotics

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15
Q

What is late onset schizophrenia?

A 
AKA paraphrenia
Onset of symptoms > 60
F>M
Persecutory delusions
Negative symptoms and thought disorder uncommon
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16
Q

What is delusional disorder?

A

Persistent delusions w/o hallucinations
Often more distressing to others than patient due to lack of insight
Patients often reluctant to seek help

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17
Q

What is Charles Bonnet syndrome?

A 
Visual hallucinations
- Simple repeated patterns
- Complex images of people/landscapes/objects
Associated with visual impairments
No role for anti-psychotic treatment
Patient usually retains insight
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18
Q

How do you manage psychosis in OA?

A

Base whether you give anti-psychotics on how much distress symptoms are causing due to S/E
Treat underlying cause - dementia/depresison/delirium

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19
Q

What is dementia?

A

Clinical syndrome of multiple causes defined by

  • An acquired loss of higher mental function affecting 2 or more cognitive domains including episodic memory, language function, frontal executive function, visuospatial function and apraxia
  • Sufficient severity to cause significant social or occupational impairment
  • Chronic and stable
  • Progressive
  • Acquired global impairment of intellect, memory, and personality without impairment of consciousness that is usually (but not always) progressive and usually irreversible
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20
Q

What is mild cognitive impairment?

A

Intermediate state between normal cognition and dementia
Often mild memory impairment, greater than expected for age but not sufficient to class as dementia
Cognitive impairment without functional impairment
Similar aetiology to dementia

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21
Q

What is the prognosis for MCI?

A

1/3 improve
1/3 stay the same
1/3 progress to dementia

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22
Q

What is pseudodementia?

A

Cognitive impairment secondary to mental illness - most commonly depression
Doesn’t know answers to questions
Impairments in executive functioning and attention
Frontal lobe changes identified
White matter hyperintensities on MRI

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23
Q

Name 3 types of degenerative dementia

A 
Alzheimer's
Dementia with lewy bodies
Frontotemporal dementia
Huntington's disease
Parkinson's disease
Prion disease eg CJD
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24
Q

Name 2 types of vascular cognitive impairment

A

Vascular dementia

Cerebral vasculitis

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25
Name 2 types of metabolic cognitive impairment
Uraemia | Liver failure
26
Name 2 types of toxic cognitive impairment
Alcohol related brain injury Solvent misuse Heavy metals
27
Name 2 types of intracranial lesions causing cognitive impairment
Subdural haematoma Tumours Hydrocephalus
28
Name 2 types of infections causing cognitive impairment
HIV Neurosyphilis Whipple's disease TB
29
Name 2 types of endocrine conditions causing cognitive impairment
Hypothyroidism | Hypoparathyroidism
30
Name 2 other conditions causing cognitive impairment
Vitamin B12 deficiency Severe or repeated brain injury Depression causing pseudodementia
31
What questions should you ask about memory?
Repetitive? Temporal gradient of amnesia? - preservation of more distant memories with amnesia of recent weeks Difficulty learning to use new devices eg computer/mobile phone?
32
What questions should you ask about functional ability?
Work performance or ability to do domestic tasks declined? Responsibility for finances and administration shifted to spouse? Get easily muddled?
33
What questions should you ask about personality and frontal lobe function?
Personality altered? More aggressive/apathetic/lacking initiative? Disinhibition? Change in food preference or religiosity?
34
What should you ask about language?
Difficulty with work and/or finding or remembering names?
35
What should you ask about visuospatial ability?
Get lost in familiar places? | Difficulty dressing?
36
What should you ask about psychiatric features?
Any features of depression
37
What other things should you ask about in a dementia history?
``` Tempo of progression FHx of dementia Alcohol and drug use Medication Any other neurological problems eg parkinsonism, gait disorder, strokes ```
38
What should you do in a dementia examination?
``` MMSE ACE FAB Primitive reflexes Limb praxis and oro-buccal praxis Neurological examination - papilloedema, parkinsonism, myoclonus, gait disorders ```
39
What does asking about recent news assess?
Episodic memory
40
What does clock drawing assess?
Visuospatial function
41
What do naming and reading tasks assess?
Language function
42
How do you test limb praxis?
Copying hand gestures and miming tasks
43
How do you test oro-buccal praxis?
Show me how you blow out a candle
44
What can increase your risk of dementia?
``` Age > 65 Ethnicity - south Asian African or afro-carribean Stroke Diabetes Hypertension High alcohol intake CVD Diet Smoking Lack of exercise Low educational attainment Obesity FHx Female ```
45
How common is dementia?
Over 65, 6% prevalence Over 85, 20% prevalence Most common type Alzheimer's 10 per 100,000 FTD prevalence before age of 65
46
What could be a differential diagnosis of dementia?
``` MCI Delirium Depression Amnestic syndromes Aphasia ```
47
How does Alzheimer's present?
Memory impairment - episodic memory, progressive loss of ability to learn, retain and process new information, temporal gradient with relative preservation of distant memory and amnesia for more recent events Loss of working memory Language impaired Agnosia Frontal executive function - organising, planning and sequencing impaired Parietal presentation - visuospatial difficulties and orientation in space or navigation Posterior cortical atrophy Personality Anosognosia - lack of insight Tempo - insidious onset, gradual progression with eventual severe deficits Late non-cognitive features - myoclonus, seizures, sleep-wake cycle reversal, incontinence, swallowing
48
How does lewy body dementia present?
Early feature of visual hallucinations Fluctuating cognition with variation in attention and alertness, sleep disorders Dysautonomia Parkinsonism Memory loss absent in early stages Delusions and transient loss of consciousness occur
49
How does vascular dementia present?
Like AD History of TIAs or succession of cerebrovascular events or stepwise course Apraxia gait disorder Pyramidal signs and urinary incontience Widespread small-vessel disease seen on MRI
50
How does frontotemporal dementia present?
Frontal - Behavioural variant - personality change, emotional blunting, apathy, disinhibition, carelessness, behavioural change Temporal - Primary progressive aphasia
51
What is the onset of Alzheimer's like? Fluctuations? Hallucinations? Progressive? Personality changes? Insight?
``` Gradual No Sometimes Yes Yes Varies ```
52
What is the onset of vascular dementia like? Fluctuations? Hallucinations? Progressive? Personality changes? Insight?
``` Step-wise Sometimes Sometimes Yes Yes Varies ```
53
What is the onset of LBD/PDD like? Fluctuations? Hallucinations? Progressive? Personality changes? Insight?
``` Gradual Yes Yes Yes Yes Varies ```
54
What is the pathology of Alzheimer's?
MRI shows atrophy in mesial temporal love structures including hippocampi, progressive eventually to generalised cerebral atrophy Beta-amyloid plaques in cortex Structural and conformational changes in tau protein Amyloid angiography
55
What is the pathology of FTD?
25% cases familial associated with mutation in tau and progranulin genes Disposition of abnormally aggregated proteins
56
What investigations should you do for dementia?
Clinical syndrome so need to exclude differentials Bloods - FBC, ESR, U&Es, glucose, liver biochemistry, serum calcium, TSH, HIV serology, B12 and folic acid Imaging - CT/MRI and DaT/SPECT Other - CSF, genetic studies, EEG, brain biopsy Formal cognitive testing - ACE-III
57
What is the management of dementia?
``` Cognitive enhancing drugs - Modest systematic benefit in AD - Not disease modifying Cholinesterase inhibitors - Increase brain acetyl-cholinesterase by inhibiting CNS Memantine - NMDA receptor antagonist Anti-depressants if depression symptoms Lasting power of attorney Inform DVLA ```
58
Name an example of a cholinesterase inhibitor
Rivastigmine Donepezil Galantamine
59
What are cholinesterase inhibitors used for?
Mild to moderate dementia in Alzheimer's and Parkinson's
60
What are the S/E of cholinesterase inhibitors?
``` Anxiety Appetite decreased Arrhythmia Asthenia Dehydration Depression Diarrhoea Dizziness Drowsiness Fall GI discomfort Headache Hyperhidrosis Hypersalivation Hypertension Movement disorders Nausea Skin reactions Syncope Tremor Urinary incontinence UTI Vomiting Weight decreased ```
61
What monitoring do you need to do with cholinesterase inhibitors?
Monitor body weight
62
What is ACE-III?
Exam assessing 5 cognitive domains Normal score 82/100 Change in score over time important Normal score doesn't exclude dementia
63
What are the sub-scores in ACE-III?
``` As important as overall score Have different cut offs for dementia diagnosis - Attention /18 - Memory /26 - Fluency /14 - Language /26 - Visuospatial /16 ```

Psychiatry (15 decks)

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