Psychiatry

Question 1

What is Dementia?

Answer 1

A syndrome characterised by an appreciable deterioration in cognition resulting in behavioural problems and impairment in the activities of daily living. Decline in cognition is extensive, often affecting multiple domains of intellectual functioning

Question 2

What is the aetiology of Dementia?

Answer 2

The majority of cases of dementia have degenerative and vascular causes:
Degenerative: Alzheimer’s disease (60%), Lewy body disease, Parkinson’s disease
Vascular (5% to 20%): multi-infarcts
Other causes: psychiatric, neoplastic, traumatic (subdural haematoma, traumatic brain injury), infectious, inflammatory, toxins

Question 3

What are some of the infectious causes of Dementia?

Answer 3

Lyme disease (spread by ticks)
Neurosyphilis
Tuberculosis meningitis
Creutzfeldt-Jakob disease

Question 4

What are some of the inflammatory causes of Dementia?

Answer 4

Demyelinating diseases
Lupus erythematosus
Sarcoidosis
Sjogren’s syndrome (autoimmune condition which mainly affects areas that produce fluids - tears or saliva)

Question 5

What are the presenting symptoms of degenerative dementia?

Answer 5

Memory decline with loss of recent memory first
Disorientation to time and place (subtle at first)
Nominal dysphasia- difficulties naming objects/people
Apathy: may not want to perform usual activities/ want to sleep more often
Decline in activities of daily living
Personality/ mood changes

Question 6

What are the signs of dementia on physical examination?

Answer 6

Early stages: unremarkable
-Mini mental state examination: nominal dysphasia, constructional dyspraxia (e.g. clock drawing test)
Advanced disease: patients tend to appear sloppily dressed, confused, apathetic, and disorientated with a slow, shuffling gait and stooped posture.
Terminal disease: rigidity and inability to walk or speak

Question 7

What is the main difference in presentation between vascular and degenerative dementia?

Answer 7

In vascular dementia executive functions of the brain such as planning are more prominently affected than memory e.g difficulty solving problems and slowed processing of information

Question 8

What are the appropriate investigations for Dementia?

Answer 8

Bedside cognitive testing
Bloods: rule out anaemia
-Thyroid function: to rule out other causes of cognitive decline such as hypothyroidism
-Renal and LFTs: to rule out other causes of cognitive decline such as liver or renal failure
-ESR: to rule out other causes of cognitive decline such as an inflammatory condition or vasculitis
-Serum B12: rule out vitamin B12 deficiency-induced dementia
CT and MRI

Question 9

What would be seen in Bedside cognitive testing for a patient with Dementia?

Answer 9

Impaired recall
Nominal dysphasia
Disorientation (to time, place, and eventually person)
Constructional dyspraxia
Impaired executive functioning

Question 10

Why should a CT or MRI scan be requested to distinguish between vascular and degenerative dementia?

Answer 10

Vascular: identify cerebrovascular lesions
Degenerative: generalised atrophy with medial temporal lobe and later parietal predominance

Question 11

What is the management for Vascular Dementia?

Answer 11

Main goal of treatment is to prevent further cerebrovascular disease by optimal control of major risk factors in people with a history of stroke or TIA e.g. regular physical activity

Question 12

What is the management for Degenerative Dementia?

Answer 12

Treatment and care should be individualised based on symptoms and social situation
Pharmacological treatment (include cholinesterase inhibitors or NDMA receptor antagonists) try to slow symptoms of disease progression by preserving memory and functional abilities and reduce behavioural disturbance
Regular monitoring (4-6 months)

Question 13

What are the complications of Dementia?

Answer 13

Depression (loss of independence/ isolation/ care home setting)
Agitation
Falls
Pneumonia: dysphagia of liquids and solids may increase the risk of aspiration pneumonia
Urinary incontinence- increase risk of UTIs

Question 14

What is the prognosis of Dementia?

Answer 14

Life expectancy is significantly shortened, generally a progressive disease.
Mortality with vascular dementia is similar or worse than that of Alzheimer’s disease

Question 15

What is major depressive disorder?

Answer 15

Also known as clinical depression
A mental state characterised by:
Persistent low mood
Loss of interest and enjoyment in everyday activities
Neurovegetative disturbance
Reduced energy
It can cause varying levels of social and occupational dysfunction

Question 16

What is the aetiology/ risk factors of depressive disorder?

Answer 16

Aetiology is still unknown- possible genetic component
Risk factors include stressful life events, personal or family history, co-existing medical conditions e.g. Alzheimer’s disease.
Also side effects to medication e.g. oral contraceptive pill, corticosteroids, propranolol

Question 17

What is the epidemiology of depressive disorder?

Answer 17

• Depressive disorders are very common and are among the leading causes of disability worldwide.
• In people aged 18-44 years, depression is the leading cause of disability and premature death
• Women are affected twice as often as men
• First onset occurs most commonly in patients aged 12-24 years or older than 65 years

Question 18

What are the presenting symptoms of depressive disorder?

Answer 18

Depressed mood
Anhedonia- diminished interest or pleasure in all or almost all activities 
Weight change
Libido change
Sleep disturbance
Low energy 
Poor concentration
Suicide ideation

Question 19

What classification system is used to diagnose depressive disorder?

Answer 19

DSM- diagnostic and statistical manual, latest edition DSM-5

Question 20

What are the signs of depressive disorder on physical examination?

Answer 20

Weight change
Libido change
Low energy
Poor concentration

Question 21

What are the appropriate investigations for depressive disorder?

Answer 21

Clinical diagnosis- DSM-5 diagnostic criteria
Normal blood test results e.g. TFTs for hypothyroidism
Screening tools:
-Patient Health Questionnaire
-Edinburgh Postnatal Depression Scale
-Geriatric Depression Scale

Question 22

What is the management for depressive disorder?

Answer 22

Antidepressants (SSRIs- citalopram, sertraline)

Psychotherapies e.g. Cognitive Behavioural Therapy

Question 23

What are complications of depressive disorder?

Answer 23

Risk of self-injurious behaviour
Risk of suicide
Side effects of anti-depressants (agitation)

Question 24

What is the prognosis of depressive disorder?

Answer 24

Therapy goals: complete remission of symptoms and return to normal functioning- this may take up to months
Depression recurs in about one third of patients within 1 year of discontinuing treatment and in more than 50% of patients during their lifetime

Question 25

What is cigarette smoking?

Answer 25

The action or habit of inhaling and exhaling the smoke of tobacco
It is the most common preventable cause of death/disease

Question 26

What is the aetiology of cigarette smoking?

Answer 26

Influenced by biological, social, genetic and behavioural factors. There is an increased prevalence in low socio-economic backgrounds and with parental approval

Question 27

What is the epidemiology of cigarette smoking?

Answer 27

Around 1.1 billion tobacco smokers worldwide

Prevalence is greater in males than females

Question 28

What are the presenting symptoms of cigarette smoking?

Answer 28

Persistent cough
Dyspnoea
Chest pain
Hoarseness
Weight loss
Frequent colds/upper respiratory tract infections
Haemoptysis
Change in exercise capacity

Question 29

What are the signs of cigarette smoking on physical examination?

Answer 29

Tar stained fingernails and teeth
Hoarse voice and wheezing
Smoke-odoured clothing
Tachycardia 
Hypertension 
Tachypnoea

Question 30

What are the appropriate investigations for cigarette smoking?

Answer 30

N/A, focus on history: number of cigarettes a day for how long (pack years)

Question 31

How do you work out pack years?

Answer 31

1 pack = 20 cigarettes a day

Pack years= number of packs of cigarettes smoked per day by the number of years the person has smoked

Question 32

What is the management of cigarette smoking?

Answer 32

1. Hospitalised patients: advise to stop, counselling, nicotine replacement therapy
2. Active smoker ready to stop: reinforce decision to stop, counselling, nicotine replacement therapy
3. Active smoker NOT ready to stop: advise to stop, motivational messages, counselling, nicotine replacement therapy

Question 33

What are the possible complications of cigarette smoking?

Answer 33

Increased risk of malignancy especially lung cancer

Other substance use e.g. alcohol

Question 34

What is the prognosis of cigarette smoking?

Answer 34

Only 3-4% of smokers successfully quit per year on their own

Highest risk of relapse is within the first 8 days after stopping