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m4 psych > 15. Psychogeriatrics > Flashcards

15. Psychogeriatrics Flashcards

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1
Q

Major Neurocognitive Disorder

A

Significant cognitive decline from a previous level of performance in 1 or more of the following domains:
- Attention
- Executive function
- Learning and memory
- Language
- Perceptual motor
- Social cognition

+ affect independence in performing daily activities

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1
Q

Which allele enhances risk of cognitive decline a/w depressive symptoms?

A

APOE-E4 allele

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2
Q

Mild Neurocognitive Disorder

A

Modest cognitive decline from a previous level of performance in 1 or more of the following domains:
- Attention
- Executive function
- Learning and memory
- Language
- Perceptual motor
- Social cognition

+ do NOT affect independence in performing daily activities

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3
Q

Which delusion is common in dementia patients?

A

Delusion of theft (accusing caregivers of stealing items)

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4
Q

Which delusion is common in delirium patients?

A

Persecutory delusions

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5
Q

Examples of cortical dementia

A
  • Alzheimer disease
  • Fronto-temporal lobe dementia
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6
Q

Cognitive assessment for dementia

A

Mini mental state examination
Montreal cognitive assessment

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7
Q

Assessing Activities of Daily Living (ADLs)

A

Basic: DEATH
Dressing
Eating
Ambulating
Toileting
Hygiene

Advanced: SHAFT
Shopping
Housekeeping
Accounting
Food/meds prep
Transportation/Telephone

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8
Q

Irreversible causes of dementia

A

Alzheimer’s
Vascular dementia
Lewy body dementia
Fronto-temporal dementia

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9
Q

Reversible causes of dementia

A

Normal pressure hydrocephalus
Subdural hematoma (bridging veins)
Vitamin B12 deficiency
Neurosyphilis (venereal disease research laboratory)
Hypothyroidism

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10
Q

Risk factors associated with Alzheimer’s disease

A
  • Old age*** (most significant risk factor)
  • APOE E4 allele
  • Head injury
  • Down syndrome
  • Poor linguistic skills
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11
Q

Protective factors against Alzheimer disease

A
  • High education level
  • High physical activity level
  • APOE E2 allele
  • Late retirement
  • Consumption of fish
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12
Q

Onset of Alzheimer disease

A

Insidious, gradual decline, progressive onset

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13
Q

How does Down syndrome increase risk of Alzheimer’s dementia?

A

Amyloid precursor protein gene is found in chromosome 21
In trisomy 21, APP increases, forming amyloid plaques and increases risk of Alzheimer’s developing at an earlier age

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14
Q

Clinical features in Alzheimer’s disease

A
  1. Clear evidence of memory decline
  2. Gradual decline in memory over time
  3. Psychotic symptoms (visual hallucination more common than auditory)
  4. Behavioural changes
  5. Personality changes
  6. Orientation (disorientation in time)
  7. Neurological features
    - reduction in REM sleep, frequent nocturnal waking periods and shortened sleep periods
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15
Q

Management of Alzheimer’s disease

A
  • Mild AD: Consider cognitive stimulation programme
  • Moderate AD: Acetylcholinesterase inhibitors: donepezil (+VaD), galantamine, rivastigmine (+LBD)
  • Severe AD: Memantine
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16
Q

Side effects of acetylcholinesterase inhibitors

A

Diarrhoea
Urination
Miosis
Muscle cramps
Bradycardia*
Bronchospasm
Emesis
Lacrimation
Lethargy
Salivation
Seizures

*can remember MIND mnemonic
- Muscle cramps
- Insomnia
- Nausea
- Diarrhoea

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17
Q

Side effects of memantine

A

CHECK mnemonic

Confusion
Headache
Equilibrium - Nausea
Constipation
Kidney function

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18
Q

Onset of vascular dementia

A

Unpredictable course, abrupt stepwise deterioration

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19
Q

Vascular dementia vs Alzheimer’s dementia

A

VaD
- abrupt stepwise deterioration
- executive function/apraxia is first to go
- memory loss later
- dysarthria
- presence of cerebrovascular event, HTN, atherosclerosis
- worse prognosis (3 years)

AD
- gradual, progressive decline
- memory loss/amnesia is first to go
- acalculi, apathy
- better prognosis (6 years)

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20
Q

Frontotemporal dementia features

A

Frontal changes
- Behavioural changes: Disinhibition
- Impulsivity
- Personality

Temporal changes
- Speech changes: speech production, word finding, object naming, grammar or word comprehension

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21
Q

Brain changes seen in Alzheimer’s dementia

A

Amyloid plaques
Neurofibrillary tangles

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22
Q

Brain changes seen in frontotemporal dementia

A

Frontotemporal atrophy
Gliosis of white matter in the frontal lobes
Intracellular inclusions
Swollen neurons

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23
Q

Lewy body dementia triad

A
  1. Cognitive impairment
  2. Parkinsonism features
  3. Visual hallucinations
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24
Q

Lewy body dementia vs Parkinsonism dementia

A

LBD:
- dementia first then Parkinsonism features
Parkinsonism dementia
- Parkinsonism features then dementia

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25
Q

Triad of normal pressure hydrocephalus

A
  1. Gait disturbance
  2. Cognition impairment
  3. Urinary incontinence
26
Q

Late onset bipolar disorder is associated with

A
  • less grandiosity
  • less violent or reckless behaviour
  • less likely a/w drug use
  • increase irritability and anger
  • increase obsessive thought
27
Q

Worried-well syndrome

A

Anxious people worrying that they have dementia

28
Q

Dementia in Creutzfeldt-Jakob disease

A

Dementia is rapidly progressive and will lead to death

29
Q

Examples of behavioural and psychological symptoms of dementia

A

Agitation
Aggression
Apathy
Delusions
- delusion of theft
- partition delusion
Depression
Disinhibition
Sleep Disturbances
Hallucinations (due to sensory impairment in elderly)
Wandering

30
Q

Phenomenon where symptoms worsen later in the day (late afternoon/early evening) due to changes in ambient light

A

Sundowning
*occurs in 2/3 patients with dementia due to disturbed circadian rhythm

31
Q

Approach to BPSD

A
  1. Is it delirium?
  2. Not delirium, is there a medical cause for BPSD?
  3. Are there reversible causes for BPSD?
  4. If all ix and solutions fail, are there meds available?
  5. Caregiver care and onward placement
32
Q

Non-pharmaco treatment of BPSD

A

Caregiver training
Aromatherapy
Exercise training
Simulated presence therapy
Music therapy
Pet therapy
Massage therapy

33
Q

Pharmaco tx of BPSD

A

*not the mainstay of treatment
*reserved for severe BPSD and when BPSD still persists despite correction of medical causes
*used when non-pharmaco therapy has failed

  1. Topiramate
    - S/E: renal stones
  2. Cholinesterase inhibitors
    - Donepezil, rivastigmine
  3. Antidepressants
    - SSRI: Citalopram, escitalopram (SSRI)

Avoid
- mood stabilisers (might reduce irritability)
- anticholinergics (worsens cognition)
- bzd (worsens cognition)

34
Q

Use of antipsychotics?

A

Yes, use 2nd gen antipsychotics but comes with a lot of dangers
*must weigh the pros and cons

START LOW, GO SLOW

35
Q

S/E of using antipsychotics in dementia patients

A
  • Worsening metabolic syndrome (increases sugar, cholesterol)
  • EPSEs
  • Fall risk
  • Increased mortality (NMS)
36
Q

Non-pharmacological treatment for dementia

A
  • Reminiscence therapy
  • Reality orientation therapy
  • Validation therapy
  • Snoezelen (utilisation pf specially designed room with stimulating environment)
  • Aromatherapy
37
Q

Risks in a dementia patient

A

Risk of self harm
Risk of harm to others
Risk of falls
Risk of fires
Risk associated with wandering
Caregiver burnout -> abuse of elderly patient

38
Q

Mini mental state examination results

A

Out of 30 points
Cut off is 24/30 for a Singaporean who has O level education
❖ 20-24: mild dementia
❖ 10-19: moderate dementia
❖ Below 10: severe dementia

39
Q

Frontal lobe assessment

A
  1. Cognition estimation
  2. Verbal fluency
  3. Judgement
  4. Abstract thinking
  5. Luria hand test
  6. Alternating sequence

*NO score, just a global impression

40
Q

Cognition estimation

A
  • How high is the ceiling? (in meters)
  • How tall is an average Singaporean woman? (in meters)

Pathology: Estimation of woman’s height is taller than that of the ceiling

41
Q

Verbal fluency

A
  • How many animals can you name in 1 minute?
  • How many words starting with the letter F/A/S can you say in 1 minute?

*At least 10 words to pass the assessment
Pathology: Repeating of words

42
Q

Judgement (probe further)

A

If there is a fire in this room, what would you do?
- How will you run?
- Where would you go?
- Will you use the lift?

If you find an envelope on the floor with an address and stamp on it, what would you do?
- Expect patient to say “I will post it”

43
Q

Abstract thinking

A
  • Name similarities between a table and a chair
  • What is the meaning of “kill 2 birds with 1 stone”
44
Q

Luria’s hand test

A

Demonstrate once, but if patient is confused can show again
Perform at least 5 times independently using left and right hand to pass the test

Pathology: Perseveration, unable to do task

45
Q

Alternating sequence

A

Draw a part of the sequence
- Square and triangle linked by a line
- Ask patient “Draw the sequence and continue drawing the sequence from the last object”
*Do not just ask the patient to copy the sequence

Pathology: Will keep on drawing the last object
*perseveration

46
Q

MMSE

A
  1. Orientation (time)
  2. Orientation (place)
  3. Short term memory (registration)
  4. Attention and calculation (acalculia)
  5. Short term memory (recall)
  6. Recognition (agnosia)
  7. Language
  8. Visual-spatial skill
  9. Motor sequence (ideomotor apraxia)

*testing parietal-temporal lobe

47
Q

Orientation (time) - 5 points

A

“Without looking at your watch/the clock”
1. Time (AM/PM - must ask!)
2. Day of the week
3. Date of the month
4. Month
5. Year

48
Q

Orientation (place) - 5 points

A
  1. Ward #
  2. Floor
  3. Name of hospital
  4. Nearest MRT
  5. Name of country you are in
49
Q

Short term memory (registration) - 3 points

A

“Let me say finish first then you repeat after me. (Say objects slowly)
Ok very good.
I will ask you a few minutes later, please remember these 3 items”

Registration of 3 items:
- Apple
- Ball
- Pillow

(maximum repeat 2 times)

50
Q

Attention and calculation (acalculi) - 5 points

A

Serial 7 or serial 3
- Start from 100, -7 and continue to minus 7 from your answer until I tell you to stop
- Start from 20, -3
*do at least 5 times

Months backwards
- Can you say the months from December backwards?

Spelling backwards
- Can you spell ‘world’?
- Can you spell it backwards?

(points scored irrespective of consecutive error)

51
Q

Short term memory (recall) - 3 points

A

Can you recall of the 3 items that I told you previously?
- Apple, ball, pillow
- If patient makes up another item, that’s confabulation

52
Q

Recognition (agnosia) - 2 points

A
  • Pen
  • Watch
53
Q

Language - 3 points

A

Write a complete sentence (testing writing ability: agraphia)
- must be grammatically correct
- let patient write on paper - any sentence
- “Write me a sentence about the weather today”

Follow a written common (testing reading ability - alexia)
- Write on paper and show patient “close your eyes”

Repeat a sentence after me (rule out aphasia)
- “No ifs ands or buts”

54
Q

Visual-spatial skill (constructional praxis) - 1 point

A

Copy my drawing
“double pentagon”

55
Q

Motor sequence - 3 points

A

3 stages command
“Only do this after I have finished my instructions
- Take this piece of paper with your left hand
- Fold it into half
- Place it on your right thigh/desk”

56
Q

Is MMSE the gold standard in establishing the diagnosis of dementia?

A

No, MMSE is a screening test and there is no gold standard to diagnose dementia

57
Q

Predisposing factors for depression in the elderly

A
  • Polypharmacy
  • Cerebrovascular event
  • Woman
  • Widowhood
  • Looking after a spouse with chronic illness
58
Q

After the age of 65, the prevalence of dementia increased by how many times every 5 years?

A

2x

59
Q

MOA of memantine

A

Reduce glutaminergic neurotransmission (glutaminergic and NMDA antagonist)

60
Q

Features more common in late onset depressive disorder

A

More somatic symptoms
More psychosis symptoms
More cognition symptoms
More anxiety symptoms
More determined to die
White matter changes
Absence of family history of depressive disorder

61
Q

Contraindications to acetylcholinesterase inhibitor

A
  • Severe dementia or MMSE < 10/30
  • Bradycardia or on beta blockers
  • GI bleed or peptic ulcer
62
Q

Potential benefits of using acetylcholinesterase inhibitor

A

Improve cognition
Improve BPSD a/w dementia
Delay nursing home placement

63
Q

Psuedodementia vs dementia

A

Pseudodementia
- Onset of symptoms: mood issues occurs before cognitive impairment)
- Poor motivation when attempting cognitive assessment (giving “idk” replies)
- Patchy inconsistent memory loss (short term and long term)
- Poor attention
- Improve of cognitive symptoms improve with treatment for mood

m4 psych (18 decks)

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