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Psychology & Neuroscience of Affective Disorders > Affective disorders and other common disorders in old age > Flashcards

Affective disorders and other common disorders in old age Flashcards

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1
Q

What characterises the increase in ageing population?

A

> Population aged +60 years worldwide

  • 2015: 12%
  • 2020: 22%

> Old age population growth is 3.5 times more rapidly than general population

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2
Q

What is the impact of the ageing population on society?

A

> Increasing socio-economic burden

> Increases demands on

  • social care
  • healthcare
  • pension

> Need for

  • larger and better trained workforce
  • more age-friendly environments

=> old age psychiatry gains significant relevance

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3
Q

What are the valuable contributions of the ageing population to society?

A
  • Carers for families’ grandchildren

- Volunteers in their local community

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4
Q

What does the demographic transition model proposed in 1929 by Warren Thompson consist of?

A

Observed changes in birth and death rates in industrialised societies over previous 200 years:

> Stage 1: high birth rate, high death rate
- stable or slow increase of population

> Stage 2: high birth rate, rapid fall of death rate
- very rapid increase of population

> Stage 3: falling birth rate, slower fall of death rate
- slowing increase

> Stage 4: low birth rate, low death rate
- stable or slow increase

> Stage 5: very low birth rate, low death rate
- stable or slow decrease

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5
Q

What is observed between developed countries (HICs) and developing countries (LMICs) in the demographic transition model of Warren Thomspon?

A
  • Most developed countries (HICs) are either in late stages or have completed the transition
  • most developing countries (LMICs) are still in process of transition
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6
Q

In the demographic transition model, what were the historical events and associated population growth between the 18th and 21st century?

A

> Stage 1: 18th century

  • infectious diseases, periodic epidemics (plague, cholera) -> high death rates
  • high fertility + high mortality = slow population growth

> Stage 2: 19th century

  • improvements in medicine, nutrition and sanitation -> lower death rates
  • high fertility + lower mortality = higher population growth

> Stage 3: 20th century

  • social changes (e.g. increased access to contraception) -> low fertility rates
  • low fertility + low mortality = imbalance of births over deaths -> rapid increase of pop. growth

> Stage 4: 21st century

  • extended lifespan and low fertility rates -> older population
  • low fertility + low mortality = increase of adult population

> Stage 5: 21st century and future

  • birth rate drops below replacement levels
  • very low fertility + very low mortality = reduction of overall population
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7
Q

What is epidemiology, as defined by WHO (2010)?

A

Study of the distribution and determinants of health-related states or events (including disease),
AND the application of this study to the control of diseases and other health problems

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8
Q

Why is further epidemiological research needed in old age psychiatry?

A

Cognitive and non-cognitive disorders represent a burden for health, social and economic systems

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9
Q

What is the worldwide prevalence of adults over 60 that suffer from a mental disorder?

A

15%

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10
Q

What is are two main factors explaining why mental health problems in old age continue to be under-identified by healthcare professionals and old people themselves?

A

> Cognitive and non-cognitive problems considered normal in old age

> Stigma
- limits help-seeking behaviour

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11
Q

What is the most frequent affective disorder in old age population?

A

Depression

  • approx. 15-25% of general population experience mild depressive symptoms
  • > distress and loss of functioning
  • unipolar major depression occurs in 7% of general older population
  • > 5.7% of YLDs in people aged +60
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12
Q

What is depression associated with in old age?

A
  • Functional disabilities
  • Cognitive impairment
  • Lower self-related QoL
  • Increased mortality
  • Poorer functioning compared to those with physical chronic conditions
  • Increased self-perception of poor health and use of health care services
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13
Q

In which cases do we commonly see depression in older age?

A

In older adults recovering from major medical conditions

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14
Q

What characterises late-onset depression in terms of recurrence and persistence?

A

Late-onset depression shows higher rates of recurrence and/or persistence

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15
Q

Which types of symptoms are frequently observed in depression in old age?

A
  • Somatic and psychotic symptoms

- Suicide is common

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16
Q

What are the available treatment options for depression in old age?

A

> Psychotropic medication (e.g. antidepressants) and psychotherapy (e.g. CBT, interpersonal psychotherapy)

> Antipsychotics

> Electroconvulsive therapy (ECT), reserved exclusively for very severe psychotic or life-threatening depression

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17
Q

What is the first-line treatment for mild depression in old age?

A

Psychotherapy, not antidepressants

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18
Q

What is subsyndromal depression?

A

2 or more symptoms of depression that last for at least 2 weeks
BUT aren’t severe enough for a depression diagnosis

  • more common than MDD in older age population
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19
Q

What is the prevalence of subsyndromal depression in older adults in primary and long-term care settings?

A

> 6-10% of older adults in primary care settings

> 30% in medical and long-term care settings

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20
Q

What is associated to increased age and depression severity?

A

Greater cognitive impairment

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21
Q

What could explain the complex relationship between depression and dementia?

A
  • Depressive symptoms as prodromal to dementia
  • Depression as causative factor in dementia
  • Potential shared risk factors
  • Cerebral white matter hyperintensities may increase risk of cognitive impairment in depression
  • Cardiovascular risk factors (e.g. smoking, hypertension) increase risk for dementia and depression
  • Several cognitive domains may be affected in depression
  • Cognitive impairment often persists even after remission of depression (40% of affected individuals develop dementia)
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22
Q

What is a prodrome?

A

Premonitory symptom of a disease

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23
Q

What is the role antidepressants in cognitive impairment?

A
  • May improve cognitive symptoms BUT cognitive impairment may hinder the effectiveness of certain psychotherapies for depression in older adults
  • Antidepressants with anticholinergic side effects should be avoided
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24
Q

What is old age bipolar disorder (OABD)?

A

> Bipolar disorder in individuals aged 60+

> Similar presentation to early-onset bipolar disorder (EOBD)but usually with less severe manic symptoms

> Good response to most mood-stabilisers

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25
Q

Why is the use of lithium for old age bipolar disorder (OABD) controversial?

A
  • Risks of toxicity

- Need for blood monitoring -> could compromise treatment adherence

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26
Q

How is cognitive impairment associated to bipolar disorder?

A

Observed in bipolar disorder patients, even when euthymic (stable mood)

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27
Q

What are the five elements important to consider when performing a psychiatric assessment in old age?

A
  1. History of present illness
  2. Onset and time course
    - acute (e.g. delirium) vs. progressive (e.g. cognitive impairment in Alzheimer’s)
    - symptoms of delirium can be easily confused with psychiatric disorders
  3. Presence of complex reciprocal relationships between medical conditions and psychiatric symptoms
    - secondary effects of physical/psychotropic mediation could be interpreted as primary symptoms
    - substance abuse might contribute to existing psychological symptoms
    - long-standing substance use may lead to multiple comorbidities
  4. Nature and pattern of symptoms
    - visual, olfactory or tactile (vs. auditory) hallucinations increase suspicion for medical causes
  5. Relevance to family and carer’s opinions
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28
Q

What is important to check in the medical history during a psychiatric assessment in old age?

A
  1. Existence of disorders
    - high comorbidity with psychiatric illness (cardiovascular, endocrine, rheumatological)?
  2. Pain
    - very common in older adults
    - may increase risk of suicide
  3. Sexual history
    - interaction of psychotropic medications in sexual functioning
  4. Medication assessment
    - iatrogenic psychiatric symptoms
    - physical and psychiatric substances
    - prevalence of polypharmacy in old age
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29
Q

What does “iatrogenic” mean?

A
  • Caused by medical treatment or by a doctor

- Secondary to medication side effects and drug interactions

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30
Q

What is a mental state examination (MSE)?

A

Structured way of observing and describing a patient’s current state of mind, under several domains

e. g.
- Mini Mental State Examination (MMSE)
- Addenbrooke’s Cognitive Examination (ACE)

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31
Q

What is the purpose of a mental state examination (MSE)?

A

To obtain comprehensive cross-sectional description of patient’s state of mind
- allowing the clinician to make an accurate diagnosis and formulation

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32
Q

What characterises a mental state examination (MSE) in older adults?

A

Similar to younger adults with an additional and more extensive cognitive assessment

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33
Q

What is important to consider when doing a mental state examination (MSE) in older adults?

A
  • Consider delirium as potential differential diagnosis

- Include detailed evaluation for suicidal ideation (higher risk of suicide in older adults)

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34
Q

What does a physical examination for psychiatric assessment in old age usually include?

A
  • Blood and urine tests
  • Brain imaging (CT or MRI)
  • Electrocardiogram (ECG)
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35
Q

What si the purpose of assessing the cardiac risk of older patients in a psychiatric assessment?

A

Before prescription of psychotropic medication such as antipsychotics which have increased risk fo cardiac side effects, stroke, and sudden death

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36
Q

What is important to consider during a physical examination for a psychiatric assessment in old age?

A
  • Increased risk of physical illness

- Impact of chronic medical illness on quality of life and functional ability

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37
Q

What are common risk factors for a psychiatric illness in old age, in combination to common life stressors?

A

> Significant ongoing loss in capacities

> Decline in functional ability

> Reduced mobility

> Chronic pain

> Frailty

> Medical comorbidities that require long-term care

> Bereavement (loss)

> Drop in socioeconomic status with retirement

> Elder abuse: physical, verbal, psychological, financial, sexual, abandonment, neglect, serious loss of dignity and respect

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38
Q

What are the consequences of elder abuse?

A

Physical injuries and long-term psychological problems including depression and anxiety

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39
Q

What is ‘ageism’?

A

Term used to describe attitudes that show a degree of stereotyping, prejudice and discrimination against old people based on their age
- marginalises and excludes older people from their communities

  • widespread and socially normalised
  • > harmful effect on health of older adults
40
Q

What are the common psychiatric disorders in old age?

A
  • Anxiety disorders (including phobias, OCD, PTSD)
  • Psychotic disorders (acute psychosis, schizophrenia)
  • Substance use disorders
41
Q

What are the common cognitive disorders in old age?

A
  • Dementia
  • Alzheimer’s disease
  • Vascular dementia (VaD)
  • Frontotemporal dementia (FTD)
  • Dementia with Lewy bodies (DLB)
  • Parkinson’s disease dementia
42
Q

What characterises anxiety disorder?

A
  • Excess worry
  • Hyperarousal
  • Fear that is counterproductive and debilitating
43
Q

What is the prevalence of anxiety disorder?

A

Lower prevalence of all anxiety disorders in older adults when compared to younger adults

44
Q

What is the common comorbidity to anxiety disorder?

A

Anxiety symptoms and depression: 30-70%

45
Q

To which disorder is generalised anxiety disorder (GAD) possibly comorbid?

A

Depression in older adults

- prevalence rate approx. 2.2%

46
Q

What are effective treatments for generalised anxiety disorder (GAD)?

A

Effective response to SSRIs and CBT for some anxiety disorders in late life

47
Q

Which psychotropic medication should be avoided in pharmacological treatment?

A

Benzodiazepines

48
Q

What characterises phobias in old age?

A

> Most common type of anxiety disorder in late life

> Lower association with panic attacks when compared to young adults

> Panic disorder is rare in late life; symptoms are often associated to physical diseases

49
Q

What characterises obsessive-compulsive disorder (OCD) in old age?

A

> New onset in late life is rare

> Symptoms are similar to those seen in younger adults

Lack of research within older population

50
Q

What characterises post-traumatic stress disorder (PTSD) in old age?

A

> Prevalence decreases with age

> However, it may still develop in response to trauma/stress or as part of a chronic lifelong illness

51
Q

What could explain the lower rates of post-traumatic stress disorder (PTSD) in older age?

A
  • Recovery with age
  • Underreporting of symptoms
  • Healthy survivor effect
52
Q

What is the healthy survivor effect?

A

“selection process whereby healthy workers are selectively retained in the work force while unhealthy workers are removed”

53
Q

What characterises psychotic disorders in old age?

A

> Up to 10% of 85 year olds without dementia may exhibit psychotic symptoms

> Approx. 23% of patients with schizophrenia have late disease onset

> Between 15-20% of patient with schizophrenia will show deterioration in their clinical course

> Paranoid ideation is a common clinical symptom

54
Q

What should be considered in older patients suffering from acute psychosis?

A

Presence of physical/organic causes

55
Q

What is the prevalence of substance use disorders in old age?

A

> Illegal drug use is uncommon

> Abuse of prescription and over-the-counter medications is common

-> understand what medication is being taken during assessment to detect potential misuse

56
Q

What is dementia?

A

Syndrome, usually of chronic or progressive nature
- deterioration of cognitive symptoms

  • mainly affects older people, although it is not a normal part of ageing
57
Q

What is the prevalence of dementia worldwide?

A

50 million people living with dementia
- 60% from LMICs

  • 82 million by 2030
  • 152 million by 2050
58
Q

What is the most common type of dementia?

A

Alzheimer’s disease

- up to 2/3 of cases

59
Q

What are the risk factors to Alzheimer’s disease?

A
  • Advanced age
  • Apolipoprotein e4 genotype
  • Cardiovascular risk factors
  • Lower education

amongst others

60
Q

What are major histological hallmarks of Alzheimer’s disease?

A

Discovery of amyloid plaques and neurofibrillary tangles consisting of tau protein
- beginning especially in hippocampus and entorhinal cortex

61
Q

What are the major clinical features of Alzheimer’s disease?

A

> Insidious onset and slow progress over the years post-diagnosis

> Early symptoms include:
- short-term episodic memory loss and for-finding difficulty

> Later-stage symptoms (‘behavioural and psychological symptoms of dementia’ (BPSD):

  • depression
  • psychosis
  • apathy
  • sleep disturbance
  • agitation/agression
62
Q

Which tools are used to confirm a clinical diagnosis of Alzheimer’s disease?

A

> Several validated cognitive and physical screening tests available (e.g. MSE, ACE)

> Blood tests to measure folate and vitamine B12 levels

> Brain imaging (MRI, CT scans)

63
Q

What are the current treatments for Alzheimer’s disease?

A

> Pharmacological:

  • Acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine)
  • Memantine (N-methyl-D -aspartic acid glutamate receptor antagonist)
  • > to slow the cognitive decline

> Psychosocial interventions for patients AND caregiver psychoeducation

64
Q

What is the prevalence of vascular dementia among all dementias?

A

Accounts for 10-15% of all dementias

65
Q

What are the major clinical features of vascular dementia?

A

> Classical presentations of large strokes -> sudden and subacute worsening of cognition AND “stepwise” progression

> Chronic microvascular disease often manifest with more “subcortical” dementia profile

> Symptoms may vary and neuropsychological testing results to be patchy

66
Q

What are the common risk factors for vascular dementia?

A

Cardiovascular risk factors: smoking, hypertension, diabetes

67
Q

What is the current treatment for vascular dementia?

A

No clear indication of benefit with acetylcholinesterase inhibitors

68
Q

What are the three common subtypes of fronto-temporal dementia?

A
  1. Behavioural variant FTD
  2. Semantic dementia
  3. Progressive nonfluent aphasia
69
Q

What is the prevalence of fronto-temporal dementia in all dementias?

A

Accounts for 5-15% of all dementia diagnoses

70
Q

What are the major clinical features of fronto-temporal dementia?

A

> Frequent early onset and strong familial loading

> Behavioural changes dominate the early clinical course

> Possible overlap with extrapyramidal disorders

> Semantic dementia characterised by specific loss of word meaning and comprehension difficulties

> Progressive non-fluent aphasia marked by agrammatic and telegraphic speech

71
Q

What are the treatment options for fronto-temporal dementia?

A

Treatment options are limited

72
Q

What is the prevalence of dementia with Lewy bodies (DLB)?

A

Thought to be second most common form of dementia

73
Q

What is a major histological hallmark of dementia with Lewy bodies (DLB)?

A

Discovery of Lewy bodies (synuclein inclusions) in neocortex, in addition to brainstem (characteristic of Parkinson’s)

74
Q

What are the major clinical features of dementia with Lewy bodies?

A

> Classic symptoms include parkinsonism, fluctuating levels of consciousness, visual hallucinations

> Common symptoms: falls, autonomic instability, REM behaviour sleep disorders

75
Q

What is parkinsonism?

A

Symptom characterised by rigidity and bradikenisia

76
Q

What is the current treatment for dementia with Lewy bodies?

A

> Use of acetylcholinesterase inhibitors show modest effect

> High sensitivity to motor side effects in DBL patients might affect treatment with antipsychotics

77
Q

What is the prevalence of Parkinson’s disease dementia among people with Parkinson’s disease?

A

Affects 30-50% of people with Parkinson’s disease

78
Q

What is a major histological hallmark of Parkinson’s disease dementia?

A

Presence of Lewy bodies diffused in cortical regions

79
Q

What are the major clinical features of Parkinson’s disease dementia?

A

> Early prominent deficits in visuospatial functioning, attention, and executive functioning

> Presence of psychotic symptoms

> Development of dementia typically slow, and diagnosed at least a year after initial diagnosis of Parkinson’s disease

80
Q

What is the current treatment for Parkinson’s disease dementia?

A

Use of rivastigmine is recommended

81
Q

What are the key elements to consider when prescribing mediation the the elderly?

A
  1. Changes in pharmacokinetics and pharmacodynamics of most drugs due to polypharmacy, due to comorbid illnesses
  2. Risk of increased frequency AND severity of side effects when taking antipsychotics and antidepressants
    - higher risk of drug interactions
  3. Possible delayed therapeutic response
  4. Higher risk of toxicity and therapeutic failure
    - > careful management of drugs with low therapeutic index
82
Q

What are the changes in pharmacokinetics of medications that can occur in older adults, in cases of polypharmacy?

A

> No significant reduction in metabolism capacity in absence of hepatic (liver) disease

> Slower absorption -> slower onset of action

> Increased volume of distribution AND higher duration of action

> Lower excretion associated with impaired renal function

=> Monitor and reduce dosage

83
Q

Why is there an increased volume of drug distribution and a higher duration of their action in older adults?

A

Older adults have more body fat, less body water and less albumen than younger adults

84
Q

Why is the rate of drug absorption slower in older adults?

A

Older adults have poorer intestinal motility than younger adults

85
Q

What is the therapeutic index of drugs?

A

Range of doses at which a medication is effective without unacceptable adverse events

  • narrow TI = minimal change in dose may cause toxicity or loss of therapeutic action
86
Q

Why are drugs with low therapeutic index not the first treatment option for older adults?

A

Older adults have a tendency to poorer adherence to treatments and high sensitivity to side effects
-> increasing physical comorbidity (e.g. renal impairment)

87
Q

What is the concept of the golden rule ‘start slow go slow’ in treatment with older adults?

A
  1. Start with small doses
    - simple pharmacological regimes (fewer side effects from drug interaction)
  2. Tolerance and response
    - expect latency of response to drugs
  3. Side effects
    - more likely to result in poor mental health due to higher sensitivity to medication
  4. Routinely perform:
    - physical examination medication review for potential drug interactions
    - basic blood and urine tests if symptoms occur
88
Q

What is to avoid in the treatment of older adults?

A

> Treating side effects with medication

> Increasing dosage

> Antipsychotics in dementia

> Medication with anticholinergic side effects

> Very sedative medications

> Drugs with very long half-life or potent inhibitors of hepatic metabolising enzymes

89
Q

Why should potent inhibitors or inductors of hepatic metabolising enzymes be avoided for older patients?

A

They lead to alterations in metabolism of other drugs and potential side effects

90
Q

Which legal act in the UK refers to cases of patients with impaired decisional capacity?

A

Mental Capacity Act of 2005
- designed to protect and empower individuals who may lack mental capacity over their own decisions on care, treatment and finances
(applicable to the 16+ year olds)

91
Q

When should a mental capacity assessment take place?

A
  • In the presence of impairment of mind or brain

- If there’s evidence to show that the impairment prevents the person from making specific decisions

92
Q

What are the four criteria defined by the Mental Capacity Act (2005) to assess decisional capacity?

A
  1. Understanding of information relevant to decision
  2. Retainment of information
  3. Use or weighing up of information
  4. Communicating a decision
93
Q

What is the most prominent illness for clinicians that raises the subject of impaired decisional capacity?

A

Dementia
- does not necessarily imply lack in mental capacity

  • assessment should be done at specific time points, as the lack of capacity is not static
94
Q

What are common treatment care strategies for older adults?

A

> Effective, community-level primary mental health care

> Focus on long-term care

> Education, training and support of caregivers (exposed to burnout)

> Early identification/diagnosis and screening

> Identification of physical comorbidities

> Management of challenging behaviour

> Development of psychosocial interventions (e.g. CBT or social inclusion programmes in community)

> Targeted health and social programmes

> Promotion of active and healthy ageing, with respect to individuals’ freedom and security, and provision of adequate living environments

95
Q

What are the requirements for the continual improvement of mental health in older people?

A

> Increasing training for health professionals in providing care for older people

> Enhancing prevention and management strategies of chronic diseases

> Designing sustainable policies

> Developing age-friendly services and settings

Psychology & Neuroscience of Affective Disorders (16 decks)

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