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Reasoning in mental health 7 > Class 8 > Flashcards

Class 8 Flashcards

1
Q

Normal Cognitive Aging, decline in

A

processing speed, attention in complex tasks, episodic (autobiographic) memory, abstraction, concept formation, mental flexibility, inductive reasoning, verbal fluency, visual confrontation naming, visuospatial: complex tasks

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2
Q

Delirium, Epidemiology in the Elderly

A

VERY common in LTC patients (in or out of hospital)
VERY common in ICU
Increased risk if comorbid NCD
Almost always part of the active dying process

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3
Q

Delirium, : Predisposing Risk Factors

A 
Age > 75, male, hx of delirium, depression, ROH, Hx of TIA/CVA, severity of medical illness, terminal cancer, fracture on admission, Rx with significant anticholinergic activity, critical care settings, Premorbid functional disability/impairments, cog impairment, vision impairment, hearing impairment, immobility, dehydration, sleep deprivation
#1 risk factor: cognitive impairment
#2 risk factor: severity of medical illness
Etiology is ALWAYS multifactorial
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4
Q

Delirium, Precipitating Risk Factors

A

Drugs (intox vs withdrawal): Opioids, benzodiazepines, anticholinergics, steroids. ANY Rx can be a precipitating factor.
Infection: Pneumonia, UTI, cellulitis, sepsis
Metabolic disturbances: Fluids, electrolytes, nutrition
Structural insults: CNS, cardiovascular, GI, pulmonary
Retention: Urinary, constipation

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5
Q

Diagnostic Criteria Delirium

A 
Disturbance attention + awareness
Abrupt onset (change from baseline) + fluctuating severity over the same day
Disturbance cognition (memory, orientation, perceptions…)
Direct physiological consequence of another medical condition, substance intox/withdrawal, toxin, or multiple etiologies
Delirium Specifiers:
Substance intoxication delirium
Substance withdrawal delirium
Medication-induced delirium
Delirium due to another medical condition
Delirium due to multiple etiologies

Acute (days) vs persistent (months)

Hyperactive vs hypoactive vs mixed

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6
Q

Attenuated delirium syndrome

A

Commonly called subsyndromal delirium
Sometimes seen in prodromal phase
Not all Dx criteria are met
Distress or impact on functioning present
Suggestive ssx (usually new-onset)
Falls, incontinence, dysphagia, dysarthria, refusal to mobilize, hypersensitivity to environmental stimuli, mild disorientation

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7
Q

Unspecified Delirium

A

Not all Dx criteria are met
Distress or impact on functioning present
Insufficient information to make more specific Dx
eg. ER assessment

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8
Q

Hyperactive Delirium

Common Presentations

A 
Psychomotor agitation
Hypervigilance
Sundowning/sleep-wake reversal
Mood lability
Delusional beliefs
Perceptual disturbances (V>A)
Language abnormalities
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9
Q

Common etiologies

Hyperactive Delirium

A

EtOH withdrawal (delirium tremens)
Sedative withdrawal
Medication-induced

Often mistaken for anxiety, mania, schizophrenia or BPSD

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10
Q

Hypoactive Delirium

Common Presentations

A 
Psychomotor retardation
Hypersomnolence
Decreased arousability
Apathy
Confusion
Perceptual disturbances (V>A)
Vocalizations (eg. muttering)
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11
Q

Hypoactive Delirium

Common etiologies

A

Post-orthopedic surgery status
Severe metabolic abnormalities
Dying process

Often mistaken for depression or misinterpreted as “normal” Rx side effect

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12
Q

Delirium with mixed level of activity

A

Normal psychomotor activity
Important cognitive symptomatology

Rapid fluctuation between hyper/hypoactive state

Controversial subtype

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13
Q

Delirium vs NCD

A

delirium onset acute, course fluctuating, often worse in the evening and night, level of awareness/ alertness/ wakefulness altered (alzheimers N), attention altered (alzheimers N)

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14
Q

Delirium Screening Scales

A

Confusion Assessment Method (CAM)

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15
Q

Delirium is often comorbid with

A

NCD (up to 90% depending on setting)

Severe medical illnesses (critically ill, terminally ill)

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16
Q

Delirium = poor Px factor

A 
Increased risk of 1-year mortality
Increased risk of cognitive decline
Increased risk of functional decline
Increased risk of institutionalization
Prolonged lengths of hospital stay
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17
Q

Dementia

Epidemiology

A

7 % > age 65
25 % > age 85
F > M

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18
Q

Dx DSM 5: Major NCD

A

Significant decline in ≥ 1 cognitive domain
Subjective (patient or else) AND
Objective (quantified clinical assessment)
Interference with independence in everyday activities (eg assistance required with complex iADLs)
Cognitive deficits not exclusively in context of delirium
Cognitive deficits not better explained by another mental disorder

Specifiers due to
Alzheimer’s disease
Frontotemporal lobar degeneration
Lewy body disease
Vascular disease
Traumatic brain injury
Substance/medication use
HIV infection
Prion disease
Parkinson’s disease
Huntington’s disease
Another medical condition
Multiple etiologies
Unspecified

Without behavioral disturbance
With behavioral disturbance
Anxiety, apathy, mood disturbances, agitation, psychotic sx, etc.

Mild
Difficulties with iADLs
Moderate
Difficulties with iADLs + ADLs
Severe
Fully dependent
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19
Q

Dx DSM 5: Mild NCD

A

Modest decline in ≥ 1 cognitive domain
Subjective (patient or else) AND
Objective (quantified clinical assessment)
No interference with independence in everyday activities
BUT greater effort, compensatory strategies, or accommodation required
Cognitive deficits not exclusively in context of delirium
Cognitive deficits not better explained by another mental disorder

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20
Q

NCD Etiology: Biological Risk Factors

A

History of stroke or transient ischémie attack, family history, lifetime history of MDD, non stabilized sleep apnea, non stabilized metabolic or cardiovascular morbidity, recent episode of delirium, first major psychiatric episode at advanced age, recent head injury, parkinson’s, mild NCD

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21
Q

NCD Common Presentations: Warning Signs

A

memory changes, loss of ADLs and IADLS, problems with executive function, impaired visual recognition, language and speech disorders, impaired ability to perform a motor ability despite intact motor capabilities, personality, behaviour and mood changes

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22
Q

NCD Common Presentations: Main Cognitive Deficits Alz

A

Learning and Memory

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23
Q

NCD Common Presentations: Main Cognitive Deficits Vascular

A

Complex Attention, Executive Function

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24
Q

NCD Common Presentations: Main Cognitive Deficits Lewy Body Disease / Parkinson’s

A

Complex Attention, Perceptual Motor

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25
Q

NCD: Assessment

A

Objective Measures: Functioning, Cognition, Behavioral Sx
Physical Examination: Neuro exam( Presence of focal signs may indicate underlying neurological disorder, cerebrovascular disease, intracranial process (eg tumor, hematoma)), Cardiovascular exam (Positive findings may be suggestive of vascular etiology to NCD), Sensory input (Vision or hearing impairment may mimic NCD)
Mobility (Gait abnormalities may orient towards NPH, Parkinson’s, cerebrovascular disease)
Blood work, MRI/ CT
Medication
Review pharmacological profile: Recent Rx changes
Drug-drug interactions, Rx with deleterious cognitive side effects, Anticholinergics, Sedatives/hypnotics, AED, Assess adherence, Unstable medical condition or serum drug level may impact cognition
MHx: Failure of major organs: eg CHF, COPD, CKD, cirrhosis, Neurological disorders eg Parkinson’s disease, MS, ALS, epilepsy, Endocrine/metabolic condition
eg hypothyroidism, hypoglycemia, B12 deficiency
Systemic illness, Auto-immune or infectious disease causing encephalitis (eg neurosyphilis), Cardio/cerebrovascular disease ** eg CAD, atrial fibrillation, TIA, Cancer (mets, chemo, radiation) Brain mets (breast, lung, colon, kidney), Brain tumor
PsychHx: Depression «pseudodementia», Anxiety disorders, Severe mental illness, Associated cognitive symptoms, SUD, EtOH and risk of Wernicke-Korsakoff
Withdrawal state, Intellectual disability and ASD, Change from baseline?, Delirium, Sleep disorders, Untreated OSAH

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26
Q

NCD Most common comorbidities

A 
#1: HTN 42 %
#2: Depression 32 %
#3: Cardiac disease 27 %
#4: TIA/CVA 18 %
#5: DB 13 %
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27
Q

NCD Most common complications

A 
Eating problems
Dehydration
Malnutrition
Febrile episode
(Aspiration) pneumonia
Seizures
GI bleeding
Fractures (hip)
CVA
MI
Distressing sx
Pain, SOB, bed sores, agitation
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28
Q

Psychiatric Complications NCD

A

NPS or BPSD:
Affective and emotional: dep, anxiety, apathy, irritability, emotional lability, exaltation of mood
Behavioral disorder: wandering, repetitive vocalisations, repetitive movements, agressive disinhibition, sexual disinhibition, gluttony, utilization behaviours, initiation behaviours
Neurovegetative disorder: sleep (night wandering, sundowning, sleep-wake cycle reversal), inappropriate eating behaviours and hyperorality

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29
Q

BPSD Possible underlying causes

A 
Physical sx / medical condition (eg UTI)
Unmet needs (eg thirst)
Environmental factors (eg noise)
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30
Q

BPSD present in

A 
both mild and major NCD
Early stage: mostly affective sx
Late stage:  mostly aggression and delusions
VERY common (<90 %)
Often chronic
31
Q

Alzheimer’s Disease: Epidemiology

A 
Most common cause of NCD
Incidence in Canada
5 % > age 65
6-8 % > age 85
F>M 
7-10 years from onset to death
32
Q

Alzheimer’s Non-modifiable Risk Factors

A

increase age, female, first degree relative with alz, down syndrome, genetic, mild cognitive impairment
Most important RF overall: age

33
Q

Alzheimer’s modifiable Risk Factors

A

hta, cholesterol, head injury, dep, db, moderate wine consumption, no exercise, low cognitive activity, smoking, increased dietary fate intake and reduced omega 3, lower education, exposure to environmental risk
Most important modifiable RF: cardiovascular
Combined effect of modifiable RFs account for 30 % of risk of developing Alzheimer’s

34
Q

Dx: Major NCD due to Alzheimer’s Disease

A

Criteria met for major NCD
Insidious onset + gradual progression
Criteria met for either probable or possible Alzheimer’s disease
Not better explained by cerebrovascular or neurodegenerative disease, effects of a substance, or another mental, neurological or systemic condition
Probable (1 OR 2):
1. Evidence of causative AD genetic mutation from FHx or genetic testing
2. All of the following:
Clear evidence of decline in memory and learning + 1 other cognitive domain
Steadily progressive, gradual decline in cognition (no extended plateaus)
No evidence of mixed etiology
Possible:
Criteria not met for probable Dx

35
Q

Criteria not met for probable Dx

A

Criteria met for mild NCD
Insidious onset + gradual progression
Criteria met for either probable or possible Alzheimer’s disease
Not better explained by cerebrovascular or neurodegenerative disease, effects of a substance, or another mental, neurological or systemic condition
Probable:
Evidence of causative AD genetic mutation from FHx or genetic testing
Possible (1 AND 2):
1. Criterion not met for probable Dx
2. All of the following:
Clear evidence of decline in memory and learning
Steadily progressive, gradual decline in cognition (no extended plateaus)
No evidence of mixed etiology

36
Q

Alzheimer’s Disease: Early Stage Red Flags

A

Short-term memory difficulties
Not paying bills or rent on time
Not showing up to appointments
Fire hazard due to inappropriate use of stove/candles
Poor Rx adherence
Disorientation
Getting lost outside of house (walking or driving)
Lack of judgment
Scams
Being inappropriately dressed for weather
Malnutrition
Not seeking medical attention despite significant health problems

37
Q

Alzheimer’s Disease: Common Presentations As the disease progresses

A 
Gradual loss of autonomy
iADLs then ADLs
Developmental regression
Language
Mobility
Continence
Swallowing
Emotions regulation
«Plongeon rétrograde»
Gradual loss of timeline of events (present -> past)
Death
Early stage: medical comorbidities
Late stage: infection (pneumonia), malnutrition, dehydration
38
Q

Dx: Mild/major NCD with Lewy Bodies

A 
Criteria met for mild/major NCD
Insidious onset + gradual progression
Combination of core and suggestive Dx features
Not better explained by cerebrovascular or neurodegenerative disease, effects of a substance, or another mental, neurological or systemic condition
1. Core Features
Fluctuation in cognition (attention and alertness)
Recurrent VH (well formed + detailed)
Spontaneous parkinsonism with onset subsequent to cognitive decline
2. Suggestive Features
Severe neuroleptic sensitivity
REM sleep behavior disorder
Probable:
2 core features 
OR
1 core feature + ≥1 suggestive feature
Possible:
1 core feature 
OR
≥1 suggestive feature
39
Q

NCD with Lewy Bodies 5 Important Sx Clusters

A 
Fluctuating Cognition
Motor Dysfunction
Sleep Dysfunction
Neuropsychiatric Features (Depression: can be very severe, Hallucinations: other than visual, Delusions: often systematized and related to VH)
Autonomic Dysfunction (OH, Repeated falls and syncope
Transient, unexplained loss of consciouness, Cardiac autonomic denervation)
40
Q

NCD with Lewy Bodies How to distinguish from Parkinson’s disease?

A

Lewy bodies > Parkinson’s:
Attention deficits
Sensitivity to neuroleptics
Postural instability and gait difficulties

Lewy bodies < Parkinson’s:
Earlier age of onset
Assymmetrical parkinsonism
Better response to L-dopa

41
Q

Vascular NCD Cognitive features depend on

A

location and size of vascular brain lesions

42
Q

Different types of lesions Vascular NCD

A

Hemorrhagic (eg subdural hematoma)

Ischemic: 
Large vessels (eg CVA)
Small vessels (eg lacunar infarcts) -> often subcortical
43
Q

Vascular NCD > x% of people age > 70 have

A

> 25 % of people age > 70 have silent lacunar infarcts

Associated with subtle decline in cognition

44
Q

Dx: Mild/major Vascular NCD

A

Criteria met for mild/major NCD
Clinical features consistent with vascular etiology by either 1 OR 2
1. Onset of cognitive decline temporally related to ≥1 cerebrovascular events
2. Prominent decline in complex attention and frontal-executive function
Evidence from Hx, P/E, or neuroimaging of cerebrovascular disease sufficient to account for deficits
Not better explained by another brain disease or systemic disorder

Probable (1 OR 2 OR 3)
1. Neuroimaging supported
2. Temporally related
3. Both clinical and genetic evidence of cerebrovascular disease
CADASIL and leukoencephalopathy

Possible
Neuroimaging not available
Temporal relationship not established

45
Q

Vascular NCD: Common Presentations

A

Abrupt Cognitive Decline («plateau»):
Abrupt change in cognition and behavior usually related to acute cerebrovascular event
If cortical lesion : Aphasia, agnosia, apraxia, amnesia (location-dependent), Motor and sensory deficits

Gradual Cognitive Decline:
Insidious onset and progressive course associated with «silent» infarcts and microvascular ischemic changes

Usually «subcortical» presentation:
Executive dysfunction
Retrieval deficits on memory testing
Psychomotor retardation
Gait abnormalities
Vascular parkinsonism
Apathy
46
Q

Depression in the Elderly: Mechanisms

A

Lower likelihood of family history, a prodrome to Alzheimers, a manifestation of cerebrospinal vascular disease, caused by a GMC, psychosocial context (end of life)

47
Q

Specific features of depression in older adults

A

cognitive impairment more common, psychotic features more common, more somatic sx, more neurovegetative sx, more disability
Patients DO NOT endorse sadness or depressed mood, but rather feel ANXIOUS or have LOST INTERESTS

48
Q

Alzheimers vs depression

A

Apathy, agitation vs anhedonia, anxiety
Sundowning vs insomnia
Weight loss without loss of appetite vs weight loss with loss of appetite
Minimizing of cognitive decline despite impaired memory and executive function vs subjective complaints of cognitive impairment that exceed objective deficits
Guesses and wrong answers during testing vs “I don’t know, I can’t”
Aphasia and apraxia vs language and motor skills intacts

49
Q

Depression in the Elderly: Dx Clues

A

ANXIETY,
ANHEDONIA
SOMATIZATION
Delayed recovery, treatment refusal, discharge refusal, high utilization of services

50
Q

Depression in the Elderly: Suicide

A

Old white males, higher likelihood to complete suicide, more violent methods (hanging, firearms)

51
Q

Anxiety Disorders in the Elderly: New Onset of Sx

A

R/O depression
R/O medical cause
Agoraphobia can be seen

52
Q

Anxiety Disorders in the Elderly: Risk Factors

A

Female, depression, cognitive impaired, physical impairment, psychosocial stress, functional limitations

53
Q

Anxiety Disorders in the Elderly: Protective Factors

A

social support, physical activity, cognitive stimulation

54
Q

Anxiety Disorders in the Elderly: GAD

A

most common (with phobias), less severe, higher percentage of health worries and worries of well-being of family

55
Q

Anxiety Disorders in the Elderly: Panic Disorder

A

Late onset is uncommon (less NE), search for depression

56
Q

Anxiety Disorders in the Elderly: Agoraphobia

A

Onset may be related to health status, falls, more common in women and widowed, often preceded by dep

57
Q

Anxiety Disorders in the Elderly: PTSD

A

Early life traumas result in higher rates of PTSD than late life trauma
Less re-experiencing sx, more avoidance
Reactivation may be related to analogous historical events or triggered by age related loss

58
Q

Anxiety Disorders in the Elderly: OCD

A

Lower prevalence
increases hand washing and fears of sinning
more hoarding

59
Q

Risk factors for mania

A

CNS disorders especially cerebrovascular disease affecting the right orbital frontal cortex

60
Q

Bipolar Disorders in the Elderly: Cognition

A

Associated with frontal executive dysfunction and language impairment, even in a euthymic state, increased risk of dementia

61
Q

Characteristics that can differentiate between late onset and early onset schizophrenia

A

More women in late onset, more positive sx, more variability in the profile of cognitive deficits, respond to lower doses, larger thalamic doses, more paranoid, more organized delusions, more sensory deficits, more partition delusions, Several sensory perceptual disturbances at the same time. More delusional

62
Q

Schizophrenia in the Elderly: Risk Factors

A

Psychosocial isolation and low social support, F, bereavement, sensory deficit, immigration, family history, childhood maladjustment, abnormal social functioning, abnormal premorbid personality, delusions in the absence of medical conditions, cerebrovascular abnormalities

63
Q

Schizophrenia vs Alzheimer’s in the Elderly

A

Schizo: single, socially isolated, major mental illness in the family, auditory hallu,
Alz: not socially isolated, alz in te family, visual hallu, delusions someone stealing

64
Q

Elder Abuse: Types

A

Neglect (+++), financial , physical, sexual, psychological

65
Q

Self neglect

A

behaviours that threatens his/her own health and safety. At risk of consumer fraud. Hoarding, sever domestic squalor

66
Q

Elder Abuse: Risk Factors

A

cognitive impairment, agressive behaviours and psychological distress, poor social network and support, low household income, need for ADL assistance, premorbid relationship with the abuser, shared living arrangements

67
Q

Perpetuator risk factors for elderly abuse

A

family relations, substance abuse, mental illness, dependency, unemployment

68
Q

Elder Abuse: Red Flags

A

bruises, pressure marks, broken bones, abraisons, burns, unexplained withdrawal from normal activities, sudden change in alertness, unexpected depression, bruises on breasts or genital area, sudden changes in financial situation, UNATTENDED MEDICAL NEEDS, poor hygiene, unusual weight loss, frequent arguments between caregiver and pt

69
Q

Capacity: Definition

A

”The ability to understand and appreciate the nature and consequences of own’s decisions and to formulate and communicate decisions concerning a specific decision-making domain”.

70
Q

Decision-making Domains Relevant to the Field of Psychiatry

A 
Medical (treatment and research)
Financial
Housing
Driving
Testamentary
71
Q

4 Abilities are required in order make decisions

A 
C omprehension  (of relevant information)
A appreciation (of how this information applies to self)
R easoning  (compare information and infer consequences of choices)
E xpression  (of a consistent choice)

If a medical or psychiatric condition impairs ≥1 of these abilities -> increased risk of having impaired decision-making capacity

72
Q

Examples of conditions commonly associated with impaired decision-making capacity in the elderly

A 
NCD
Delirium
Parkinson’s disease
Severe mental illness
Systemic illness impacting brain function (eg vasculitis)
Brain tumor or metastasis
TBI
End of life
73
Q

Capacity: Key Facts

A

Capacity is task-specific
Ability to make a decision at a specific time regarding a specific situation)
Eg: Someone with NCD can be capable of deciding whether he wants surgery for his cataracts, but be incapable of making finance-related decisions at the exact same time

74
Q

Capacity IS NOT

A

Determined by a Dx or committal statusD
Eg: Dx of schizophrenia ≠ loss of decisional capacity necessarily
The same as agreement with the clinician’s decision
Patients may agree with proposed treatment without understanding associated risks
Determined by an MMSE or MoCA score

Reasoning in mental health 7 (12 decks)

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